America’s Growing Waistline: The Challenge of Obesity

The United States is in the midst of an epidemic. Obesity rates across the country are staggering, having increased dramatically over the last 25 years. Research suggests that more than one third of adults, or over 72 million people, were obese in 2005–2006.1

Though there was no significant change in obesity numbers between 2003–2004 and 2005–2006 for men or women, this does not negate the need to direct attention and intervention efforts into mitigating the effects of obesity and addressing the underlying reasons for its high prevalence.2 And while this problem runs rampant among adults, it has been steadily encroaching upon children and is particularly disproportionate among minorities.

Defining obesity: a refresher

According to the Centers for Disease Control and Prevention (CDC), the body mass index (BMI), which correlates with body fat, determines overweight and obesity ranges using weight and height. An adult with a BMI of 25–29 is considered overweight; a BMI of 30 or higher is considered obese.3 BMI is calculated by weight in kilograms and height in meters squared (kg/m2); for English measurements, use lb/in2 x 703. BMI charts are also widely available on the Web, including at the CDC website (

Obesity has been linked to a number of chronic health conditions, including diabetes, cardiovascular disease, and some forms of cancer, as well as increased health care expenditures—it simply costs more to be obese.4 In particular, an obese person spends $1,429 more in medical bills compared to a person of a healthy weight. The annual obesity expenditure in the United States is an estimated $147 billion dollars.5

While the pervasiveness of obesity is troubling in and of itself, some of the more shocking statistics are found amongst minority populations. A 2009 CDC Morbidity & Mortality Weekly Report revealed that from 2006–2008 African Americans had 51% higher prevalence of obesity compared to Caucasians, with Hispanics having a 21% higher prevalence.6 African American and Hispanic women seem to be particularly vulnerable and representative among these numbers. Recent data show racial and ethnic obesity disparities for women, but not for men. Non-Hispanic black and Mexican American women were more likely to be obese than non-Hispanic white women. For men in general, obesity prevalence rose from 27.5% in 1999–2000 to 32.2% in 2007–2008.2

The disproportionate instances of obesity within minority populations may have roots in a number of factors. However, none can be addressed without examining the effects of U.S. health disparities, as well as the impact of social determinants of health. Two overarching national public health goals in the United States are to increase healthy life expectancy at all ages and to eliminate health inequalities according to gender, race or ethnicity, education or income, disability status, geographic location, and sexual orientation.7 But persistent health disparities—inequalities in health outcomes because of social disadvantages—have been an ongoing challenge within minority communities, hindering those national goals.4 According to Carter-Pokras & Baquet (2002), any health disparity should be viewed as a chain of events signified by a difference in environment; access to, utilization of, and quality of care; health status; or a particular health outcome that deserves scrutiny.8 Education and income levels contribute to disparities, but living conditions and behavioral risk factors also impact health.

These disparities become more notable considerations as the minority population increases. A U.S. Census Bureau population profile of 2010 indicates that over the past decade America’s population has grown by 9.7%, accounting minorities for 92% of that growth. The number of Hispanics grew approximately 43%, with the Asian population at the same rate, and the African American population increased in number by 11%. The total minority population increased 29% over the past decade, and now comprises approximately one-third of the American population.9,10

Evidence also suggests a relationship between socioeconomic status, income, education, and higher rates of overweight and obesity.1 Members of minority communities often reside in more urban areas, and these areas may provide limited or no access to healthy options for food, physical activity, or security. Residents in low-income urban areas are more likely to report greater neighborhood barriers to physical activity, such as limited opportunities for daily walking or exercise and reduced access to stores that sell healthy foods, especially large supermarkets.11

Nurses in the fight against obesity

Public health nurses are effective in responding not just to the needs of the majority population, but also allowing for, even ensuring, the inclusion of minority segments. Aware of the unique challenges these populations face, nurses can educate—and advocate—for change where they work and live. After all, isn’t the term “public” indicative of representation of diversity among the population?

Obesity is a complex problem, and finding the root causes will help to inform possible solutions. Contributing to the problem is a lack of income and education, cultural differences, environmental changes, learned behaviors for coping, and food advertisements. From an economic perspective, people purchase foods they can afford; they are not necessarily thinking about the future consequences of those choices. And with lower-income populations—also consistently disproportionately composed of minorities—affordable healthy food alternatives should be strongly advocated, (i.e., farm cooperatives, farmers’ markets, free community nutrition workshops, etc.). Safety concerns might also make it hard for people to walk about their neighborhoods and for children to go out and play; nurses can inform their patients of known safe exercise areas and other community resources, like high school gymnasiums or free athletics classes at a public park or YMCA.

The influence of social factors, access to quality food and exercise, and individual factors around maintaining a healthy weight must be addressed. Each has an indirect and direct influence on behavioral choices and may ultimately impact weight. Individual-level characteristics (including income, cultural preferences, and genetic predisposition) contribute to macro-level considerations (neighborhood services, government health initiatives, education, etc.). These all feed the obesity epidemic, the significance of which public health nurses cannot overlook. Structures that affect physical activity behaviors and dietary choices are emerging as important and are potentially amenable to public health intervention efforts.

Yet, nurses cannot fight alone. A collaborative effort must be sought to help sustain community programs, which means establishing dialogue and partnerships between all stakeholders. Key legislative offi cials, health care providers, local businesses, community residents, journalists, educational administrators, nursing organizations—all must rally to address the problem of obesity systemically. The CDC’s Division of Nutrition, Physical Activity, and Obesity and the American Obesity Society ( have online resources to help nurses and other health care professionals combat obesity. On an individual level, nurses can assess their own living, working, social, and other environments. They can engage and advocate for their immediate community and, ultimately, their state and country. Nurses working in public health facilities can be especially influential, as they may treat patients with the fewest resources. Educating one’s patients—whether through simple instructions during an exam, dispersing informational brochures, or even volunteering to speak at local schools and community centers—is the fi rst step in prevention.

