Racially and ethnically diverse populations have grown in the US. The US Census Bureau finds that approximately 37% of the population is made up of minority groups. Nurses currently make up the largest group of health care professionals in the US, and the need for culturally diverse nurses in the workplace has been identified by many nursing leaders. The demand for culturally competent care has brought attention to the need for culturally diverse nurses. Several studies have identified that failure to provide culturally competent care can influence health outcomes. A 2009 study published in Health Affairs found that increasing minority representation in the health care workforce could have a positive effect on curbing the health care disparities found in minority populations.
The need for culturally competent health care highlights the need for a diverse nursing workforce, particularly since patients tend to migrate towards providers that share their ethnic background. Minority nurses and possibly advanced practice nurses are in a position to help these often underserved minority communities receive care that will increase their likelihood of compliance with medical treatment and increased health literacy.
Additionally, implementation of the Affordable Care Act will allow for the expansion of health insurance to historically underserved populations. This expansion will require an increase in the number of health care professionals available to care for these populations.
Of the almost 3 million registered nurses in the US, approximately 133,000 are black and 55,000 are Hispanic. A 2013 study published in Journal of Transcultural Nursing reveals that minority students account for about 27% of the students in undergraduate schools of nursing. The low number of minority students represented in the undergraduate nursing school enrollment numbers highlights the difficulty noted by graduate schools when it comes to attracting and enrolling minority registered nurses.
Federal initiatives like the Promoting Postbaccalaureate Opportunities for Hispanic Americans program authorized under Title V of the Higher Education Act of 1965 are designed to expand postbaccalaureate opportunities and academic offerings for universities that are educating the majority of postsecondary Hispanic students. According to a 2010 brief published by Excelencia in Education, there were 176 emerging Hispanic-Serving Institutions (HSIs) in 2007. Federal law requires that in order to receive a designation as a HSI, an institution must have at least 25% Hispanic undergraduate enrollment. Emerging HSIs are those with Hispanic enrollment within the range of 12% to 24% and have the potential to become HSIs over the next few years. The HSI designation allows an institution to qualify for grants and other modes of funding. A 2010 study published in Journal of Latinos and Education found that, behind funding, the most important issue facing the presidents of HSIs was the lack of academic preparedness of the students.
Challenges are faced by Hispanic nurses desiring to pursue advanced nursing degrees. Like undergraduate enrollment, the number of registered nurses with baccalaureate degrees applying for advanced practice nursing tracts is low. There are four HSI institutions that offer nurse anesthesia in these fine programs: University of Miami, Kaiser Permanente / California State University, Inter-American University of Puerto Rico, and the University of Puerto Rico. A relatively large Hispanic applicant cohort of prospective students submit to these diverse nurse anesthesia programs along with other urban located institutions within the US. A barrier that some underrepresented students encounter is the lack of academic preparedness and/or lackluster graduate exam scores. This lack of academic preparedness equals fewer applicants who are adequately prepared for undergraduate and graduate education. In the event that a student is successful in an undergraduate program, lack of preparedness could lead to the preparation of a graduate application packet that is not representative of the candidate’s true potential.
Optimization of the nurse anesthesia program application packet can mean the difference between acceptance and rejection. The graduate application for nurse anesthesia school normally contains many components. The application is the first glimpse of the candidate presented to the admission committee. One crucial component of the process is the essay. The essay should contain information that the candidate wants to express describing his or her participation in leadership and extracurricular activities. Admission committee members take note of well-rounded candidates. Candidates should include evidence of involvement in professional nursing organizations and hospital committees. These types of activities highlight the candidate’s desire for professional development. The essay should be edited for grammar, spelling, and content before the packet is submitted to ensure that the candidate appreciates attention to detail.
The construction of a comprehensive application will most likely yield an interview, but the interview process can be intimidating. Most admission committees attempt to evaluate the student’s preparedness for the rigors of the program. The types of questions revolve around principles of physiology, pathophysiology, and pharmacology. Candidates who recognize their deficiency in interviewing should seek out opportunities to practice these techniques. Career centers may offer opportunities to hone interviewing skills.
Prospective students tend to focus on securing a seat in a nurse anesthesia program, but it is unclear how many actually consider the rigorous nature of the program. The amount of preparation that goes into the admission to a nurse anesthesia program is only minimized by the challenges of the didactic and clinical experiences for a new student. These challenges should be considered in conjunction with other stressors that can include financial obligations, reduction of income, and family responsibilities.
