Even though this issue of MN profiles several minority nurses who have broken through the glass ceiling to attain executive-level positions, the unfortunate reality is that persons of color are still severely underrepresented in the field of health care management. For example, a 1997 survey conducted by the American College of Healthcare Executives (ACHE) and the National Association of Health Services Executives (NAHSE) revealed that 35% of white female respondents held top-level management positions–such as CEO, COO and senior vice president–compared to only 23% of African-American women, 26% of Hispanic women and 15% of Asian-American women.
The good news is that a growing number of associations, foundations and universities have launched innovative leadership development initiatives to help level the health care management playing field and prepare more minority health professionals to move up to the executive suite. This summer, the National Center for Healthcare Leadership (NCHL), a Chicago-based not-for-profit organization, received an $80,000 grant from GE Medical Systems to develop diversity-focused educational and coaching programs designed to support the advancement of racial and ethnic minorities and women into senior management and leadership positions.
NCHL will work collaboratively with the Institute for Diversity in Health Management to create education programs that will bring together teams of racially and ethnically diverse mid- to senior-level leaders in health care management. The programs will focus on strategies that will teach aspiring managers and executives to be change agents within their organizations, creating and fostering environments that encourage and support diversity in health care. The target audience for the leadership training will be health professionals from a variety of fields, including nurses, physicians and administrators.
One of the new diversity initiative’s most innovative features is a coaching component, which builds on the belief that individual mentoring and coaching is an important part of professional development for all health care managers and is particularly essential to the career progression of minority managers. The coaching program will work in tandem with the educational programs, so that individual coaches and mentors will be available to alumni of the leadership training program to help support their continued growth and achievements in health care management.
“The creation of these programs is in keeping with the NCHL’s overall objectives to improve health care leadership in America and to better prepare leaders to address the extraordinary challenges that have been expounded in recent reports by the Institute of Medicine,” says Gary Mecklenburg, president and CEO of Northwestern Memorial HealthCare and co-leader of the NCHL’s Advisory Council on Recruitment and Diversity. “The network of leaders who will emerge from these programs will be better equipped to address these challenges, including the troubling racial and ethnic disparities in treatment and health outcomes in America.”
Arneatha Martin, RN, MSN, ARNP CEO and Co-President Center for Health & Wellness, Inc. Wichita, Kan.
Nobody has yet officially counted the number of minority nurses who hold upper management positions. But everybody knows what such a census would reveal: There aren’t that many of you at the top. Despite the rapidly increasing racial, ethnic and cultural diversity of the U.S. population, nurses of color are still finding it difficult to break into the executive suite at the nation’s health care facilities.
“I think for a lot of minority professionals, there’s not just a glass ceiling at the top—it’s more like a cement ceiling,” says Arneatha Martin, RN, MSN, ARNP, who is the CEO and co-president of the Center for Health and Wellness, a health care center serving the predominately African-American community in northeast Wichita, Kansas. “After you hit your head on that cement too much, it starts bleeding.”
In a 2002 research study, Minority Nurses in the New Century, led by pioneering African-American nursing scholar Hattie Bessent, RN, EdD, FAAN, 46% of African- American nurses surveyed felt they had been turned down for a job promotion that they were qualified to fill. Almost 60% of these nurses believed they lost the job because of their race. The study was funded by the W.K. Kellogg Foundation and sponsored by the American Nurses Foundation (ANF), an affiliate of the American Nurses Association (ANA).
“The African-American nurses often said that their supervisors had less education than they did, and they often had to teach their supervisors how to do their job,” says Bessent, who is director emeritus of the ANA’s Ethnic Minority Fellowship Program.
But despite the odds, a growing number of minority nurses are indeed rising to upper-level management and administrative positions across the United States. How did they manage to break through the barriers to get where they are today? According to the nurse managers who were interviewed for this article, it takes a healthy mix of hard work, tenacity and courage. As Ruth W. Brinkley, RN, CHE, president and CEO of Memorial Health Care System in Chattanooga, Tenn., puts it: “I’ve run into some glass ceilings, but I didn’t let them stop me.”