Though health care is not yet available to all at this moment in history, public health nurses can reduce the impact of obesity on the nation’s most vulnerable populations.


  1. C.L. Ogden, M.D. Carroll, M.A. McDowell, and K.M. Flegal, “Obesity among adults in the United States—No Statistically Significant Change Since 2003–2004,” NCHS Data Brief No 1, National Center for Health Statistics (2007). Accessed 2011.
  2. K.M. Flegal, M.D. Carroll, C.L. Ogden, and L.R. Curtin. “Prevalence and Trends in Obesity Among US Adults, 1999-2008,” The Journal of the American Medical Association, 303, no. 3 (2010): 235–241. Accessed 2011. doi:10.1001/jama.2009.2014.
  3. Centers for Disease Control and Prevention, “Defining Overweight and Obesity,” (2010). Accessed 2011.
  4. A. Stratton, M.M. Hynes, and A.N. Nepaul. “The 2009 Connecticut Health Disparities Report,” Connecticut Department of Public Health (2009). Accessed 2011.
  5. Diana Holden. Fact Check: The Cost of Obesity. “Fit Nation” coverage, February 2010. CNN. com, accessed 2011.
  6. L. Pan, D.A. Galuska, B. Sherry, A.S. Hunter, G.E. Rutledge, W.H. Dietz, and L.S. Balluz. “Differences in Prevalence of Obesity Among Black, White, and Hispanic Adults—United States, 2006–2008.” Centers for Disease Control and Prevention. Morbidity & Mortality Weekly Report 58, no. 27 (2009): 740–744. Accessed 2011.
  7. Sam Harper and John Lynch. “Trends in Socioeconomic Inequalities in Adult Health Behaviors Among U.S. States, 1990–2004.” Public Health Reports 122 (2007): 177–189.
  8. Olivia Carter-Pokras and Claudia Baquet. “What is a ‘Health Disparity’?” Public Health Reports 117 (2002): 426–434.
  9. “The Census: Minority report,” The Economist, Accessed March 31, 2011.
  10. “Population Profi le of the United States.” U.S. Census Bureau. Accessed 2011.
  11. J.L. Black and James Macinko. “Neighborhoods and Obesity.” Nutrition Reviews 66, no. 1 (2008): 2–20.

Fighting the Deadly Three: Heart Disease, Hypertension, and Diabetes

Rosemarie Jeanpierre remembers the cruel comments as if she heard them yesterday. She was riding a crowded bus to work in Los Angeles when a perfect stranger got on and said, “move over, fatso,” as they all jostled for more standing room. Feeling ashamed, she wanted to get off the bus immediately, but kept riding, all the way to her job as a treatment nurse at Western Convalescent Hospital.

At the time, Jeanpierre weighed 220 pounds, and at 5’2″, she was considered obese. In 2003, her doctor told her she had pre-diabetes, a condition of elevated blood sugar and a harbinger for a diabetes diagnosis down the road. She had been overweight her whole life. As a girl in the Philippines, she learned the habit of overeating for emotional comfort. She had the classic symptoms: her blood sugar was “out of control,” yet she felt hungry all the time. She felt short of breath, propping up pillows at night to breathe while sleeping. And her co-workers told her she looked stressed.

“My doctor got upset with me,” Jeanpierre, L.V.N., recalls. “She said, ‘You’re only 39 and you’re a nurse!'” Being scolded by her physician was upsetting, but not nearly as traumatic as dealing with her father’s death of a massive heart attack a few years before. He had been a diabetic and suffered from high cholesterol and high blood pressure as well.,

“That gave me a big realization that I needed to do something about my health,” Jeanpierre says. “I said to myself, ‘I’m a nurse, and I want to set a good example for my patients.'”

In a dramatic reversal of fate, Jeanpierre lost half her body weight in 18 months through a disciplined regimen of exercise and dietary changes. She forced herself to reduce her daily caloric intake from 6,000 to 1,800. The trips to McDonald’s and a local bakery stopped. What began with 45-minute walks on the treadmill gradually morphed into an abiding passion for running. Jeanpierre ran her first marathon in 2005 at the urging of her nephew. Now, she routinely wins shorter distance races in her age division and plans to run the Nanny Goat 100-mile race this year.

Jeanpierre’s story is exceptional, yet could have turned out much differently if she hadn’t found the willpower to change her behavior. Diabetes, heart disease, and hypertension are chronic diseases and are among the leading causes of death in all populations, but more acutely strike minority groups: African Americans, Latinos, Native Americans, and certain Asian ethnicities. They also happen to be diseases where behavioral changes can reverse—or at least mitigate— their impact.

Nurses possess greater knowledge of these illnesses than the average person, but are no exception. In addition, researchers have recently discovered nurses may be particularly vulnerable to developing key risk factors.

Diabetes: bad for our blood vessels

If not properly managed, diabetes sets the stage for poor heart health. Grim statistics prove cardiovascular disease is the leading cause of death among people with diabetes. Two out of three people with diabetes die of heart disease or stroke; a middle-aged person with type 2 diabetes has as much of a chance of having a heart attack as someone without diabetes who has already had one heart attack, according to the National Institute of Diabetes and Digestive and Kidney Diseases.