How to Strengthen your Application and Secure an Interview
According to the American Association of Nurse Anesthetists (AANA)’s 2012 demographics of nurse anesthetists in the United States and Puerto Rico, as an aggregate number, there is less than 10% of underrepresented minority nurse anesthetists from the 44,000 advanced practice nurses practicing in hospitals, surgery and endoscopy centers, and dental and pain management offices. Less than 3%, 3.2%, and 0.5% are from Hispanic, African American, and American Indian groups, respectively. To learn more about becoming a certified registered nurse anesthetist (CRNA), visit www.aana.com/ceandeducation/becomeacrna. Here, students will find information about the requirements of becoming a CRNA as well as a list of accredited nurse anesthesia programs, frequently asked questions, and a list of related published articles. It is imperative that prospective applicants into a nurse anesthesia program peruse not only the nurse anesthesia program of interest website, but also our national nurse anesthesia association website.
It is vitally important that underrepresented minority nurses learn more about the history of nurse anesthesia and national implications of advocacy. The book Watchful Care by Marianne Bankert is a great resource. It will expand your knowledge about nurse anesthetists and prepare you adequately for the interview, if the admission committee members ask any questions about this well-read topic. The top candidates definitely shine during the interview if they have read this material.
Another way to strengthen your application is to include your shadowing experience with a CRNA in the operating room. You should contact the CRNA and ask to meet him or her in the operating room on an agreed time. Be prepared to witness the CRNA prepare the room by checking the anesthesia machine and related equipment as well as prepare medications for the planned anesthetic prior to a patient’s arrival in the operating room. In addition, you will witness the CRNA interview the patient extensively about his or her medical and surgical history, review and secure the anesthesia consent, and perform an oral exam to assess a Mallampati score (I – IV) to anticipate an easy or difficult intubation prior to entering the operating room. During the shadowing experience, ask plenty of questions about what type of anesthetic is being administered (such as general, regional, or sedation), fluid management, positioning considerations, and more.
Along with learning the history of nurse anesthesia, as a critical care nurse with a baccalaureate degree, you should study and schedule the critical care registered nurse (CCRN) exam offered by the American Academy of Critical Care Nurses (AACN). Information regarding this exam can be found on the AACN website (www.aacn.org). This test demonstrates aptitude in critical care nursing and professional commitment towards excellence. A significant number of nurse anesthesia programs require applicants to earn critical care experience and sit for and pass the CCRN exam prior to actual submission of the essay for a nurse anesthesia program.
Another viable option for underrepresented minority nurses to improve the application process, handle the stressful interview, comply with the rigor of a nurse anesthesia program, excel for clinical preparedness, and learn about doctoral programs in nurse anesthesia programs is to register and attend Diversity CRNA Information Sessions & Airway Simulation Labs scheduled in 2014. This event, sponsored by the Diversity in Nurse Anesthesia Program (www.diversitycrna.org), offers an opportunity to those interested in nurse anesthesia education to fully engage oneself and learn comprehensive information about the process, network, and participate in a hands-on simulation experience in the lab. You will also have the opportunity and access to meet four nurse anesthesia program directors, AANA senior leadership, minority CRNAs, and nurse anesthesia students from across the country. As a result, you will have the ability to include details about your experience in your eventual essay and articulate it during your interview.
An additional application requirement of some anesthesia programs is the Graduate Record Examination (GRE). It is incumbent of any prospective applicant to visit the GRE website (http://www.ets.org/gre) to learn about the comprehensive information about the scores and the actual make-up of the exam (verbal reasoning, quantitative reasoning, and analytical writing).
So, now it is up to you. Will you peruse through the suggested websites to broaden your knowledge base about proper preparation for entry into nurse anesthesia? Do you want to be a competitive applicant for a nurse anesthesia program? Do you want to be academically and clinically prepared for such a program? If you answered yes to these questions, be proactive in your educational goals to advance your professional development in a nurse anesthesia program. You can do it!
Wallena Gould, CRNA, EdD, is the founder and chair of the Diversity in Nurse Anesthesia Mentorship Program (www.diversitycrna.org) and chief nurse anesthetist at Mainline Endoscopy Centers.
Martina Steed is a CRNA and Associate professor and Assistant director in the Department of Nurse Anesthesia at Webster University in St Louis, Missouri. She is also a small business owner and PhD candidate in the College of Health Sciences at Walden University.
About 30% of Hispanic Americans and 20% of African Americans don’t have a usual source of health care, but less than 16% of white Americans lack a source.
For women who have had an abnormal screening mammogram, the length of time before a follow-up test is conducted is twice as long in Asian American, Hispanic, and black women than it is in white women.
It’s no secret that there are racial and ethnic disparities in health care. These statistics, which come from the Agency for Healthcare Research and Quality’s Medical Expenditure Panel Survey, highlight a major concern in the field of medicine. Not all patients receive the same level of high quality treatment—or in some cases, receive treatment at all.