Start with the Right Education and Experience
The first step to the executive suite is a solid education. “[Minority nurses] need to eliminate as many excuses as we can for people not promoting us to the next level,” says Martin. “If you have the right education, then you will have the ability to get a [promotion] when it becomes available. And if you don’t get the job, you’ll know it’s not because you don’t have a degree or the right kind of degree.”
Ampy de la Paz, RN, MS Assistant Administrator / Compliance Officer Doctor’s Hospital Tidwell Houston, TX
While some nurse executives have earned MBAs, Martin strongly recommends pursuing the appropriate nursing degrees before seeking degrees in business or other fields. “If you’re a nurse, you should have a BS in nursing,” she advises. “Then, when you pursue a master’s, first get an MS in nursing. If you think you need to know accounting or business, then get a second master’s in those fields. But you’ll have better luck if your first degrees are in nursing, which is your field.”
Strong, versatile career experience also counts. Ampy de la Paz, RN, MS, assistant administrator/compliance officer at Doctors Hospital Tidwell in Houston, Texas, recommends acquiring as many varied work experiences as you can. “If you stay in one specialty, for instance, you will limit yourself,” she cautions. “But if you spend time in medical/surgical, orthopedics and other specialties, then you will have a lot of marketable skills that you can transfer to any setting.”
But sometimes having the appropriate education and experience may still not be enough. When Bessent’s survey asked minority nurses why they were turned down for promotions, the respondents often reported a Catch-22 scenario: Their supervisors said the nurses lacked appropriate leadership training and experience. But how can minority nurses get that experience if they are not taken under the wing of management?
Ruth W. Brinkley, RN, CHE
“One of the barriers for minority nurses is the lack of mentoring and exposure that will help them cultivate the skills they need to be quality executives,” Bessent says. “There are many [nurses of color] working under Caucasian executives. But the Caucasians often don’t pull the minority nurses up the career ladder with them.”
G. Rumay Alexander, RN, MSN, EdD, cites the lack of mentorship in her career as a major disappointment. “I needed to be mentored by someone in upper management,” says Alexander, a former senior vice president for the Tennessee Hospital Association who is now director of the Office of Multicultural Affairs at the University of North Carolina School of Nursing in Chapel Hill. “But no one ever really reached out to do that. It meant cross-racial and often cross-gender mentoring, and I don’t think people were comfortable doing that. As a result, I had to do a lot of my learning by trial and error.”
Fortunately, many nursing schools and programs now offer leadership development courses that can help minority nurses acquire the management skills they need. The Minority Nurse Leadership Institute at Rutgers University in New Jersey is just one example. Bessent has also created Project Lead, an ambitious program designed to help minority nurses develop and enhance their leadership skills.
Currently in its third year, the project pays for minority nurses to come to Washington, D.C., on a regular basis for intensive weekend seminars on various management topics, such as conflict resolution, strategic planning, fundraising, hiring and firing. Project Lead is funded by the Kellogg Foundation and sponsored by ANF.
Take on Tough Assignments—and Risks
For most minority nurses who have risen to upper management positions, the road to the top was paved with hard work and long hours. “You have to seize opportunities,” says Rose Gonzalez, RN, MPS, director of Government Affairs for the American Nurses Association in Washington. “Sometimes you volunteer to do things and, during that process, other opportunities open up to you.”
Brinkley agrees. “You can’t be afraid to take risks,” she stresses. “You have to be on the lookout for people who need someone to take on a hard assignment. Then, you can’t be afraid to tackle that assignment.”
Sometimes a little persistence can pay off, adds Martin. “Don’t be afraid to ask for a position or demand it. Because if you think you’re the best-qualified person, then you should demand the job.”
