Because he wanted a “visceral take” on his potential subjects, Christopher Coleman, Ph.D., M.S., M.P.H., A.P.R.N.-B.C., A.C.R.N., F.A.A.N., sat for weeks in the waiting rooms of five Philadelphia clinics just getting to know older HIV-positive African American men, their families, and friends. He didn’t want to wait until he was ready to recruit volunteers for his latest HIV/AIDS study to introduce himself.
The experience not only allowed Coleman to build strong relationships with his possible study candidates, but to understand the challenges and unique cultural nuances that may impact their access to services.
His early engagement paid off. Besides getting input from the men and a buy-in for his research, Coleman, a Fagin Term associate professor of nursing psychiatry and multicultural diversity at the University of Pennsylvania School of Nursing, didn’t lose a single person during the ensuing study. More importantly, the professor was able to explain in detail how his study could truly benefit its participants in the end.
“They knew that I wasn’t out to hurt them,” says Coleman. “Once they trusted me, they were more likely to say to their neighbors, ‘Yes, this is a good person. Participate in his study.'”
Barrier of history
Recruiting minority patients for clinical research may be the most important challenge you undertake as a nurse. Racially and ethnically diverse people suffer many major health issues in disproportionate numbers to their populations, often with increased intensity. There are ample better health reasons to target such communities for clinical trials and research.
These same groups are underrepresented in the very studies that could improve or save their lives. The National Cancer Institute funded trials between 2003 and 2005, for instance, which underscored the disparities: although black people made up 8% of the study cohort—more than any other ethnic group—they were overshadowed by the nearly 90% of white enrollees.
As a minority nurse, you’re not only well positioned to bring parity to the research ranks, but you’re also doing it at an opportune time. With federal granting and regulatory agencies calling for better minority representation in health studies across the disciplines, there is definite focus on improving racial and cultural participation.
By pairing your nursing skills and cultural awareness with a foundation in research basics, you can be the ambassador for a study in your office or the conduit between investigators and the larger community. But be forewarned: that doesn’t mean people won’t question your motives. Even a shared culture doesn’t break down every barrier. However, by taking a page from Coleman’s experience and reaching out to the community, you can start building trust.
Why is that important? In recent years, racial and ethnic minorities have been noticeably underrepresented in research studies and clinical trials, partially due to lingering mistrust and a simple lack of outreach and community awareness. Given the suspicion many individuals still harbor from past abuses, specifically the notorious Tuskegee Syphilis Study, you’ll likely have to override general skepticism and even hostility.
The missing link
Fortunately, more recent studies suggest the overriding reason minorities don’t enroll in research has nothing to do with being afraid of the concept. Rather, it’s that they’re unaware of, and have no access to, clinical trials. Either their physicians aren’t involved, or the sites are far removed from where they live or work. (Minorities represent only 7% of the physician force—and an even smaller percentage participates in trials.)
Although those are challenges, they’re manageable challenges. With the right skill set and perspective, minority nurses are more than capable of facilitating trust building and serving as a conduit between investigators and communities. Sharing a common racial, cultural, and/or ethnic background with patients allows minority nurses not only to draw on the generic trust people have for nursing, but perhaps a certain kinship as well. Shared language, history, and values—these commonalities should help you advocate on behalf of other racially and ethnically diverse patients to investigators.
That’s not to say you’re automatically prepared to connect with another minority simply because you are a minority. Having an ethnic surname or proficiency in a second language is not enough to qualify. But if you’re aware and sensitive to the nuances and challenges of other ethnicities—and exhibit what anthropologists fi rst coined as cultural competence—you can be very effective promoting clinical trials to patients. You’re not only able to navigate research as a health care professional, but as a true cultural broker, making you well-positioned to bring others on board because you appreciate their concerns.
“People will react positively if someone takes the time to speak their language and communicate in a way that makes sense to them,” says Margaret Avila, M.S.N., M.S., R.N./N.P., P.H.N., a Los Angeles–based clinician and National Association of Hispanic Nurses board member. “We’ll hear patients say, ‘She really understands me. Even though she’s not like me, she still knows me.’ That attitude builds trust.”
Beverly Malone, Ph.D., R.N., F.A.A.N., and Chief Executive Officer of the National League for Nursing, agrees. “When I look in the mirror, I see you. You remind me of my daughter. You remind me of my family. And there’s an expectation that you’ll only be giving me information that will help me.”
Your efforts shouldn’t stop at the door of your hospital or clinic either. Although your persona and one-on-one interactions in the office will go far to establish your credibility, you still need to connect with the larger community. Even if volunteers for a given study can be identified in your clinic, being engaged outside the office strengthens your hand.