“Diabetes is a risk factor for cardiovascular disease, and any diabetes education program must include information about heart disease,” says Cristina Rabadán-Diehl, Ph.D., M.P.H., Deputy Director of the Office of Global Health at the National Heart, Lung, and Blood Institute.

In fact, researchers have come up with a special name for the cluster of traits that make a person prone to both diabetes and heart disease: metabolic syndrome, meaning he or she has three out of the following five conditions.

  1. Excessive abdominal fat
  2. High levels of triglycerides
  3. Low amounts of HDL, or “good,” cholesterol
  4. Hypertension
  5. Fasting blood sugar level of 100 milligrams per deciliter

So how exactly does diabetes compromise cardiovascular health? By adding stress to our circulatory system, which carries blood and oxygen to vital organs and tissues.

In type 2 diabetes, cells become resistant to insulin, the hormone needed to extract sugar from the blood and metabolize it into energy. Having excess sugar, or glucose, in the blood contributes to the deterioration of blood vessels, but researchers have yet to pin down glucose’s specific role in this process.

“Glucose exacerbates the action of other risk factors, [and] the process of atherosclerosis gets accelerated,” says Rabadán-Diehl. Atherosclerosis is the process by which arteries become clogged and hardened by plaque, a waxy substance made of cholesterol, fat, calcium, and cellular waste, thereby narrowing the channel through which blood can flow.

According to Rabadán-Diehl, excess blood sugar could also “stimulate the production of fatty acids, and makes plaque a bit vulnerable.” By producing fatty acids, glucose potentially destabilizes pieces of plaque, moving them through our arteries to potentially form blood clots.

“Glucose likely contributes to the formation of plaque and might also contribute to the instability of plaque, causing particles to drift,” she says.

The narrowing and blockage of blood vessels is the root cause of all major cardiovascular problems, from stroke (caused by blockage of arteries leading to the brain) to coronary heart disease (blockage of arteries leading to the heart) to peripheral arterial disease (blockage of arteries leading to the legs). In addition, more pressure is felt by the arterial walls because of the constricted space through which blood can flow, giving rise to hypertension.

Why nurses are vulnerable

Nurses shoulder a unique burden among health care providers. Not only are they the primary caregivers and conveyers of health information to their patients, but they are often expected to be role models of healthy behaviors. Among nurses who care for diabetic or cardiac patients, the burden is greater since risks for both can be mitigated by behavioral changes like weight loss, dietary modifications, and exercise.

Sally K. Miller, Ph.D., F.N.P.-B.C., and clinical professor of nursing at Drexel University, has studied obesity rates among nurses and their ability to provide weight management counseling to their patients. She links a nurse’s own health status to her credibility among those in her care: “‘Do as I say and not as I do’ is not very effective. People in general put more weight on advice from someone who is modeling that behavior and has been successful in that behavior.”

Yet how easy is it for nurses to maintain a healthy weight and avoid chronic metabolic disorders? Not terribly, according to two studies published last year.

At the University of Maryland School of Nursing, postdoctoral fellow Kihye Han, Ph.D., R.N., and professor Alison M. Trinkoff, Sc.D., M.P., B.S.N., R.N., F.A.A.N., found that nurses who worked long shifts were more likely to be obese than underweight or at a normal weight. Their results, published in the November 2011 issue of Journal of Nursing Administration, show that among the 2,103 female nurses surveyed, 55% were obese and reported less physical exertion and movement in their jobs.

“Long hours affect circadian rhythms,” Han and Trinkoff wrote in an e-mail interview. “Disrupted day/night cycles have detrimental effects on sleep quality and quantity, which are important independent risk factors for obesity, more important than even physical inactivity and high fat intake.”

Han and Trinkoff conclude that nurses who work long shifts might not have the time and energy to participate in regular exercise and that sleep deprivation also stimulates the appetite, forcing nurses to snack during shifts when healthy food choices might not be available.

Nutrition researcher An Pan, Ph.D., goes a step further by solidifying the connection between nurse’s shift work, obesity, and a dispensation towards type 2 diabetes in a study published in the December 2011 issue of PLoS (Public Library of Science) Medicine.

Pan and his colleagues at the Harvard School of Public Health analyzed responses from 177,184 nurses surveyed over a span of two decades. They discovered that a nurse’s risk of developing type 2 diabetes grew in direct proportion to the number of years she worked night shifts. A nurse working night shifts for three to nine years had a 20% chance of becoming diabetic, while that risk jumped to 58% if a nurse worked night shifts for over 20 years.

Weight gain became inevitable after years of working nights, says Pan in an interview: “Women who worked rotating night shifts gained more weight and were more likely to become obese during the follow-up.”

Nurses also say they have a tendency to turn a deaf ear to warnings about their own health, opting to take care of everyone else—patients, spouses, children—first. Eva Gómez, M.S.N., R.N., C.P.N., and a staff development specialist at Children’s Hospital in Boston, waited 13 years before following up on a diagnosis of a heart murmur she received in her 20s. In 2010, she found out she had a misshapen aortic valve, causing her aorta to bulge with backed-up blood. She scheduled valve replacement surgery for later that year and says if she had waited any longer, her aorta could have burst.

“At one point, I said, ‘That cannot be me; that’s something that happens to patients. I take care of people who have this,'” says Gómez, a national spokeswoman for the American Heart Association’s Go Red Por Tu Corazón campaign. “It never occurs to you that it could happen to me.”