Capturing that major assignment or position is just half the battle, of course. Then comes the problem of having to prove yourself. Many minority nurses feel like they have to work even harder than Caucasian nurses in the same position. “I think we are always aware that we are a minority, so we always want to do our best and exceed our peers,” says de la Paz. “But there’s a big sense of pride when you accomplish something despite the odds.”
Stay Visible
Because health care management is still such a predominantly Caucasian environment, invisibility is another barrier many minority nurses face as they try to climb the career ladder. “Sometimes a person of color will make a statement in, for example, a leadership meeting and that statement is ignored,” Alexander explains. “But then someone from the majority group makes the same statement and all of sudden it’s profound.”
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Sound familiar? It’s a tough obstacle to get around, says Alexander, but not impossible. “You have to continue to contribute,” she advises. “You must be willing to be part of task forces and take on chairmanships of committees to show that you are a strategist, have good ideas and can think on your own two feet.”
Minority nurses sometimes need to assert themselves to be recognized, de la Paz feels. “I think we need to learn how to blow our own horn from time to time. For instance, when you are writing a major report, include your name at the end so people know the report was prepared by you. Then, if the report goes to administration or the corporate headquarters, those leaders may say ‘Hmmm…this is good, and she or he did it.’”
Break the Language Barrier
Raised in the Philippines, de la Paz is committed to helping other Filipino nurses move up in their careers. She says that for some ethnic minority nurses, especially those who are recent immigrants to the U.S., language differences can be a major barrier to advancement.
“Ethnic minorities have a tendency to group together and speak their language,” de la Paz notes. “But you need to start communicating in English so it becomes second nature. You can talk your native language when you are by yourself or on break
. But in the patient care area, speak English. I know of a lot of [ethnic minority nurses] who are very smart people, but they have had difficulty going up the ladder because of their inability to express themselves.”
Keep the Dialogue Open
When minority nurses start breaking through the glass ceiling, they often find that they are one of very few people of color in their organization’s management ranks—perhaps even the only one. “This can get lonely,” says Alexander. “I’ve had moments of alienation and isolation.”
G. Rumay Alexander, RN, MSN, EdD
But Alexander also sees her position as an opportunity for positive change. In a way, she argues, minority nurses in management act as ambassadors for their race and culture, opening up doors for younger nurses to follow in their footsteps.
But change doesn’t happen with silence, Alexander continues. What is needed is “courageous dialogue” when you encounter stereotyping or distrust. “You have to take a chance and go to the individual,” she explains. “You have to be candid and say, ‘This is what I heard. Help me understand why this was said or why you have this perception.’ But you don’t want to embarrass people. If something occurs in a meeting that bothers you, you need to go to the person privately.”
These conversations are not easy, Alexander adds. “Most people think that they are further along on the race relations continuum than they are. Some of that is fueled by what I call ‘virtual integration,’ or the fact that you now see more people of color on TV so it feels like we’re integrated. But we’re not really having true human face-to-face experiences with people of other races.”
For true integration to occur, she believes, there needs to be more honest dialogue among people of different races and cultures. But Alexander also advises minority nurses to stay true to their own cultural identity rather than try too hard to assimilate into the majority culture.
“I think it is challenging to work in the majority culture and try to help bring attention to some of the issues that people in your own culture face,” agrees Gonzalez. “I try to be myself as much as possible at work. I try to talk a little bit about my culture, which is Puerto Rican. I share some of my perspectives and try to highlight the differences. A lot of nurses and nursing organizations talk about the need to tolerate [cultural] differences. But I don’t just want to be tolerated, I want to be respected.”
Profiles in Leadership
G. Rumay Alexander, RN, MSN, EdD Director, Office of Multicultural Affairs University of North Carolina at Chapel Hill, School of Nursing Chapel Hill, N.C.