Rebuilding reputations
Most minority nurses already understand the importance of outreach in helping people of color take an interest in their overall well-being. They present at health fairs, talk at senior citizen centers, and organize other wellness events. They form partnerships with community leaders and organizations to engage individuals about their own health. Perhaps that describes you. Finding partners, making connections, and working throughout the community are powerful methods to change the health of any cultural group, but they’re also the very tactics that can help you establish your research bonafides.
Whether you’re collaborating with religious leaders or neighborhood figures, securing the support of influential decision makers is crucial for enrolling minorities. If you can prove to a respected fi gure in the community that your trial has merit and that you’re not just looking for guinea pigs, he or she can be an enormous asset in bringing others on board.
Besides someone vouching for you, your biggest asset may be your own reputation. By being a familiar face and positive force within the community, you solidify your standing so that when you need to convince others that participating in research is a good thing, you’ve already laid the groundwork. They’ll not only listen, but they may sign on with confidence that you’ll be there for the long haul.
“There’s a belief among people of color that researchers just parachute into the community, get them to participate, and then disappear,” says Daniel Montoya, Deputy Executive Director of the National Minority AIDS Council. “Nobody comes back and explains to them what role they played in finding answers. If more researchers followed through, people would have a better understanding of the importance of clinical trials and why they should participate.”
Tuskegee: A Foundation of Abuse Although the Tuskegee doctors had a serious goal of tracking unchecked syphilis in black men when they started their research in 1932, by the time the federal government shut down the project in 1972, investigators had amassed a plethora of ethical violations. The most profound charge was that they denied penicillin when it finally became available so they could finish their work. A bevy of federal regulations and professional guidelines ensuring safe, ethical trials were put in place to prevent anything like Tuskegee from happening again. Yet the specter of past research abuses still haunts. For years, many physician investigators wouldn’t work with minority populations, particularly African Americans, for fear of being stigmatized as taking advantage of vulnerable individuals. “People still reference Tuskegee,” says Debra A. Toney, Ph.D., R.N., F.A.A.N., president of the National Black Nurses Association and President/ CEO of the Las Vegas– based TLC Health Care Services. “How do you get past something that devastating so they’ll trust and believe that things are different today?”
When Martha Funnell, M.S., R.N., C.D.E., research investigator for the University of Michigan Medical School and spokesperson for the American Diabetes Association, and her colleagues were organizing diabetes studies among African Americans in the Detroit area, they knew it was essential to visit black churches. As the center of community life, houses of worship were natural outlets for recruitment, especially since their pastors knew which parishioners could benefit.
Funnell and her colleagues also organized community center meetings to ask potential participants for their input. Although the studies had to address specific questions, they considered those responses in the design. As a thank you, the team offered to participate in any church or community health-related events. Now they have a cadre of church members and others willing to share their study experience with potential volunteers.
“Success in life is all about creating relationships,” says Funnell. “In this case, it’s getting to know respected people within the community. It’s involving patients in developing studies so we can truthfully say, ‘Your friends and neighbors with diabetes have been part of this design.’ It’s all about creating trust.”
Connecting with volunteers There are multiple other tools to connect with potential volunteers. For instance, many research studies are facilitated based on input from community advisory boards. By participating in such panels, health professionals not only have a say in who gets recruited but also in how protocols are shaped and marketed. For example, by knowing that the distance between East Los Angeles and UCLA might be too far for a cancer or HIV/ AIDS study volunteer to realistically travel, a minority nurse can make sure that investigators set up shop closer, or suggest the best ways to reach that audience.
When pharmaceutical companies contact New York City’s Charles B. Wang Community Health Center to enroll a drug trial, administrators don’t have to look far for potential participants. Besides working with clinic doctors to identify Asian Americans or Pacific Islanders who might qualify, they also reach out to their community partners in Manhattan, Staten Island, Brooklyn, and Queens.
Because the Center has established a reputation over the past 40 years as a stellar health care resource, people have come to trust its direct patient care as well as the health educational events it sponsors, supports, and/ or staffs in the community. So when the clinic lends its clout to a drug trial, it means something, at least in terms of trusting the source.
Despite the center’s reputation, many of the patients who’ve participated in the hyperlipidemia, depression, and hepatitis B medication studies have been as apprehensive as other minorities about the research process. For instance, they want to know “What happens to my blood test results?” or “Is this drug going to work?” or, of even greater concern, “Are you going to take away my medication?” Fortunately, because the types of pharmaceutical trials undertaken by the Center have either compared drugs or tested the efficacy of combined therapies, nurses can assure patients of continued treatment. Nevertheless, calming fears, Susan Seto-Yee, R.N., M.P.A., the center’s Clinical Director, notes, “is definitely still a challenge.”