This concern is important within nursing schools, because they are tasked with making sure our country’s future nurses fully understand racial disparities and what can be done to address them, says Mary Green, PhD, MN, RN, interim chair of the Dillard University School of Nursing in New Orleans.
Schools must show the latest research and best practices to the next generation of nurses, and take them into communities so they can see firsthand the effects of health inequality, argues Green. “Nurses need to get the broadest experiences they can.”
Learning in the Community
Many nursing schools have mandatory community health courses that expose students to inequalities among groups of people. Nursing students learn about the statistical differences in health care outcomes, and along with that, many of these institutions require nursing students to meet the people behind the statistics.
For example, at the University of Alabama-Birmingham (UAB) School of Nursing, undergraduate students, along with faculty, go into communities in the greater Birmingham area that have historically had less access to health care, says Linda Moneyham, PhD, RN, FAAN, senior associate dean for academic affairs at UAB. There, nursing students learn how to master their clinical work while partnering with neighbor representatives who are interested in improving the community’s health, she adds.
“These tend to be communities that are lower income, have high minority populations, and have a lot of health needs,” she says. “In fact, Alabama is often the epicenter for some of the major health problems the country faces.”
Moneyham explains that Alabama ranks near the top for prevalence of heart disease, obesity, and HIV—and minorities are disproportionately affected. “We have to focus on these populations because they are the populations nursing students are going to be caring for,” says Moneyham.
At the University of Washington School of Nursing in Seattle, there is a similar approach. “We have for years had a required course on community health nursing that addresses health disparities and inequities,” says C. June Strickland, PhD, RN, associate professor, psychosocial and community health nursing, at the school. “It’s [often] the very first course that students take when they come into our program to study,” she says. “Essentially, it focuses on health disparities, equities, and social justice.”
“In addition, we have clinical sites in multicultural environments that include American Indian, African American, Latino, and Asian populations,” explains Strickland.
“When faculty members take students to those clinical sites, they get a cultural immersion and opportunity to understand some of the issues people are facing. For instance, with Native people, some of what we experience is the impact of colonialization that continues on in our community.”
The School of Nursing also attracts other students that plan to work in related fields, such as social work, public health, and psychology, says Strickland. “I teach a core course in assessment and that course also draws students from all over campus, because certainly these issues come up [in those disciplines].”
There are also graduate level courses that dig deeper into problems associated with inequalities. Deborah Ward, PhD, RN, FAAN, is associate dean for academics at the Betty Irene School of Nursing at the University of California-Davis in Sacramento. “We have a course in health status that all of our masters and PhD students take. That course looks at health status around the world, and it certainly looks at disparities in the US,” says Ward.
“We also have another course called Community Connection. Our masters students in the leadership program take this course where pairs of students work with community agencies,” she continues. Examples of these agencies include the Sacramento Unified School District and the local food bank’s parent-child program to provide support for parents with a variety of special needs. “Students come face to face with the issues that community agencies are working on, which includes the health effects of disparities of all kinds,” says Ward.
For example, one pair of students working with the county health department looked at soft drink vending machines in certain schools. School districts that are strapped for funds—and often in minority neighborhoods—can get money by having vending machines for soft drinks in their schools, Ward explains. “But on the other hand, if you have vending machines in schools that deliver sugary drinks, you’re contributing to the obesity epidemic that places students at all kinds of risk.”
Students who are obese are at great risk for many health problems, such as diabetes, says Ward. So the nursing students learned how school pupils in minority neighborhoods are exposed to factors that contribute to the obesity epidemic.
In this particular course, nursing students wanted to address the question of whether or not it was good for a cash-strapped school system to get immediate money from vending machines, or if it was better to ban the vending machines and have students ingest fewer sugary drinks.
“The students did a sophisticated analysis of the cost and benefits to the community in having soda machines in the school,” says Ward. “Armed with that kind of data, you can come back to your community as a nurse leader and demonstrate the long-term advantages of not having soda machines in a school.” The students learned how to work at system-level changes that are going to help communities make decisions about important health issues in their community, Ward adds.
Filling in Gaps
With upcoming changes in health care laws, there are going to be thousands of people from different communities who are going to be seeking health care services they might not have sought in the past, says Moneyham. In many areas, especially rural areas, nurse practitioners will be called on to help fill in the gap between patients requiring care and available physicians, Moneyham explains. Nursing schools are teaching their students that this is something that can directly help reduce the inequalities that have historically existed in those communities, she adds.
In addition, nursing students will be called on to share information about programs that help disadvantaged patients. For example, there are pharmaceutical companies that may supply medication for patients for minimal charge, particularly if the shelf life of the medicine is short. “Sometimes they’ll distribute those to poorer patients,” says Moneyham, and a nurse can be the link between that patient and the pharmaceutical company.
