For medical professionals working in hospitals, the daily effort to balance our patients’ personal and clinical care, paperwork, and the tangled web of hospital, state, and federal compliance takes its toll. It’s a complicated soup of evidence-based medicine and best practices, seasoned with patient and organizational quality requirements and measurements that are increasingly redefining multiple elements of care. Additionally, there is the human factor, involving our patients, their families, and the nurses who serve them.
Nobody likes being in the hospital. Despite this, I see a hospital as a place for happy beginnings, recovery, hope, and respect. Behind every surgical mask and pair of scrubs is a warm human being who is highly trained, empathetic, sympathetic, and dedicated to the patient’s full recovery.
Nurses work hard to achieve peak performance while remaining emotionally and intellectually focused. Our patients and their loved ones are managing a multitude of emotions over the patient’s well-being, and they need accurate, useful information, support, and comfort. If English is not their first language, we face additional obstacles in ensuring comprehension and compliance, which has a direct impact on recovery, readmissions, and patient satisfaction ratings. Simply, the more patients understand the importance of the role they play in their own recovery and longer-term wellness, the better it is for everyone involved.
Communication is more complex than language barriers alone. Culture, geography, gender, and patient age change the dynamic, as do the demographics of caretakers once patients have returned home.
Many hospitals have moved past old-fashioned videos and are now using interactive patient-engagement technology to deliver on-demand digital videos as part of their education programs, including features that allow nurses to build content into the patient’s condition-specific care plan. These systems also offer interactive capabilities, such as electronic documentation, detailing what programming the patient has viewed, in addition to simple testing to measure patient comprehension and retention. The nurse or physician can then meet with the patient and family for follow-up opportunities, ask and answer questions, and provide additional education or resources as required. All of this becomes part of the patient’s electronic medical record (EMR), moving toward mandates that will eventually link all care and recordkeeping digitally, and will provide concise documentation for reimbursement, compliance, and accreditation needs.
Additionally, these interactive capabilities can be used for service assistance and service recovery, as well as report generation and analysis for quality improvement. Leading hospitals are embracing multiculturalism in their patient-engagement communication outreach, providing on-screen information, direction, and educational programming in popular alternative languages, including Spanish, Russian, Mandarin, and a whole host of other tongues based on local demographics.
Removing cultural barriers improves retention and outcomes
When patients are ill, their comprehension is already compromised. Stress, pain, fear, and lack of sleep exacerbate that disconnect, so when we can provide educational information and guidance in their native language, it improves comprehension for the patient and the caregivers, and increases their comfort level. Today, there are hundreds of educational programs that have been translated into foreign languages, as well as on-screen commands and prompts, and related follow-up testing, all conducted through the patient’s bedside phone and visually navigated on the television screen.
When this multicultural transition first gained momentum, it was often completed with alternative-language subtitles or voiceovers. Also, the programming often does not reflect cultural differences still apparent in ethnic communities, further devaluing the authenticity of the message and credibility, even if the information is accurate. In contrast, when the person delivering the message is a native speaker and is aware of cultural behaviors, norms, and practices, patient acceptance of the message improves dramatically.
These changes are more than just pragmatic. Having nurses hindered by language barriers reduces our effectiveness. The Joint Commission (formerly the Joint Commission on the Accreditation of Healthcare Organizations), the National Committee for Quality Assurance, and other ratings organizations are relying on hospitals to better involve patients in their own care and are surveying patients on their satisfaction levels. By making this effort, we’re saying to our patients and their families, “We recognize and respect your cultural differences.” That bridge also requires that we recognize different dialects and even regional variances, such as colloquialisms and slang.
To ensure improved understanding and enhanced compliance, hospitals are also turning to multilingual educational materials in simpler, more customized vehicles, such as PowerPoint presentations done in multiple languages and complemented with native-language voiceovers recorded by skilled translators. Another cultural trend well established within the Latino community is to use fotonovelas, which are photographs with copy bubbles created in multiple languages. Comic book-like illustrations are used as well. Some hospitals offer phone systems that automatically connect the patient or his/her family member to a translator or a multilingual menu, rather than having the patient wait until a translator is available to visit the room. These efforts drastically increase the patient’s adherence to the care plan.