When Constance Dallas, Ph.D., R.N., an associate professor at the University of Illinois at Chicago College of Nursing, recruited subjects for a longitudinal study on paternal involvement of low income African American teen fathers, she identified her target area, a swath of communities from the southern suburbs of Chicago north to Rockford, Illinois. Then she blitzed ads on predominantly black radio stations because she knew, as part of the community, that her prospective participants might be listening. “My colleagues were astonished,” she says. “I had a wonderful response.”
Dallas wasn’t surprised that the number of respondents who ultimately fit the study was fairly low, but she was shocked with the number of others who called in just to share, knowing they didn’t meet the criteria. “They were so pleased that somebody was interested in their story.”
Transparency
Making sure people understand what’s expected of them in a clinical trial is essential. With potential misunderstandings and lingering mistrust from past research abuses, it’s imperative that you can translate a study, put it in context, and make sure that it’s a good patient fi t. You also need to be honest so that everyone’s expectations are realistic.
A major problem with Tuskegee was that participants had a general sense that doctors were tracking their “bad blood,” a local euphemism for any number of problems, but they hung in for decades without full disclosure. This was likely because a nurse from their own community, Eunice Rivers, kept them tethered, despite her own ignorance of the facts.
“Nurses really need to be careful not to fall into what I call ‘the Nurse Rivers trap,'” says Dallas. “It’s very important that they educate themselves about the research process and a particular study before they recommend or recruit someone into it.”
Nurses have had an introduction to research if they graduated with a university-based baccalaureate degree, but unless they’ve pursued a master’s or Ph.D., nurses are likely to not have been exposed to research in any significant way. In fact, one of the challenges facing nursing education today is increasing research experience at the undergraduate level while encouraging nurses of all ethnicities to raise their academic sights to the highest degree possible. Not only would an M.S.N. or Ph.D. give them a solid research footing, but also a seat as full-fl edged investigators at the study table.
Dallas’ study with the African American teen fathers, for instance, grew out of her experience as a family nurse practitioner working in a school-based clinic. As the principal investigator, she had input from beginning to end. “I think it’s wonderful to have people who are similar to the community involved in recruitment and data collection,” she says. “But if you leave out the interpretation and other decision-making steps, you’re leaving out the most important parts.”
In the meantime, there are other ways to boost your research acumen. Although many nursing organizations sponsor their own workshops and even institutes to bring members up to speed, another helpful resource is the Center for Information and Study on Clinical Research Participation (CISCRP), a Boston, Massachusetts, organization dedicated to educating both professionals and the public about clinical trials (www.ciscrp.org). CISCRP not only funds attitudinal studies, but it also offers many different tools to communities to dispel myths surrounding research.
Diverse health care needs
By engaging diverse peoples in clinical research, health professionals can speak with statistical confidence about a disease, diagnostic procedure, or treatment in a particular population. They also know that when they order a therapy, it’s dosed appropriately so they’re not doing any harm.
Not all research is going to lead to a cure or answer every question. But by recruiting individuals of different backgrounds, health care professionals not only have the possibility of understanding a disease, but also of creating more tailored treatments. By participating in that process, minority nurses can facilitate positive health changes—if not in this generation, then certainly in future ones. They also offer a safe, stable connection between investigators and patients.
“There isn’t anything more reassuring than having a nurse with familiarity look at you and say, ‘When they studied this drug, this is what they found worked and this is what they found didn’t work,'” Coleman says. “That kind of straightforward talk can have a huge impact on getting the public, particularly people of color, more involved in clinical trials. It’s putting our nurses out there.”
Though they may be half a world away, nursing schools in India face problems similar to those in the United States when it comes to recruiting men. The following study sought to discern the opinions of 78 senior nursing students studying in and around Pondicherry, India, regarding gender roles in their field. It aimed to determine the following:
Whether nursing students have different opinions of what professional roles male and female nurses should occupy.
Whether gender affects the image and status of the nursing profession.
The results of the survey indicated that most of the nursing students prefer men to occupy administrative or teaching positions. Additionally, there were statistically significant results between female and male students’ perceptions surrounding the effect of males on the image and status of nursing. These findings may impact local nursing education recruitment programs for both men and women, and perhaps the health service organization as a whole.
Men in nursing
Though they still represent a slim minority, men are increasingly pursuing careers in nursing, attracted by abundant job opportunities, good salaries, and the opportunity to make a difference in people’s lives. This is in no small part due to the fact that the nursing profession has worked for years to dispel misconceptions surrounding men in this female-dominated field.