Why certain races and ethnicities are at risk

Nurses face serious occupational challenges when it comes to managing their weight and stress level, and those who belong to certain racial and ethnic groups face even steeper barriers.

Latinos, African Americans, and Native Americans are at particular risk for becoming diabetic, while cardiovascular disease remains the #1 killer of all populations, despite race. While genes play a role that researchers are only beginning to understand, lifestyle, socioeconomic, and environmental factors have been the focus of most public health campaigns.

Relying on staples like rice, beans, and bread products and cooking techniques like deep frying, many Latin American cultures eat “diets that are richer in carbs and fats,” says Maria Koen, F.N.P., C.D.E., a bilingual nurse practitioner and diabetes educator at the Joslin Diabetes Latino Initiative in Boston. In addition, “they’re not necessarily having regular exercise as part of their lifestyle [or] making it a priority.”

Getting patients to eat more fruits and non-starchy vegetables remains a challenge, and fast food is perceived as a reward in certain communities. “Going to a fast food restaurant is considered to be aspirational; it’s a treat” among Latinos, says Marleny Ramirez-Wood, Communication Manager of the AHA’s Go Red Por Tu Corazón campaign. “We want to focus our message…in terms of cooking traditional meals, how they can make them healthier, [and] how they can incorporate physical activity into what they’re doing.”

For many ethnic groups, questions about access and affordability arise in conversations about eating healthier, since the corner markets in their neighborhoods may offer nothing more than liquor, cigarettes, and lottery tickets.

“Access to fresh fruits and vegetables is not available in certain communities we’re talking about,” says Lurelean B. Gaines, R.N., M.S.N., Chair of the Department of Nursing at East Los Angeles College and President-elect, Health Care & Education, of the American Diabetes Association. “If it’s not there and you don’t have the means, and with gas prices what they are, you’re not going to drive out of your community to get better food.”

A diabetes educator at the Mattapan Community Health clinic in Boston, Sharon Jackson counsels Haitian immigrants and African Americans from the neighborhood, many of whom work multiple jobs, have no time for exercise, and struggle to manage their disease.

“There isn’t a two-hour stretch where a person who is conscientious isn’t trying to take care of their diabetes,” says Jackson, M.S., R.D., C.D.E., a clinical research program manager at the Joslin Diabetes Center. “Taking care of diabetes is a full-time task…[it] becomes a luxury when you’re in a lower socioeconomic level.”

Managing the deadly three

A nurse’s hectic schedule is often beyond his or her control, especially early on in the career. Scarfing down meals on the go, never getting a decent night’s sleep, working crazy hours to make ends meet, and juggling the demands of work and family life is the norm for many.

These habits take their toll, yet are not simply a matter of individual nurses making bad choices. Institutions play their part in either discouraging or promoting a culture of health for nurses.

One hospital is taking an aggressive approach in helping nurses and other hospital staff get control over chronic diseases like diabetes, heart disease, and hypertension. For the past decade, the Cleveland Clinic has offered its staff disease management programs as part of its employee health plan. Employees are assigned case managers who help them set and reach specific goals related to their condition, says Patricia Zirm, B.S.N., R.N., M.P.H., Senior Director of Employee Health Plans at the clinic.

The clinic is known for its culture of wellness, with nine different fitness areas scattered among its 12 hospitals, reimbursement of gym memberships, a ban on regular soda in vending machines, and healthy food choices in its cafeterias.

Of more than 30,000 employees enrolled in the health plan, approximately 18,000 have one of the diagnoses for which the clinic has a disease management program, and roughly 8,000 are already enrolled in a disease management program.

In 2010, the clinic started to incentivize employee health through a program called Healthy Choice, which ties participation in one of six disease management programs to lower monthly premiums. The six programs are focused on diseases, including diabetes and hypertension, where behavioral changes in diet and exercise deliver a huge impact.

Healthy Choice is a three-tiered system of insurance premiums where the highest level of discount (gold) is awarded to employees who are complying with their disease management goals. In the case of a diabetic, one goal is to maintain a blood sugar level of less than 7%. The silver rate is for employees participating in disease management, but aren’t completely meeting their goals; the bronze rate is the standard rate, where an employee is insured but not enrolled in disease management.

Attaching health outcomes to an employee’s paycheck seems to be a smart strategy. Since 2010, Healthy Choice participation among the staff has tripled. Over the past year, 17% of clinic employees went from the standard rate to the gold rate, and employees are making fewer trips to the ER and are being admitted less frequently to inpatient care, says Zirm. These are all signs of progress, yet work remains to be done.

“Anybody who is doing shift work is more prone to stress, diabetes, and heart disease,” says Zirm. “The clinic tries to do a [favor] of addressing these issues related to shift work…we’re trying to remove barriers, but the fact remains, because of the nature of the job, we can’t fix it for everybody.”

Minority Mental Health: Shining a Light on Unique Needs and Situations

A recent Institute of Medicine report documented evidence that minorities in the United States received lower levels of mental health care, even when variables such as insurance status and income were controlled, says Debbie Stevens, P.M.H.C.N.S.-B.C., a doctoral student at Emory University’s School of Nursing in Atlanta, Georgia. That’s because nurses play a major role in helping reduce these disparities by educating patients, families, and their communities, Stevens says.

Overcoming cultural barriers

Finding treatment for an illness, such as depression, can be difficult for members of minority groups because they may face stumbling blocks to care, says Vicki Hines-Martin, Ph.D., R.N., F.A.A.N., a professor in the University of Louisville School of Nursing in Louisville, Kentucky.