There are a number of third-party content vendors offering video educational programming services, and in my travels, I have seen more than 400 health care titles in close to 30 languages. Once these and other customized programming are incorporated, they allow hospitals to offer 24/7 on-demand programming complemented by entertainment channels, relaxation channels, hospital information, Internet access, and other amenities offered in multiple languages.
Multiculturalism in action
Northridge Hospital Medical Center in Southern California has a large Hispanic population and many patients with low literacy rates. A 2004 survey that sampled 42% of Northridge’s maternity patients revealed health literacy challenges in deciphering, retaining, and using patient education information on labor, delivery, recovery, and infant care. Twenty-three percent of California adults lack basic literacy skills, according to 2003 (most current) statistics from the National Assessment of Adult Literacy. And a 2009 study from the University of California, Berkeley also revealed that 25%–33% of people in the area couldn’t speak English well or at all.
Northridge’s Perinatal Program Manager, Ruth Gonsoski, R.N.C.-O.B., C-E.F.M., M.S.N., also discovered that despite their best clinical efforts, the hospital’s maternity department was receiving low patient satisfaction scores related to questions like, “How well did you learn how to breast feed or bottle feed your baby”? Recognizing that they needed more practical tools to help patients make a successful transition from hospital to home, they searched for ways to improve educational proficiency. Additionally, Gonsoski knew there were common cultural myths involving care, such as patients’ belief that epidurals cause permanent back problems, privacy around breastfeeding, issues involving eye contact with male nurses and physicians, the use of herbs and home remedies that weren’t healthy for the pregnant mother or fetus, and more.
The hospital’s solution was to implement TeleHealth Service’s TIGR® interactive patient-education system, and to develop a directory of videos that met the language, literacy, and informational needs of Northridge patients. Their library addresses issues such as care of the newborn, breastfeeding, pain management, general health and wellness topics, diabetes, congestive heart failure, cancer, stroke, and other common conditions. Many of the titles are available in both English and Spanish.
Gonsoski, part of the Hospital’s centralized education department, led the effort to integrate multilingual videos and programming into maternity. In addition to Spanish-language videos and on-screen interactive navigation, they used a simple 10-question comprehension test to measure understanding. After completing the video, the patient was transferred to the comprehension test and prompted through the questions. This information then became part of their permanent electronic medical record, and posed opportunities for nurses to provide follow-up support. They also gave patients a Spanish-language post-partum package with materials such as booklets and magnetic refrigerator checklists.
Gonsoski says they’ve seen significant improvements in patient satisfaction scores since implementing these multilingual educational tools. Before the installation of TIGR, 46% of Northridge’s obstetric patients had trouble retaining critical information such as how to feed a baby or respond to an emergency. With the use of TIGR’s multisensory teaching method, retention has risen to 95%. By posing questions at the beginning and end of a video, Northridge nurses can determine the comprehension rate of their patients and can easily fill in the gaps. This resulted in their winning a nationwide Avatar 2007 Award for Most Improved Unit for Exemplary Service. Of the many videos that play each month at Northridge, infant care-oriented videos, such as infant CPR (in English and Spanish) and breastfeeding, are highly utilized. These videos have become so effective that they are now required elements of obstetric patients’ care plans.
Not only is this effort on focused cultural outreach improving results for patients, it provides an electronic record for ratings organizations to review and helps nurses feel better about their efforts and patient outcomes. It also frees nurses for more clinical functions. Hospitals don’t just want nurses trained to conduct tests and work through translators; they want nurses empowered to make a difference. These principles of adult learning are now being embraced throughout the industry.
As the synergistic worlds of health care technology, staff resources, and patient needs mesh with funding challenges, compliance mandates, and escalating quality requirements, one truth remains evident: the critical roles of technology and personal, face-to-face care will remain essential in today’s evolving health care world.
If there is one thing surgical nurse Rochelle Scott has learned from her patients, it is to assume nothing. No matter how well she might think she understands a culture or a tradition important to her patients, Scott learned through repeated interactions that each patient, no matter what his or her heritage, will interpret and use cultural norms in slightly different ways.
“Giving the culture respect, and honoring that when it is appropriate, shows the patient they can trust you,” says Scott, who is midway through her master’s degree in the nurse practitioner program at Mount Saint Mary College in Newburgh, New York.