What is interesting about today’s perceptions of gender in nursing is that until the days of Florence Nightingale in the late 19th century, nursing was a male-dominated profession.1 Nightingale considered nursing a suitable job for women because it was an extension of their domestic roles. Her image of the nurse as nurturing, domestic, humble, and self-sacrificing became prevalent. Qualities associated with women, like compassion and dependency, align with those often attributed to nurses.2 In modern times, the social construction of the role of a nurse has typically meant a caring, hardworking woman. Nursing, in the span of Nightingale’s lifetime, became identified as a profession deeply embedded in the female gender.3
On the other side of the gender divide, men who enter nursing may still face questions about their masculinity or sexuality. Sociologists describe sex role socialization as “instrumental” for men and “expressive” for women. The characteristics of instrumental socialization include aggression and the ability to compete, lead, and wield power to accomplish tasks. Expressive socialization includes learning to nurture and be sensitive to needs of others. Many female dominated positions, including nursing, have difficulty attracting male recruits. This can be attributed in part to issues such as status and pay, but also to the gender stereotyping of the profession. Although the number of males in nursing has increased in recent years, the underlying feminization of nursing is still an important issue.4 Persistent and outdated gender stereotypes are a big part of the problem.
Today, men still only make up between 5%–10% of the nursing workforce in the United States, United Kingdom, and Canada. Although it’s a small percentage, today’s statistics actually represent an over 20% increase in the number of male nurses in the past two decades.5 There are many supposed reasons for the lack of men in nursing. For example, if a man’s peers consider nursing emasculating, he has a disincentive for becoming a nurse.6 Another reason suggested is the lower economic status associated with the nursing field.3 However, the most commonly proposed reason is that men are less likely to enter jobs associated with women than women are to enter those positions traditionally held by men.
Despite the obvious disproportion of male nurses to all men, studies have also shown men are overrepresented in senior nursing posts.2 They achieve promotion more quickly than women at all levels of the nursing hierarchy above the entry-level positions. This could be attributed to the vast difference in the number of female nurses who work part time, compared to part-time male nurses. Some researchers suggest that managers perceive part-time female staff to be less attached to their careers.7 Studies have consistently reported that one of the major reasons for women’s slower progress in nursing is the number and length of career breaks taken, particularly to have children. One such study indicated that women were 10 times more likely than men to have taken a career break to care for children.8 Furthermore, male nurses may be thought to bring stability to the nursing profession, which had always been considered at the mercy of marriage and motherhood, reflecting hidden advantages for men and disadvantages for women.1
Study specifics
Participants were assured informed consent and confidentiality. All students received an explanation of the study before introduction of the questionnaire, and only those who agreed to participate continued. Students’ names were not sought in the questionnaires and their confidentiality was respected. Sixty-two percent of those surveyed were female and 38% were male.
The first part of the survey included socio-demographic data, while the second part asked students about their perception of males in nursing and the effects of recruiting males to the field. The third section asked students about their perception of gender stereotypes. Questions included:
How do you feel about men in nursing?
Do you think nursing is a woman’s job?
Do men and women differ in their professional role?
What do you think are the suitable work places and positions fit for male nurses?
What do you think of the effect of men on the image of nursing?
Male nurses as perceived by both genders
Most of the female students and nearly half of the male students chose emergency units as the most “suitable” area for male nurses. Nearly 42% of the female nurses preferred men to work as instructors in nursing schools after graduation. There were significant differences between both genders’ perceptions about the nursing positions men should occupy after graduation. While 48% of the female students considered men as staff nurses, most of the male students said they should occupy administrative (40%) or teaching posts (38%) after graduation.
Significant differences were also found between the female and male students’ perceptions regarding the effect of males on the image of nursing. When asked if men improve the image of nursing, 54% of the female respondents agreed, compared to 90% of the male respondents. Cultural values, a lack of understanding about what nurses really do at work, and the way nurses are portrayed in popular media highly affect the public image of nursing.
The results of the survey show that male students prefer administrative/instructional positions after graduation. In contrast, female students said they more often preferred men to assume staff nurse positions. While there are difficulties for men working in female-dominated professions, male nurses tend to have a faster and more straightforward career progression than their female counterparts. Male students exhibited gender role tension about nursing, as 43% considered nursing a “female” profession. (Some research reports numbers as high as 82% of male high school students would not choose nursing as a career, believing it should be a female-only profession.9, 10)
Conclusions and recommendations
The results of this study indicate that nursing continues to be seen as a female-dominated profession, especially by male students, despite the ever-increasing number of men in nursing. Stereotypical notions of gender roles possibly affect male students’ desire to occupy administrative positions after graduation, though further studies are needed.
Nursing as a profession can only benefit from a talent pool drawing a proportionate number of men. Nursing schools, health care organizations, and the media should continue to advocate for the profession, portraying positive images of the field and male nurses. A community education campaign to improve the image of nursing could also be initiated. To emphasize a nurse’s role identity without any gender segregations, school educators should encourage students to manage gender-related problems.