A major barrier is a perceived cultural stigma of mental health issues. Hines-Martin says some minority populations don’t talk about suicide or depression because it’s seen as shameful. “You may have people who say, ‘I know about suicide, but it has nothing to do with my family or my group,'” she says.

Another problem is that many people may not understand the seriousness of their needs, says Harriett Knight, R.N., a nurse at Sinai Hospital in Baltimore, Maryland. Some people may initially seek an appointment with a specialist, but if treatment involves ongoing medication for an illness, such as depression or schizophrenia, the patient may be resistant to taking the drug as prescribed, or they don’t fully accept that they should continue to take it, says Knight.

Sylvia Hayes R.N., M.S.N., is a nurse in the mental health unit of Peninsula Regional Medical Center in Salisbury, Maryland. She says many patients she sees also don’t accept that mental health is a specific medical science. “They tend to believe their issues are caused by a physical problem,” she says. So they may seek help for a persistent headache, when the real issue may be anxiety related, she says.

In many cases, if a patient realizes that his or her medical issue does involve mental health, they may face another barrier—the fear of being stigmatized. Hayes says she’s seen many African American patients who are afraid that they’ll be “labeled” if they admit to having mental health issues.

“They don’t want to be considered ‘crazy,’ and their family doesn’t want them to be considered ‘crazy,'” says Hayes. “They may be afraid their family will isolate them if they seek help, because then they’ll become an embarrassment.”

Of course, many families support their loved ones suffering from mental illness, regardless of any perceived social stigma. In fact, when relatives are accepting of their loved ones and are willing to help them find care, they can be a vital part of the recovery plan. Many patients will even turn to family members for help before they turn to the medical system, says Hayes. This is good, as long as well-meaning relatives encourage patients to seek professional help when necessary. “It can be a negative if the family delays the patient from receiving the treatment they need,” she says.

Many families actually hold the key to helping patients understand their medical histories, Hayes says. “I’ve seen people with family secrets. They had an uncle or aunt who may have dealt with the same mental health issue,” she says. But if the family shunned that aunt or uncle, the patient may not be as open to finding help.

Family cooperation is also important in treating children and teens. Hayes says many mental illnesses are present at a young age. “I’ve worked with kids as young as two years old,” she says.

However, it may be difficult for well-meaning families to receive satisfactory care. A recent press release from the National Alliance on Mental Illness (NAMI) reports “63% of families reported their child first exhibited behavioral or emotional problems at seven years or younger,” but at the same time, “only 34% of families said their primary care doctors were knowledgeable about mental illness.”

Language and cultural obstacles present another challenge for mental health patients. If a person can’t find a medical professional they can simply talk to, they are less likely to seek medical care, says Patricia Lazalde, Ph.D., Director of Behavioral Health at San Ysidro Health Center in San Diego, California.

San Ysidro serves many Spanish-speaking Latino clients, so it’s important for minority nurses to be able to speak Spanish too, she says. “Minority clients may come in with a variety of stressors, but due to language issues they often don’t seek help until it reaches a crisis,” says Lazalde.

Immigrants of various backgrounds encounter similar stressors. In Louisville, Kentucky, there are increasing numbers of members in immigrant and refugee communities, particularly form Somalia and Myanmar, says Hines-Martin. “They’re newcomers, and they’re dealing with the stressors of changing from one environment to another,” she says. “How they deal with these stressors and whether they want to talk about them is important.”

Members of minority populations may also postpone or avoid seeking care for mental health issues, Hines-Martin says. It’s not so much related to an ethnicity or racial group, but it’s associated with people who hold more traditional values related to their culture, and are less likely to follow mainstream care, she says. “People who are less acculturated into the general population may be less likely to seek help if their culture says it’s not something they should do.”

Financial stress and mental health

The slow economy is also creating a barrier to care for some people, even as it’s identified as a stressor for many. Patients are dealing with the stress of lost jobs, eviction, and foreclosure, says Hines-Martin. She recently completed a study of 127 people in a low-income area and found that poorer residents had almost double the rate of depression as the general public.

“When you look at the economic factors they have to deal with, it makes perfect sense,” Hines-Martin says. The stress of constantly figuring out how to survive can wear down a person, and those factors are associated with depressive systems, she says. “If you have problems in several areas of your life, it can affect your mental health.”

Obviously, financial setbacks don’t always cause mental illness, but they can exacerbate problems in people who are vulnerable, says Knight. “A lot of patients don’t know they’re getting sick until there’s a trigger,” she says. For example, a person may get a call from their mortgage company informing them that they’re being foreclosed on, and they can’t handle their emotions, she says.

Lazalde agrees that whenever there is a loss of financial status within the family, nurses tend to see people with increased levels of depression and anxiety, particularly with wage earners.

“Traditionally, Latino males are the primary breadwinners for families, so the loss of a job and the inability to properly care for the family can really create an additional sense of anxiety, depression, and worry. It’s because they can’t live up to the more traditional roles that they would typically fulfill for the Latino family,” Lazalde says. As a result, there’s an increase of male Latinos coming to seek help for depression and anxiety, she says. The issues affect the entire family. “It creates marital problems. Parents are fighting, and we see the kids coming in with levels of anxiety as well,” Lazalde says.

Residents often have to move out of their homes and move in with relatives and extended family because of financial problems, she says. “Family members have to change schools and meet new friends, and there are not a lot of places they know to go to in terms of seeking resources and finding a shoulder to cry on,” Lazalde says.

Financial problems can also limit access to health care, including treatment for mental health needs. “Many clients are losing medical or health insurance coverage,” says Lazalde. This means fewer people can afford their doctor visits, and they have a more difficult time paying for their prescriptions.