When you care for patients of Southeast Asian descent, with cultures that may include but are not limited to Hmong, Vietnamese, Chinese, or Thai people, learning a bit about the cultural norms and traditions can positively impact health care outcomes. But the languages and traditions of this group are incredibly diverse and have many nuances that impact literacy, child-rearing practices, elder care, and self-healing. Thankfully, nurses are in a great position to do some research, interact frequently, and discover the individual subtleties of their patients’ heritages.
When Dr. Madeleine Leininger introduced the idea of transcultural nursing in the 1950s, the idea was outside the norm. As cultural diversity and the promotion of cultural competence in health care settings becomes more mainstream, the idea continues to take shape in nursing programs. Dr. Priscilla Sagar, R.N., A.C.N.S.-B.A., C.T.N.-A., professor of nursing at Mount Saint Mary College, says nurses are often called on to lead the journey, bringing cultural competence standards into practice in academic settings, health care practices, and research.
“One of the biggest barriers is the lack of research about the populations,” says Sagar, referring to Southeast Asian patients. “Usually [research] has lumped them in saying ‘Asian/Pacific Islanders’ instead of separating them.”
The distinctions are vitally important when trying to determine something like typical growth and development for instance, says Sagar. Growth and development in a Filipino child might look delayed to some when, in fact, it is normal for that group, she says.
On the job
When on the job, though, cultural competence may not be as well defined. For instance, Dr. Margaret Andrews, R.N., F.A.A.N., C.T.N., Director and professor of nursing at the University of Michigan-Flint, cites instances of health care practitioners suspecting child abuse when children have shown up at doctors’ offices with red marks from the Asian practice of coining. Coining—the custom of rubbing coins over the skin (especially ribs of children with a cold) to create friction and warmth to rid the body of what is assumed to be bad winds or to fight off a cold—also leaves red marks on the skin. If you are not aware of the practice, it might raise suspicions of maltreatment.
The idea of coining, says Andrews, is not so different from Western practices of trying to restore balance to the body. The outcome looks a little different, but it helps if the medical staff is aware of the practice and any other practices of the cultures they frequently treat. They can then respectfully and effectively treat the patient without seeming to dismiss their beliefs. For example, if a child’s cough really is pneumonia, more intervention is necessary. If any herbs have been used for self-treatment, there has to be enough trust so the patient will share what has been used without fear of rebuke. Andrews recommends nurses reference the National Center for Complementary and Alternative medicine’s website at nccam.nih.gov for more in-depth information.
For many nurses, the desire to understand other cultures is the first step toward effective change. “Without the desire, it would be difficult for health care providers to embark on this journey,” Sagar says.
For instance, many cultures in Southeast Asia are family focused and oriented, Sagar says. In the United States, where medical decisions are generally made independent of the extended family, a medical decision that weighs the opinions of many family members might seem different. “But in many of these cultures, the family is involved,” she says.
And while the health care providers have to recognize that, they also have to gain a sense of any underlying factors. Sometimes, especially for immigrants, there is a sense of being in two worlds, both of which might have conflicting values, Sagar says. “If they are second generation and if they were born here and have grown up here, their values may be more Western than Eastern,” while the family values remain decidedly Eastern. The opinions can create a real family conflict.
For nurses, it is a matter of figuring out how it all reflects on the patient’s care. “When you first get educated, it is all about retaining it and incorporating it into the health care with the patient,” Scott says. Even something as simple as being aware of major holidays for that culture can make a patient feel recognized and feel his or her culture is respected. No one wants to schedule a procedure around a major celebration if it is not necessary.
Perform cultural assessments and learn about the top three or four cultures you work with, even small details like how to address the patient, Andrews recommends. In some Asian cultures, the first and last names are in reverse order from Western usage. “Ask them, ‘By what name may I call you?’” Andrews says. “Generally, it is better to address more formally and wait to see if they give you permission later to call them something else.”
Andrews also recommends being aware of the tradition of wearing an amulet to bring good luck or a talisman to ward off bad luck that many Southeast Asian populations honor. “That may give a signal to the nurse that they have spiritual beliefs they are bringing to a health care setting,” Andrews says. “You need to respect those.”
When traditions or beliefs that are important to the patient are not recognized, it can set up a rocky start to a relationship between nurse and patient. “It is the little things that can be frustrating for the patient,” Scott says. “Then the patient feels neglected or disregarded.”