References
Mackintosh, C. (1997). “A Historical Study of Men in Nursing.” Journal of Advanced Nursing, 26, 232–236.
Evans, J. A. (1997). “Men in Nursing, Issues of Gender Segregation, and Hidden Advantage.” Journal of Advanced Nursing, 26, 226–231.
Meadus, R. J. (2000). “Men in Nursing: Barriers to Recruitment.” Nursing Forum, 35(3).
Davies, C. (1995). Gender and Professional Predicament in Nursing, Open University Press.
Trossman, S. (2003). “Caring Knows no Gender: Break the Stereotype and Boost the Number of Men in Nursing.” Nevada RNformation, 12, 19.
Poliafico, J. K. (1998). “Nursing’s Gender Gap.” RN, 61, 9–42.
Whittock, M., and Leonard, L. (2003). “Stepping Outside the Stereotype. A Pilot Study of the Motivations and Experiences of Males in the Nursing Profession.” Journal of Nursing Management, 11, 242–249.
Finlayson, L. R., and Nazroo, J. Y. (1997). “Gender Inequalities in Nursing Careers.” London: Policy Studies Institute.
Cakmakci, A. (2003). “Senior High School Students’ Perceptions About Nursing as Career.” Nursing Forum, 6(1), 33–42.
Andrews, K. E. (2005). “Perceptions of High School Boys Toward Nursing as a Career Choice.” Doctoral dissertation, University of Missouri. UIM number 3167305.
It’s no secret that health care professionals must identify, respect, and care about their patients’ differences, values, preferences, and expressed needs. Nurses, physicians, allied health professionals: all need to be attentive when interacting with patients, and be sensitive to and respectful of their perspectives regarding health and wellness. The health care reform law currently being debated in Congress shifts some of the attention from how doctors are paid and how medical care is organized to how medical decisions are made and how those decisions affect care receivers. Some patients’ backgrounds might be similar to those of the care provider and some may be different. It’s the differences that cry out for attention.
More significantly, the differences, particularly the rampant socioeconomic disparities observed among racial and ethnic groups in the United States, can influence whether patients can even access high quality health care—perhaps care of any kind. The need for understanding, and for cultural competency training becomes clear when you look at the high incidence of diabetes and prostate cancer among African Americans; the high number of stress-related disorders among South Asian men; and the fact that Latinos have the highest median cholesterol level of any other group. Each of these facts impact communities and compounds aspects of public health. They affect the quality and vitality of, as well as exacerbate, public health issues.
“Diversity is our strength,” rolls off the tongues of politicians, community activists, and academics; even consultants and the mass media spread the mantra. In health care, where patient-provider interactions, empirical and inferential research, and clinical procedures continue to illuminate the importance of diversity, these differences have, perhaps, the greatest impact. This can be clinically referred to as cultural health care competence—one aspect of the national health care sector that has taken on enormous significance as a public health concern.
CULTURAL COMPETENCY: Test Your Work Environment Have you ever examined your workplace’s cultural competency— or your own? There are plenty of diversity and cultural competency assessments available online, or you can start with the questions below. Does your workplace… – Involve everyone on staff in developing more culturally competent practices? – Promote diverse hiring practices and leadership? – Use media, such as informational/educational films, that reflect diverse peoples? – Disseminate printed materials that take into account the average literacy levels of those the facility serves? – Feature posters, artwork, and other promotional materials representing diverse peoples? – Stock magazines and other reading materials in reception areas related to diverse peoples, including non-English publications? – Serve foods, including those used in research or clinical trials, that take into consideration the dietary restrictions and/ or preferences of diverse peoples? – Provide toys and playthings in reception areas and/or during research or clinical trials that reflect different cultures and feature diverse peoples?
It is estimated that in another 15 years, our country’s demographic landscape will reflect a minority representation of roughly 40% of the U.S. population; already African Americans represent 13% and Hispanic Americans represent 16%. The National Institutes of Health are focused on how these statistics have galvanized the health care sector and are attempting to close the gap between the health status and health care of minorities versus the rest of the population.
Tackling this issue is not exactly new. What’s missing is firm commitment. In 1999, physician Lisa Cooper-Patrick researched to understand the extent to which racial and ethnic disparities, in health status and use of health services, were related to the nuances within the physician-patient interaction. She examined how physicians’ participatory decision-making style impacted the quality of care. Her findings provided evidence that physician bias was a significant contributor to the disparities in providing quality care to certain minorities and ethnic groups.