In order to give quality care to people who are from different cultures and ethnicities, all nurses, including minority nurses, need to learn to overcome misconceptions and even prejudices they may have about the patients they serve, says Moneyham. “For example, one stereotype is that if someone is overweight or they have health problems, they don’t care about themselves, and you can’t help those people because if they wanted to lose weight they could.”
But the nursing school helps students understand that there are often external affairs that affect a person’s health, and health professionals should understand what those factors are in order to effectively help a patient, she says. “We provide the experiences to nursing students to help them walk in the [patient’s] shoes, and try to understand their perspective about their weight problem and their challenges.”
The methods used when approaching people should be appropriate and respectful. If nurses don’t understand someone’s situation, any recommendation will likely not be effective, says Moneyham. She conducts focus groups with women who may be classified as obese, and she finds that many may not see themselves as overweight. Students learn that in these cases, giving lectures on losing weight likely won’t work. “What we need to focus on are things that help these women feel healthier, such as getting enough exercise or watching the types of food they eat,” she argues. “We have to work where the person is ready to work.”
Even then, minority nursing students should learn that individual actions are only a small piece of what impacts health, argues Vicki Hines-Martin, PhD, CNS, RN, FAAN, director of the office of health disparities and community engagement at the University of Louisville School of Nursing. In fact, students are often surprised to learn that social factors outside of a person’s control have a very large influence on their health. These “social determinants of health,” as outlined by the World Health Organization, identify that a person’s health status, access to care, and health outcomes are all influenced by things that are not specifically health-related, says Hines-Martin. Those determinants include economic status, education, and even access to transportation. “If you have people who have lower income, less education, and who live in communities that are less friendly to activity [and exercise], their health by definition is going to be less,” explains Hines-Martin.
“Increasingly, students at both the undergraduate and graduate levels are expected to think critically about the context from which a person comes. And as a result of that, faculty are changing where they do their work clinically, how they do their classroom teaching, and the examples they use to help a nursing student make better decisions about the populations they work with,” says Hines-Martin.
“Not only do we need to teach our nurses what they should be doing directly with the patient, we also need to put them into the context of where that patient comes from. Then we realistically adjust, adapt, or support that person’s ability to maintain whatever wellness they can,” she continues.
At Dillard, nursing students learn to address disparities and overcome their own prejudices by looking at case studies, says Green. She gives the following example of a case study:
Let’s say we have JM, who is a 47-year-old African American male who is currently homeless, jobless, and suffers from schizophrenia, uncontrolled diabetes, and hypertension. Because of the behavior attributed to his mental illness, he may be in and out of jail and perceived as a threat to the community. As nurses, what do we do?
Green explains that nursing students learn how to deal with urgent problems, such as the uncontrolled diabetes, as well as seek out other resources, such as helping to locate a case manager who could help JM access mental services that may be available.
These case studies are then followed up by actually visiting similar neighborhoods. “Going into the community gives a more accurate picture of the racial and ethnic disparities that exist,” says Green.
Understanding disparities can occur with one-on-one teaching, but diversity initiatives should also occur on an administrative, school-wide level, says Strickland. This means having a nursing school that reflects and celebrates racial and ethnic diversity in addition to teaching it. “It’s important to have systems and structures in place that support these behaviors.”
Strickland states that the University of Washington has a diversity council and an office of minority affairs that’s very active. “There is also a diversity council within our School of Nursing, and some of the activities have included working with faculty to design an evaluation so faculty can evaluate how effectively they’re addressing disparities and diversity in their course content,” she says. Strickland adds that the school recently voted to include diversity in their promotion and tenure documentation for faculty.
At UC-Davis, Ward says the first area where the school practices the goal of cultural inclusiveness is with its faculty and staff. “We like to think of what we’re doing as a multi-faceted approach,” she says. “This means cultural inclusiveness, teaching cultural approaches to care, and working with all of our communities to improve care and health.”
At the UAB School of Nursing, Moneyham says that more than 26% of students are minorities. “This is high compared to the national average,” she explains. “A lot of that has to do with where we sit in the Deep South region of the United States.” Moneyham adds that cultural diversity in nursing schools is good because nurses are able to accurately reflect the communities they serve.
When nursing schools cover minority populations and health care inequality effectively, they produce nurses who are more competent at addressing those inequalities. This in turn produces better nurses who are more likely to take a leadership role in helping eliminate disparities, says Hines-Martin. “It is a strategy of engaged scholarship, engaged teaching, and engaged research that has evolved.”
Margarette Burnette is a freelance writer based in Georgia.
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