A typical day in her current position: Alexander’s responsibilities are 80% administrative and 20% teaching. Her charge is to create an environment at the school where everybody has the opportunity to be their best selves. She spends much of her time in meetings, discussing and developing strategies for student and faculty recruitment and retention.
Her first job as a nurse: Staff nurse on a pediatric unit at a hospital
Some milestones in her career:
Senior Vice President for Clinical and Professional Practices, Tennessee Hospital Association
Member, American Hospital Association’s Commission on Workforce for Hospitals and Health Systems
Has authored books on corporate culture and management styles
Advice for future minority nurse managers: “Stay in character, stay authentic. Know in your heart that you can make a difference.”
Ruth W. Brinkley, RN, CHE President and Chief Executive Officer Memorial Health Care System Chattanooga, Tenn.
A typical day in her current position: As CEO, she is responsible for putting strategic plans and operating plans in place to achieve Memorial’s mission. Her days usually start about 7 a.m. and last till 8 or 9 p.m. She meets with many people on a day-to-day basis, including physicians and members of the community.
Her first job as a nurse: Clinical nurse at a hospital
Some milestones in her career:
Associate Executive Director, University of Alabama Hospitals
Senior Associate and Engagement Manager at APM/CSC Healthcare, a consulting firm
Senior Vice President for Performance Management at Catholic Health Initiatives
Advice for future minority nurse managers: “Get a solid education and experience. Take management courses, business courses and leadership courses. Don’t be afraid to get out of your comfort zone.”
Ampy de la Paz, RN, MS Assistant Administrator/Compliance Officer Doctors Hospital Tidwell Houston, Texas
A typical day in her current position: She oversees multiple departments, including compliance, quality management, risk management, medical staff credentialing, physical therapy and occupational therapy. There are no typical days. Because she’s in charge of RM and QM, she spends a lot of time investigating issues, and she is currently very involved with HIPAA compliance. She also runs all the medical staff meetings.
Her first job as a nurse: A charge nurse on a medical/surgical unit
Some milestones in her career:
Chief Nursing Officer, Doctors Hospital Airline
Executive Director, Philippine Nurses Association of America
The Exchange Visitors Program, which enabled her to come to the United States for post-graduate training
Advice for future minority nurse managers: “I think how you present and market yourself is very important.”
Rose Gonzalez, RN, MPS Director, Government Affairs American Nurses Association Washington, D.C.
A typical day in her current position: She’s responsible for moving the ANA’s legislative agenda through the U.S. Congress and Capitol Hill, as well as the state legislatures. She meets with ANA lobbyists, helps organize letter-writing campaigns and other grassroots efforts, and works on fundraising and endorsement campaigns for candidates that ANA supports.
Her first job as a nurse: Staff nurse on a medical/surgical unit
Some milestones in her career:
Nursing Manager, Post Anesthesia Unit/Same Day Surgery/Endoscopy Lab, Vassar Brothers Hospital
Executive Secretary, Board for Optometry and Veterinary Medicine, State Education Department, State University of New York
Vice President, National Association of Hispanic Nurses
Advice for future minority nurse managers: “You have to have an open mind. Use your skills and don’t be afraid to translate them into other arenas.”
Arneatha Martin, RN, MSN, ARNP CEO and Co-President Center for Health and Wellness, Inc. Wichita, Kan.
A typical day in her current position: The Center for Health and Wellness is a state-of-the-art primary health care facility that focuses on prevention and wellness education. Its mission is to provide first-class, affordable health care to a predominately African- American community. As CEO, Martin spends much of her time on fundraising activities, such as grant writing. She also oversees all the day-to-day business of the clinic.
Her first job as a nurse: A psychiatric nurse counselor for the County Department of Mental Health
Some milestones in her career:
Director, Department of Education and Research, St. Joseph Medical Center
Director of Development, Via Christi Health System
Robert Wood Johnson Community Health Leader Award—2001
Advice for future minority nurse managers: “When you see other [people of color getting management jobs], you think you can do it, and you go ahead and try. The fact that I was able to see strong black women doing what to me was an awesome job made me think, ‘I could do that.’ I think minority nurses need to try for management positions. Put your application in, ask for the job, be prepared to answer all the questions and maybe you’ll get the position.”