Other research has shown a discrepancy in patients’ access to organ transplants. When changes to Medicare passed, also in 1999, African Americans and Hispanics were 28% and 31% less likely, respectively, to be recommended for kidney/pancreas transplants. These disparities are likely tied to the inordinately high numbers of diabetics in both African American and Hispanic communities.
Cooper-Patrick’s research uncovered that African American patients described less participatory visits with their physician compared to Caucasian patients’ visits. When the patient and the physician shared race or ethnicity, patients reported a more participatory experience. She concludes, in part, that physician factors such as “unintentional” (my emphasis) racial biases contributed qualitatively to the patient’s experience and implicated the clinical outcomes. These results demonstrate how disparity affects patient care. Cooper-Patrick also studied a lack of physician capability regarding how to negotiate treatment and engage the patient across cultures.
When Kerry Watson, Chief Executive of Durham Regional Hospital in North Carolina, assumed leadership of the facility a few years ago, he addressed this issue after securing the support of the senior leadership of the Duke System. Watson then issued a directive that “every employee—every manager, every physician, every nurse, all 1,200 employees—would receive eight hours of cultural competency training, and this training was and remains the business case central to erasing the facility’s reputation as providing substandard care.”
Its impact was transformational. Employee morale and performance, community support, and the hospital’s financial performance improved significantly. “It’s about providing exceptional customer-patient service,” he added. Watson tackled a tradition of care once tainted by bias. The transformation, as reflected in evolving patient satisfaction data, continues to validate the ongoing need for cultural health care competency training, essential to the hospital’s integrated-care programs.
In short, diverse patient needs and race-related health disparities necessitate cultural competency training. If the treating physician is incapable of or lacking in cultural competence to engage these patients so that they may fully participate in their own wellness, the consequences are not only issues of disparity, but threats to the larger community as a public health issue.
In 1909, Lillian Wald, founder of the Visiting Nurse Service of New York (VNSNY) and the “mother of public health nursing,” hosted the NAACP’s inaugural meeting at her agency’s early headquarters, at a time when integrated meetings were forbidden by local ordinance. Last year, the NAACP remembered Wald’s courage and work during its centennial anniversary celebration in New York City. On their website, they refer to Wald as one of the organization’s “first and oldest friends.”
Wald truly set a tone for the agency she established. From its founding in the late 19th century, the VNSNY has served a broad range of diverse communities, played pioneering roles in the civil and women’s rights movements, and blazed a trail for diversity in the workforce.
In the late 1800s, Manhattan’s Lower East Side neighborhood was deemed the world’s most densely populated slum. At that time, Wald was a young graduate of New York Hospital’s nursing program, studying medicine and teaching immigrant women about home health and hygiene. Galvanized by the public health needs she saw among immigrant communities in the area, she and a fellow volunteer launched VNSNY in 1893. Wald and her colleague became the first public health nurses in the country.
Wald championed women’s rights by hiring and promoting women. In fact, the National Women’s History Project included her among its 2009 honorees. She played a prominent role in the women’s suffrage movement and is enshrined with Susan B. Anthony, Elizabeth Cady Stanton, and others in the National Women’s Hall of Fame. From Wald’s 1933 retirement to present day, women have led the VNSNY, culminating in 1989 with the arrival of current President and CEO, Carol Raphael. Ten years ago, the VNSNY staff was composed of over 90% women. Today, that figure stands at about 80%. Because of the agency’s highly diverse clientele, VNSNY has been at the forefront of promoting cultural awareness, developing and retaining a diverse workforce, and creating an inclusive environment—all elements that are crucial to effective service delivery. According to U.S. Census data, nearly 37% of New York City’s population is foreign-born, and 48% of the city’s residents speak a language other than English at home. More than a quarter of VNSNY patients are non- English speaking, and its staff members speak more than 50 languages.
Following their founder’s example, the agency has a proud legacy in the hiring of minorities. In the 1920s, when mortality rates in the black community were 200% higher than elsewhere in New York City, African Americans comprised 15% of VNSNY’s patients. Wald and other agency leaders responded by increasing its African American nursing staff from one supervisor and four nurses to two supervisors and 18 nurses, a number commensurate with their patient load. In her 1933 book Windows on Henry Street, Wald noted that VNSNY was the first organization to hire black nurses on equal terms. Today, roughly a quarter of its patients and more than half of its employees are descendants of the African diaspora, including African Americans, Afro-Caribbeans, and colleagues from Nigeria, Sierra Leone, Togo, and other African nations. VNSNY has also been caring for Asian and Hispanic immigrant patients and hiring staff of the same descents.
For most of its history, VNSNY also has been caring for patients in a number of other ethnic communities, while employing clinicians who share their cultures and heritages. In recent years, VNSNY developed multicultural home care programs dedicated to serving New York’s Hispanic, Asian, and Russian communities. Patients often feel more comfortable and, in some cases, recover more quickly, when they receive care from nurses and other caregivers who speak their language and have in-depth knowledge of their culture.