According to Guadalupe Pacheco, Senior Health Advisor at the Office of Minority Health, there is a disconnect that exists between the demographics of the nation and that of health care professionals. Pacheco says that while various ethnic groups compose nearly one-third of the population, the nursing population does not mirror that proportion.
When the patient and provider come from a similar cultural background, the common factor often inspires trust Pacheco, says, but even the most radically different backgrounds can still work well. “It is all about communication,” says Pacheco. “If you establish that rapport with a provider and patient, they will come back to you. They are going to trust the diagnosis you make and the treatment you are prescribing.” And while health care professionals work hard to overcome any language barriers, understanding the cultural barriers as well will ensure that a patient not only trusts a provider, but also understands what is being prescribed and why it is important to follow through.
Think like your patient
Imagine being in your patients’ shoes, says Pacheco, where the system may seem very foreign and difficult. Creating a calm environment is a big step toward putting a patient at ease, he says, despite the difficult time and pressure nurses are under.
Sometimes thinking like your patient, even briefly, gives clues as to how to proceed. Eunice Lee, Ph.D., G.N.P., a UCLA School of Nursing associate professor, had success in implementing change to get more Korean American women to have mammograms. Even the cultural differences between Korean and Korean American women can be vast. “I am struck by how cultural norms impact women’s behavior,” Lee says. “Korean American women do not tend to take care of themselves. Women prioritize family needs first with husbands and children. They are at the bottom of the list, especially if they have no symptoms.”
In the late 1990s, only 10%–20% of Korean American women were getting mammograms, says Lee. The number has since doubled but is still very influenced by the cultural context.
Lee implemented a program where she used a popular Korean vegetable dish as the program’s acronym, KIM-CHI (Korean Immigrants and Mammography: Culture-Specific Health Intervention). By presenting mammography as a normal, routine health screening and educating the husband and the woman together, screening rates jumped 15% in Lee’s intervention group.
“When you educate the woman, you need to consider and evaluate her support system and how they can help her, rather than have it purely focused on the individual,” Lee says. Health care providers might want to encourage the husband to support the woman in taking time off from work or family obligations to get screened. Lee also expressed the strong cultural resistance to getting treated, even in a screening manner, for illness in the absence of any symptoms. “When you don’t have symptoms, you are not ‘sick,’” she says of some patients’ beliefs.
Use your resources
At Lowell General Hospital in Massachusetts, Brenda Murphy, R.N., a med/surg float, works closely with the hospital’s cultural interpreters to give her patients the best care. In addition to taking advantage of work-sponsored cultural education and training, she picks up appropriate behaviors within each culture from observing and asking questions.
Murphy, who works with Lowell’s extensive Cambodian population, says she always put her hands together to give an elderly patient a small bow as a sign of respect when leaving. At the advice of a cultural interpreter, she adjusted the height of her hands, as hands that are placed too low can be seen as insulting, rather than respectful. Murphy also says she is careful when touching the head of a Khmer patient as the cultural traditions of some Khmer say the soul resides there. If it is possible to ask permission, she always does. Eye contact might be unnerving to Khmer patients as well, who sometimes avoid it as a sign of respect. They may prefer also very limited physical contact.
Many hospitals prefer to use medical interpreters to ensure accuracy in translation of complex medical terms and to protect a patient’s privacy. In their absence, nurses might have to rely on more rudimentary methods like flash cards or pictures to help both patient and nurse. Pacheco discourages the use of family members as interpreters, especially children. “Sometimes you have no choice, but it is best to introduce a bilingual neutral party who also understands medical terms,” he says. Family members can help fill in the missing information about symptoms the patient is experiencing or treatments used.
Moving forward
“It is encouraging,” Sagar says of the progress being made. In the next couple of decades, as minority populations grow, cultural competence in nursing will become much more crucial to quality patient care. “I am passionate about cultural diversity and the promotion of cultural competence,” she says. As an immigrant herself, Sagar says she knows the experience of “being different from the rest.”
When Lowell General Hospital was forming plans for diversity training, staff recognized that diversity was as much of an essential component of patient care as medicines and procedures, says Deborah Bergholm-Petka, Manager of Training and Development. Nurses have the opportunity to learn about cultures through monthly celebrations in the hospital. The staff is also encouraged to reference the book Culture & Clinical Care,which gives general summaries of many cultural beliefs and attitudes. Use what your work environment offers and know a little bit about the cultures served. “Know who your resources are and how to access them,” Murphy suggests. “Now we are more proactive and aware of who makes up our communities.”