A patient was scheduled to have open-heart surgery at a Nashville hospital last year when a thorny problem arose. The woman’s husband insisted that no African-American men be present in the operating room during the surgery. According to newspaper accounts, he told the surgeon that his wife did not want black men viewing her nude body. The couple had approached a doctor at another hospital, who had refused the request. But the surgeon in this case chose to honor it, fearing that the patient would not agree to the lifesaving operation otherwise.
So when an African-American male perfusionist was assigned to operate the heart-lung machine on the day of the operation, the surgeon replaced him with a white technician. The move angered many local health care professionals and the surgeon later called his decision a mistake.
But for the Tennessee Hospital Association, the troubling incident became an opportunity for learning. The association’s Council on Diversity addressed the issue head-on and developed a case study for its member hospitals to use in their diversity training initiatives.
Diversity has been a buzzword in the corporate world for the last decade. Many large corporations have hired diversity consultants and created internal diversity management positions to help their organizations recruit and retain a more diverse work force, create corporate cultures that value diversity and address racial conflicts. Some of these initiatives came about after companies were sued for bias, while others grew out of employers’ proactive realizations that having a culture that valued diversity would give them a competitive edge in the marketplace.
Although health care organizations have been a bit slower to come to the diversity table, a growing number are beginning to address this issue. Groups such as the Tennessee Hospital Association’s Council on Diversity are working hard to open up discussion on difficult topics and spark action to encourage equal opportunity in the workplace. Some of these efforts are being led by minority nurses, whose education, training and life experience have specially equipped them to handle this critical issue.
Bringing Passion to the Table
“Certainly I think nurses are well suited for these [diversity management] roles,” says G. Rumay Alexander, RN, EdD. “Nursing is a good springboard for a lot of things, but the rest of the world has wanted to keep nurses in traditional roles.”
Alexander, an African-American nurse, leads the Council on Diversity for the Tennessee Hospital Association. She helped create the group through her position as the association’s senior vice president for clinical and professional practices.
Rupert M. Evans Sr., MPA, FACHE, president and CEO of the Institute for Diversity in Health Management (IFD) in Chicago, also believes minority nurses can play an important role in diversity initiatives, particularly in efforts to build better relationships with communities and remove cultural barriers to health care.
“Nurses have a lot of experience in patient education and staff development,” he points out, adding that this makes them naturals for helping health care organizations improve their cultural competence.
Deborah Washington, RN, MSN, director of diversity for patient care at Massachusetts General Hospital in Boston, says nurses are passionate about caring for patients, which is the basis of equal opportunity health care–providing quality care regardless of race, gender, age or ethnicity. “A good nurse will never back off from the question of ‘What can I do to provide the best for my patient?’” she says. “Nursing, regardless of a nurse’s race or ethnicity, is all about quality of care.”
Minority nurses, Washington adds, bring directness to discussion about diversity. “We are initiators of the conversation that needs to be had. We bring energy to that conversation.”
Evans reports seeing a significantly growing interest in diversity among health care organizations in the last year. He believes this stems from the simple recognition that society is changing rapidly and that organizations must respond accordingly. Creating workplaces that value diversity isn’t just about doing the right thing—it also makes good business sense.
“It’s really a matter of survival,” agrees Cynthia Barnes-Boyd, RN, PhD, FAAN. “With so much competition in the health care industry, hospitals can’t afford to have patients not select them because they don’t feel comfortable there.”