Currently, VNSNY employs the largest pools of Asian and Hispanic caregivers in the New York area, offering home health care teams trained in providing culturally sensitive care to patients in their native languages, incorporating their customs and values. Staff tailor comprehensive home health care and community-based services to the more than two million Spanish-speaking residents of New York City, who trace their heritage to 35 nations worldwide. Patients from these communities make up approximately 20% of active cases, a fi gure that mirrors the 20% of VNSNY colleagues who self-identify as Hispanic/ Latino.
Features offered include a Spanish-language telephone hotline for referral and information; nutritional diet plans specifically designed for Hispanics; patient forms and educational materials in Spanish; partnership programs with key Hispanic community organizations and referrals to community resources; and a close alliance with Hispanic community agencies, doctors, hospitals, and managed-care organizations. In late 2008, VNSNY was honored with a special institutional award from the New York chapter of the National Association of Hispanic Nurses for extraordinary outreach in that community.
The composition of VNSNY’s workforce and patient populations also reflect a spike in Asian immigration to New York City over the past decade. The staff now includes more than 700 colleagues of Asian descent, including Chinese, Filipino, Indian, Korean, Pakistani, and other nationalities. These colleagues speak several dialects of Chinese, Tagalog (Philippines), Korean, Hindi, and other Asian languages. They provide home health care familiar with the cultures, values, and customs of many different Asian groups. VNSNY also administers the Chinatown Community Center, which has served more than 65,000 community residents since it opened in 1999. The facility administered hundreds of free fl u shots last year, and it regularly provides free cholesterol, diabetes, and blood pressure screenings; health classes; community outreach; and other services to residents, particularly seniors, of New York’s Chinatown. VNSNY also runs the Chinatown Neighborhood Naturally Occurring Retirement Community (NNORC) program, launched in 2006. In addition to the public health services offered at its Chinatown Community Center, the Chinatown NNORC nurses and social workers visit homebound seniors to assess their individual needs and provide culturally sensitive care.
To serve the more than one million émigrés from the former Soviet Union now residing in the New York area, VNSNY has hired more than 200 colleagues who immigrated from Russia and former Soviet republics, including Ukraine, Azerbaijan, and more. The agency also employs escort translators who speak other languages, ranging from Korean and Japanese to Haitian Creole. In addition to the VNSNY Multicultural Home Care Programs, the agency makes a number of smaller, less formal arrangements to coordinate caregivers and patients in New York’s many other diverse communities. VNSNY also regularly sponsors events tailored to recruit nurses and other staff members from various multicultural NYC communities.
In 2009, CATALYST, a global organization dedicated to promoting diversity in the workplace, added VNSNY to its roster of “case studies”—models of inclusive practices in the workplace.
Comfortable with their knowledge of other cultures, VNSNY staff often act as the organization’s ambassadors to various New York communities and teach coworkers about their cultural heritages. VNSNY has carried its 117-year-old inclusive, multicultural approach well into the 21st century, a philosophy suited to a highly diverse workforce and its patients.
Together, the New York City metropolitan area’s Chinatowns constitute the heaviest concentration of Chinese outside Asia. The oldest and largest is the 24-block Chinatown neighborhood in Manhattan, where registered nurses and other clinicians from the Visiting Nurse Service of New York’s Asian Hospice team care for patients and their families.
Comprised of interdisciplinary nursing professionals, the group reaches out to neighborhood physicians and the community. With a combination of specialized skills, extensive experience, and cultural familiarity, the team brings a unique blend of strengths to their Chinatown practice. Their fluency in Mandarin, Cantonese, and other dialects builds rapport and reduces cultural barriers to quality care. Just as essential is the team’s cultural sensitivity, particularly toward end-of-life issues.
Reaching the community
In Chinese culture, discussion of dying is taboo. The color white and the number four are associated with death and considered inauspicious. Death is viewed as a harbinger of more bad luck for the families of the deceased, so elderly Chinese sometimes try to avoid dying at home. To deal with the matter in a culturally appropriate way, the Asian hospice team collaborates with VNSNY’s broader Asian Program, the Chinatown Community Center, and the Neighborhood Naturally Occurring Retirement Community (NNORC) to reach community leaders and organizations like the Chinese Consolidated Benevolent Association. Team members also grant interviews about hospice issues to Chinese radio, TV, and newspapers, in an effort to make the subject more accessible.
“Patients and families feel comfortable talking to me not only about physical but also spiritual problems,” says Hsiao Hui-Chen, R.N., a Taiwan-born coordinator of care who brings culturally relevant experience from her work in oncology and the fi rst-ever hospital hospice unit in Taiwan.