Immigration issues are another stressor in many minority communities. There’s a lot of anxiety and depression when people hear about immigration reform on the news, and they’re worrying about what the outcomes and changes will be, says Lazalde.

“Many of our families are being impacted. A number are split up, with half the family living in the United States and the other half in the native country,” Lazalde says. As a result, wage earners have to support two homes, while they’re responsible for the cost of attorneys and other fees. “They have the stress of keeping the family together.”

Getting involved

One way nurses can help patients deal with their stresses, and improve mental health care overall, is to become active in the communities they serve. This helps build trust between residents and medical professionals, says Hines-Martin.

She says that’s a goal of the Office of Disparities within the University of Louisville’s School of Nursing, where she serves as the center’s Director. The office was started because the school of nursing identified a need to focus on how nursing education, practice, and research could help populations that experience disparities in health, Hines-Martin says.

The Office of Disparities sponsors a variety of programs, including faculty and student activities. Hines-Martin’s most recent project involves working with an entire low-income public housing community. “There are about 700 people in a one-block area,” she says. “It’s a way for us for us to see how economics, food, and trans-generational housing affect how people cope.”

Hines-Martin and her nursing students have found they don’t necessarily see people who are actively engaged in behaviors that are detrimental, such as self-inflicted violence or substance abuse. “But I do see people taking risky behaviors because they don’t care anymore,” Hines-Martin says. These people put themselves in dangerous situations, such as drinking excessively, and the drinking is actually related to depression or a depressed state of mind, she says.

There are many challenges, but the program is yielding results for patients who receive care, says Hines-Martin. She says she’s seen people who received help for psychological conditions and didn’t need to be readmitted to a medical facility after receiving treatment.

There’s also been a decrease in the number of people who have been evicted from their homes because of problems that could be tied to mental illness, such as drug use, says Hines-Martin.

“The community is in partnership with us,” Hines-Martin says. “We’ve learned that people are really invested in having a better understanding of their lives and mental health. It makes it easy to partner with them and invest in them.”

Another way to help build trust is to work with other professionals and community leaders to help educate the population about mental health topics. “Many Latino families aren’t likely to go to a behavioral health specialist initially. Instead, they’re more likely to seek help from clergy or a medical doctor,” Lazalde says. With regards to minority nurses, if they are connected to these influencers, they can help patients find needed behavioral care more quickly, she says.

Identifying red flags

Finding good mental health care is not simply a task reserved for nurses who specialize in behavioral health. Minority nurses in all specialties can help identify red flags that a patient may need a referral for a behavioral health specialist, Lazalde says.

When a nurse in any practice area sees a patient, he or she should look for issues such as a high frequency of usage, she says. The primary care doctor is usually the first person a potential mental health patient will visit, Lazalde says. If a patient has historically only visited the doctor’s office once or twice a year, but now they’re visiting two or three times a month, that’s a red flag, she says. These patients tend to have physical complaints with no apparent cause, so the real issue could be stress or anxiety related, she says.

Minority nurses also need to pay attention to comments patients make during their visits. “They may see a doctor and complain about a headache, or pain in the chest or back, but at the end of the session they bring up family problems,” Lazalde says.

Another red flag could be visits from multiple family members. “If you’re seeing a mom, dad, and siblings for physical problems, all within the space of a month, it could be a sign that there’s some sort of turmoil in the family,” Lazalde says.

And nurses shouldn’t wait until the visit is nearly over before addressing mental health issues. “I think it’s really important for nurses to ask questions early on,” says Lazalde. “Ask how things are going in the family and at home. If the questions are addressed by the medical provider or nurse, it normalizes the situation and allows the family to speak more freely,” she says.

When nurses are rushed for time, sometimes really important pieces of information fall through the cracks. This can be prevented by having a patient fill out a survey at the start of their visit, Lazalde says. She encourages the use of a questionnaire, such as the Generalized Anxiety Disorder 7-item scale (GAD7), to help assess a patient’s mental health needs. “It only takes a few minutes and can be completed in the waiting room, and it doesn’t take away the nurse’s time,” she says.

If it’s determined that a patient should receive specialized care, Lazalde recommends that referrals be “normalized.” For example, when nurses make a referral to a provider who’s an oncologist, it’s normal because the oncologist is simply a member of the health care team, she says.

“So we have to find a way to make the behavioral health provider a member of a team. Instead of making the client feel as if there’s something wrong with them when they receive a referral, they’ll know that they’re just meeting another member of the team,” she says.

Lazalde also has another important piece of advice for minority nurses: don’t give up on your patients. “It often takes more than one referral to be successful. Sometimes we have to refer the patient three, four, and five times,” she says. If nurses approach their roles knowing that it takes multiple referrals before they reach a successful linkage to the other provider, then nurses may be less likely to get discouraged, she says. “We’ll know that the family hears the referral more times and there’s a higher likelihood the patient will go and complete the referral and receive the services they actually need.”

Erasing stereotypes

Perhaps the most disappointing barrier minorities face are the ones caused by the attitudes of medical professionals. Minority nurses can exhibit the same biases about their patients as anyone else, and if they’re not careful, they may start to form negative opinions that could affect their levels of care, says Stevens. “Just because a nurse is a minority doesn’t mean they’re immune to stereotyping,” she says.

Some nurses, particularly those who serve low-income communities, fall into the trap of assuming that some poorer patients check into medical facilities to access prescription drugs, three square meals, or a warm bed, she says. “I’ve heard people say ‘the patients are looking for three hots and a cot,'” Stevens says.