Be ready for all situations when you work with many different cultures. Continually ask yourself reflective questions, suggests Venus Watson, chair of Lowell General’s Diversity Council. For instance, how will you navigate various cultural wishes and accommodate a patient while ensuring the best care and follow up? If family members want to speak for a patient, how can you best introduce an interpreter?
“It is not about the nurse,” Scott says. “It is about the patient. You can offend people when it comes to culture.” Never assume you know what a patient wants, she says. Rather, gain knowledge, be aware, and ask the patient—the solution is often that simple. “People do pass judgment on beliefs,” Scott says, “but it is education that will change the system.”
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
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.
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 NursingSpectrum 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 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…”
It is often said, “We are a product of our environments.” In many respects this is true. In the African American culture, we tend to embrace the habits and behaviors of our surroundings. We don’t think of our childhood or adulthood lifestyles as unhealthy because we tend to repeat the behaviors we have always known.
Fast-paced and stressful workdays, a lack of physical activity, poor nutritional choices, and sedentary downtime are all factors that have led to skyrocketing levels of obesity, but are the norm in the American lifestyle. Consequently, problems like hypertension, heart disease, peripheral vascular disease, diabetes, some forms of cancer, pulmonary disease, depression, and conditions involving the musculoskeletal system plague obese populations. Additionally, the study of obesity reflects underlying economic and income inequalities, community disadvantages, and social class divisions. With the rapidly increasing pace of obesity, the weight of the matter is both individual and societal.
The term “obese” is often confused with “overweight.” We know the difference as health professionals, but the communities we serve may not. Healthy weights are determined using the Body Mass Index (BMI). People with a BMI between 25 and 29.9 are considered overweight. Those with a BMI of 30 or greater are obese.
Obesity has become one of the most serious public health problems of the 21st century, due to its prevalence, cost, and health effects. It cuts from a wide swath of people, spanning all ages and genders, making it a national priority. Obesity has reduced the lifespan of entire communities and dismantled their quality of life. African Americans are killing their bodies when they do not make the connection between lifestyle behaviors and their outcomes.
One effective strategy for solving the obesity epidemic is through educating ourselves. Taking ownership of our bodies, recognizing the problems, and changing our attitudes will help us make knowledgeable decisions about our health. Although countless excuses, from a lack of role models to fast-food conveniences, may attempt to undermine addressing the real issue, the life or death importance of seeking solutions should resonate beyond the perception that fighting obesity is futile.
For the Fort Bend County Black Nurses Association (FBCBNA), the fight against obesity is persistent. This year, FBCBNA is celebrating its 10th anniversary. We challenged our members to lose 10 pounds in honor of the occasion. The National Black Nurses Association (NBNA) awarded the FBCBNA a $1,000 seed grant to fund the initiative and develop strategies to tackle obesity. The grant will be used to introduce interventions, like personal training tips and group exercise activities, as well as community education, such as teaching people how to read food labels.
As nurses, we need to practice what we preach. Fighting obesity from within our local chapter seems like a sensible choice. Nurses do an excellent job giving advice and caring for others, but don’t always do a good job caring for themselves. Reducing one’s BMI requires changing behaviors and making lifelong healthful decisions. The FBCBNA’s obesity initiative is titled “BMI Beware: A Nursing Association’s Strategy for Changing Body Mass Index.”
The pillars of combating obesity are balanced nutritional meals and physical activity. Portion control, knowledge of ingredients, informed reading of food labels, and nutritious food choices are fundamental in changing unhealthy behaviors and developing improved lifestyles. The fight to conquer obesity must have multiple layers of intervention. Aerobic and resistance fitness programs, avoiding fast food purchases, planned healthy meals and snacks, and adequate hydration, specifically water, are all positive ways to intervene in this epidemic.
The goal in all this is to make a conscious assessment of our obesity problem. Personal lifestyle and behavior changes must be developed and then practiced daily to make a real impact. Opportunities to take on new and rewarding lifestyle changes are all around us. We just have to get moving—one day at a time, one step at a time. We owe it to ourselves, our families, and society. The obesity epidemic is serious. As we collectively transition toward healthier choices and better lifestyle routines, sharing knowledge and becoming more educated as health professionals will lead our communities to positive results.