Another member of the team, Heidi Chan, R.N., draws on her Chinese roots when administering care. She is a Chinese-American after-hours RN with 20 years of hospice experience, and she conducts in-service seminars at a major city hospital and elsewhere regarding culturally informed home care for Chinatown’s end-of-life patients and families. Her Buddhist faith enhances her ability to comfort patients and families.
But not all of the team’s members are fl uent in Chinese dialects. Charles G. Meys, R.N., a highly experienced hospice nurse, has cared for patients in Chinatown for five years, with support from his escort/translator, Fong Fai Chow. “My escort not only translates but also interprets everything from moods and circumstances to clinical, emotional, and fi nancial concerns,” he says. “Mr. Fong builds a bridge to our Asian patients.”
Nurses collaborate with the team physician, Dr. Leonard Bakalchuk, a former Hong Kong resident who speaks both Cantonese and Mandarin, a rarity in a Caucasian American. He coordinates with VNSNY’s Asian Program in meetings with the New York Department of Health, doctors practicing in Chinatown (particularly oncologists and cardiologists), and the Chinese American Independent Practice Association to build awareness of hospice care in the neighborhood.
From a psychological perspective, Pamela Yew Schwartz, Ph.D., a Chinese-American bereavement counselor, gives follow-up care to surviving relatives. Last April, Dr. Yew Schwartz and other team members organized the region’s fi rst presentation on improving end-of-life treatment for Chinese Americans, co-sponsored by a major hospital. Serving as a panelist at that presentation was an additional team member: Kei Okada, a spiritual care counselor who relies on his upbringing in Japan to offer culturally sensitive support. Gui Loo, L.C.S.W., a Chinese- American social worker, rounds out the team, led by nurse Alice Palatnick, R.N., B.S.N., M.S.W., also a social worker.
The team’s current initiatives include translating hospice brochures, consent forms, and Advance Directive forms and cooperating with the Asian Program and Chinatown MDs to give community presentations on Advance Directives. Last summer, they joined with VNSNY’s Chinatown NNORC to organize an Advance Directive Task Force. They held their first workshop on health care proxies (HCP) earlier this year at Confucius Plaza in the heart of Chinatown, attended by several city agencies and 150 residents. To expand on their community outreach, the team also provides cultural sensitivity hospice training at a nursing home on Manhattan’s Lower East Side, in-service presentations at a major hospital and settlement house, and ongoing work with community organizations and senior centers to promote hospice care in Chinatown.
Other examples of culturally competent care include supporting the patients’ surviving relatives in their practice of traditional rituals (such as displaying photographs of the deceased). Dr. Yew Schwartz notes that sometimes her work involves counseling family members on their experiences and “encounters with ghosts” in the wake of bereavement.
Perhaps the most meaningful facet of their work is the connections the team RNs and other clinicians have made with patients and their families. One patient’s daughter, an oncology nurse in Hawaii, kept in touch with Hsiao Hui-Chen by phone, enabling her to travel home when the end was near. The wife of another of Hui-Chen’s patients went from resisting hospice care to appreciating having her spouse pass away peacefully at home.
History of service
VNSNY’s outreach and service in Chinatown stretches back to the agency’s founding in 1893, when they began caring for poor immigrants on the adjacent Lower East Side. In 1910, founder Lillian Wald went to Asia and chose the Chinese character “bao” (meaning “We are all one family.”) as an agency symbol still in use today. VNSNY has photos and footage from the 1920s when a Chinese RN named Zing Ling Tai made her rounds in Chinatown. Ten years ago, Liu Fang Mien, R.N. (now retired), launched VNSNY’s Community Center. After 9/11, the center helped residents cope with the terror attack and has since provided thousands of free flu shots; cholesterol, diabetes, and blood pressure screenings; health classes; and other services.
RNs on the Asian hospice team join fellow clinicians in bringing awareness of the benefits of end-of-life care to Chinatown. Thousands of residents have been exposed to information on Advance Directives and end-of-life issues through the NNORC and Community Center efforts, in addition to ongoing outreach in hospitals and nursing homes. Dr. Bakalchuk reaches out to local doctors as well as the New York State Department of Health. Other team members partner with neighborhood pharmacies and local, state, and national organizations like the Charles B. Wang Community Health Center, the American Cancer Society Eastern Initiatives, and the Taiwan-based international Buddhist nonprofi t Tzu Chi Association. Through VNSNY’s Asian Program, the team also reaches out to Asian nurses and patients in New York City’s other Chinatowns in Queens and Brooklyn and beyond.
The nurses and their teammates measure outcomes one patient at a time, while continuing their progress in bringing hospice care to Chinatown.