These biases are often reinforced when patients have high rates of repeat visits, she says. But despite the challenges, many minority patients who do receive appropriate care become better and are able to function in society, she says. Minority nurses must provide the best service possible by making a sincere effort to view each patient as deserving of quality medical attention, Stevens says. “Nurses have to fight to eliminate negative stereotypes they see, even if they may have had those same stereotypes themselves,” Stevens says.

Translating policy into practice can be difficult because of how pervasive some biases are, but it can be fought the way any ethnic or cultural stereotype is fought, says Stevens. “It starts with education and awareness.”

Some patients will be difficult, Stevens concedes. But if mental health care is your specialty, you should remain confident that you are helping your patients. Standards of care have to be the same, regardless of who the patient is or where he or she comes from, Stevens says.

Minority nurses are specially suited to help break down barriers and stigmas, build trust among their communities, and help their patients live the best lives possible.

Culturally Competent Care for Hmong and Southeast Asian Populations

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 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.”

Peer Power

The year is 1988. Seeking fellowship and peer support, Filipino nursing students at San José State University in California begin to meet regularly to share their feelings about the issues and challenges they face as they work toward their BSN degrees. For many of the students, especially those who have recently immigrated to the U.S., cultural issues–such as overcoming language barriers, homesickness and adjusting to an unfamiliar cultural environment—are an especially important concern.

Through these peer discussions, the students quickly realize that their learning reaches beyond the classroom and clinical areas, challenging who they are and whom they need to become in order to be successful in their studies and their future nursing careers. The group is a safe place to “vent,” to receive support and to learn appropriate techniques for overcoming obstacles.

Flash forward to 1997. After nearly a decade of these informal group meetings, the Filipino Nursing Students Association (FNSA) at San José State University School of Nursing was officially formed—and it has become so successful that it has developed into a national model to help Filipino students at other nursing schools across the country unite and assist one another.

Each year, on the first Saturday in February, the FNSA holds a conference at San José State. The most important development to emerge from the 1999 conference was the decision to create a national organization for Philippine nursing students, with San José’s FNSA as the flagship chapter. As a result, the Philippine Student Nurses Association of America (PSNAA) was born, holding its own first annual conference in 2000.

Katherine Abriam-Yago, RN, EdD, associate professor and student retention coordinator at San José State University School of Nursing, is the faculty advisor involved in the creation of both the FNSA and the PSNAA. As a Filipino American herself, Abriam-Yago attended nursing school at the University of San Francisco with only a handful of other minority students. She always knew that she would use the wisdom she gained through her experiences to mentor other students from culturally diverse backgrounds through the difficult years of nursing school.

“My father used to tell me, ‘You will always be judged by the color of your skin, but your education will open doors for you. When you are involved in an important role, you must help others,’” she remembers.

Cultural Coping Strategies

Abriam-Yago is particularly proud of the FNSA’s success in creating an environment where Filipino students—who make up approximately 20-25% of the San José State nursing school’s student population—can come together to share their feelings, problems and advice. The students bond with each other as they work together to master the cultural and professional components that will help them become successful nurses. The group provides guidance and emotional support to help its members realize that they don’t have to travel this academic journey alone. In fact, they find that other students are facing the same issues, and together they discuss ways to resolve them.

Abriam-Yago first saw the need for a group like the FNSA 14 years ago when she developed and launched the San José State nursing school’s orientation program for new students. At that time, only 25% of the students were persons of color—a figure that has since risen to 75%.

Today, orientation sessions for incoming Filipino students are also a key part of FNSA’s support network. A panel of nursing undergraduates welcomes the new students to the nursing program, answers any questions they may have about what they can expect during their course of study and discusses strategies for becoming successful students. At this session, the new students are introduced to the FNSA, as well as other groups and associations that can provide peer mentoring and support.

As the students begin to settle into their nursing studies, they help each other master academic skills–such as time management, critical thinking and prioritizing—and overcome cultural obstacles that can interfere with the learning process. According to Abriam-Yago, some of the most common cultural challenges Filipino students face include adjusting to American communication patterns, learning to be assertive with authority figures and trying to balance the demands of their studies with the pressures of their traditional family responsibilities.

Because strong communication skills are such an essential component of a successful nursing career, language barriers can be a significant impediment for Filipino students who speak English as a second language. Not only must they learn the basics of American English, including idiomatic and slang expressions, they need to master nursing and medical terminology as well.

“Being able to articulate their needs is an important issue with Filipino nursing students,” says Abriam-Yago. “For example, they will respectfully say they understand [what they hear or read in class] when they really do not.” Sharing strategies to help each other identify their needs, become better communicators and integrate their new knowledge with their cultural background is the essence of the FNSA.

When students are just beginning to learn their future profession, they often have difficulty feeling confident enough to be assertive—and for Filipino students, cultural barriers can compound the problem. Because questioning what others say, especially those in authority, is not generally taught in Filipino culture, they must learn to balance respect with appropriate ways of speaking up on behalf of their patients’ interests, such as questioning doctor’s orders that they feel are incorrect.

FNSA members collectively address these issues by participating in group assertiveness training and leadership development activities. Additionally, Abriam-Yago and other professional nurses who are members of the national Philippine Nurses Association of America (PNAA) and the regional Philippine Nurses Association of Northern California (PNANC) act as role models to inspire the students and help them further boost their self-confidence.

“I have found that there is a stereotype that Filipino nurses are not competent enough or they cannot communicate as well [as other nurses],” says Kathleen M. Morales, current president of the FNSA. “I don’t think about that; I demonstrate that I am competent, that I can do what any nurse can do and that I am proud to be who I am.” In addition to her leadership role in the FNSA, Morales has been accepted into the Golden Key National Honor Society, has received several scholarships and recently completed an internship at the University of California at San Francisco (UCSF). She has decided to attend graduate school at UCSF to become a geriatric nurse practitioner.

Filipino culture’s strong emphasis on family values is still another factor that can complicate matters for students already struggling to handle the stress of a rigorous BSN program. Some students may be responsible for supporting members of their extended family back in the Philippines—for example, sending a relative to school or helping in the care of younger children and elderly family members.

Furthermore, if students fall behind in their studies or do not do as well as they had hoped, the disappointment can be painful and families can be harsh. “Filipino parents are very strict about education,” notes Morales. “I have heard of parents putting their children to shame because they received a B rather than an A. Or if the student fails a class, the parents get really upset and regard their child as a failure. You wouldn’t believe how many students are scared to tell their parents they failed.”

From the Classroom to the Community

Membership in the FNSA is open to all students, regardless of ethnicity. For example, a Caucasian or Hispanic nursing student who is interested in working with the local Filipino community may find it helpful to join the group, not only to find fellowship with other students but also to participate in the association’s community health and outreach programs. This gives them first-hand opportunities to learn more about Filipino health issues and the cultural nuances that can help them provide more culturally sensitive care.

These community health projects are an important part of the FNSA’s broader mission to improve the health of Filipinos living in the San José area (see “Students with a Mission”). “Our intention is not only to help one another [as students] but also to give back to our community by providing volunteer services to different community centers and associations around the Bay Area,” explains Morales. “Our mission is to better ourselves so that we may in turn benefit others.

“When the Filipino community sees Filipino nursing students, they are proud of their culture and feel a sense of security and comfort with us,” Morales continues, adding that some Filipino immigrants are fearful of seeking health care, either because of language barriers or a lack of trust in Caucasian health providers. Being able to work with student nurses who share their cultural heritage can do much to help these patients overcome their fears, she says. “And they can also speak their own language [with us], so they do not need to speak English.”

FNSA members have collaborated with the PNANC on projects such as blood pressure screenings, blood drives and health fairs. They also recently participated in a multiple sclerosis walk, a breast cancer walk and an Asian bone marrow drive. Of the latter project, Abriam-Yago says proudly, “I received a letter of thanks for our participation. We were able to recruit over 50 individuals to donate their bone marrow.”

Priming the Pipeline

Will the fledgling Philippine Student Nurses Association of America eventually become affiliated with the PNAA? It’s too early to tell, says Abriam-Yago, noting that the PNAA is still in the process of officially defining its relationship with the student group. In San José, however, its local chapter, the Philippine Nurses Association of Northern California, works closely with the FNSA to provide the students with mentoring and support, and to encourage them to join the PNANC when they graduate.


According to PNANC President Araceli D. Antonio, RN, MS, “Our mission is to promote fellowship and unity among Filipino nurses, to foster a positive image and to provide activities that assist in the professional development of the Filipino nurse.” As part of that commitment, the association provides scholarships to deserving Filipino undergraduate and graduate nursing students.

In addition, the PNANC invites FNSA members to attend its board meetings, workshops, seminars and other educational events. It also offers assistance, such as registration discounts and help with travel expenses, to nursing students who want to attend the PNANC’s annual conferences and the national PNAA annual convention.

Participating in these professional networking events beyond the nursing school campus gives the students an invaluable chance to learn about future career opportunities and make connections with other Filipino nurses who can serve as mentors and role models. As Abriam-Yago, who brought a delegation of FNSA members, including Morales, to the 2001 PNAA convention in Chicago, puts it, “We’re preparing the next generation of Filipino nurses.”


Going National

In the three years since the FNSA first set its sights on expanding into a national organization for Filipino nursing students, it has been working to create sister Philippine Student Nurses Association of America chapters at other schools around the country. Currently, FNSA members are mentoring a group of students at the Rutgers University College of Nursing in New Jersey to help them start a chapter based on the successful San José model.

Abriam-Yago adds that the February PSNAA annual conferences at San José State provide an ideal forum for students nationwide to network with FNSA members and discuss issues and challenges involved in forming a chapter. The recently completed 2002 conference brought together some 65 students, most of them from other parts of California.

Are you a Filipino nursing student or faculty member who would like more information about the Philippine Student Nurses Association of America? The FNSA invites you to contact Kathleen M. Morales at [email protected] or Katherine Abriam-Yago at (408) 924-3159, [email protected]. Students who are interested in starting a PNSAA chapter at their school will need a faculty advisor to help them with the process.

Students with a Mission

The Filipino Nursing Students Association at San José State University has come a long way since its early days as an informal peer discussion group. Today, its mission statement includes the following ambitious goals:

To support and mentor Filipino nursing students and to promote the health of the Filipino community.

1. To provide culturally sensitive information and resources to Filipino nursing students in the School of Nursing.
2. To promote mentorship and fellowship of Filipino nursing students.
3. To support and participate with other Filipino community and nursing organizations locally and nationally.
4. To participate in the planning, development and evaluation of health care delivery and policy making for Filipinos in the San José area.
5. To promote quality nursing care for the Filipino communities in the San José area.
6. To compile and maintain a Directory of the Filipino nursing students at San José State University.
7. To promote and undertake research that promotes the health of the Filipino population in the San José area.
8. To establish resources to support scholarships for Filipino nursing students.