Boyd, an African-American nurse, is director of the Great Cities Neighborhood Initiative at the University of Illinois in Chicago. In her job, she administers a variety of community-based projects, such as school-based clinics and a home health care program for families with special needs. She is also an expert in helping organizations, such as hospitals and health care centers, meet the needs of diverse communities. In her position at Massachusetts General, Washington, who also is African-American, facilitates conflict resolution among staff and management, teaches culturally competent care and serves on a variety of committees that address diversity issues. A former biomedical tester, Washington had begun a second career as a staff nurse at Massachusetts General when a supervisor asked her to chair a committee to address work force issues. Later she was appointed to her current position.
Washington says her training as a psychiatric nurse provides a valuable background for helping people resolve conflicts and discuss issues openly. “I like to be straightforward and direct,” she explains. “This is an environment where nothing is swept under the rug, and I like that a lot.”
Blaze Your Own Trail
Not all diversity management positions are formally appointed posts created by organizations. Sometimes these jobs are initiated by individual health care professionals who feel strongly about the issue and want to be a part of the solution.
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Alexander, for instance, started the Council on Diversity for the Tennessee Hospital Association because she saw the need to recruit more minorities into health care. Better patient-care decisions are made when there is racial, ethnic, age and gender diversity, she says, because a wider variety of perspectives is represented.
When confronted with the lack of minorities in hospital management positions, hospital administrators would often say they wanted to hire people of color but seldom came across qualified minority applicants. The Council on Diversity responded with a summer internship program that places minority management students in Tennessee health care facilities.
Similarly, Boyd created the position she holds at the University of Illinois. Early in her career as a critical care nurse in neonatal and intensive care units, she realized she wanted to work on the other end of disease. Rather than treating people after they had become desperately ill, she wanted to help prevent illness and develop programs for underserved populations. Boyd has since led a variety of programs at community health care centers and the university. She urges minority nurses to be proactive and create opportunities to address diversity issues, rather than waiting to be appointed.
“Every position I’ve had I wrote the [job] description for and pitched it to the organization,” she recalls.
Boyd feels strongly that nursing professionals should become actively involved in championing diversity. “The way to be a part of it is to make yourself part of it,” she says. For example, nurses can volunteer for diversity committees at their institutions, become active in community programs that promote diversity, and propose solutions when they see problems of bias or conflict.
Supporting Diversity From the Top Down
As the health care industry becomes increasingly concerned with maintaining profitability and cost-effectiveness, nurses who want to pitch the idea of initiating a diversity committee or diversity management position must be ready to show how it will benefit the organization’s bottom line. Picking the right time to present your case can also make a difference.
Alexander says she would not have been able to create the Council on Diversity when she started working for the Tennessee Hospital Association in 1980. At that time, she was the association’s first minority in upper management. “Initially I knew I could not bring the issue up,” she remembers. “First I had to gain trust.”
Through the years, she sent up “trial balloons” to gauge receptiveness. “I kept being that gentle little nudge,” she says. And then five years ago, she received the go-ahead to work on developing the minority internship program and the Council on Diversity.
A nurse must have support within an organization to succeed in leading any new effort. A turning point for Alexander was when she got a new boss who truly understood and supported the diversity initiative—and her. “The more allies you have, the better,” she stresses. “You have to have that nucleus of support. You can’t do it by yourself.”
For diversity efforts to succeed, Evans says, their goals must be woven into the organization’s strategic mission and be supported from the top down. Diversity initiatives that are assigned to only one position or department without being integrated throughout the organization run the risk of being lopped off when it’s cost-cutting time.
Washington agrees. She says valuing diversity is part of Massachusetts General’s mission, and she feels she has strong support from her organization’s leadership. But that’s not the case at every health care facility, she cautions. Sometimes diversity initiatives occur at the middle-management level and suffer from a lack of support from the top.
Many Paths, One Goal
Diversity is also important in scientific research, where it encompasses more than just ethnic, racial and cultural differences. In her position as senior associate for science management at United Information Systems, Inc., in Bethesda, Md., Rosemary Torres, RN, JD, also serves as diversity and outreach manager. It’s her job to recruit a diverse group of scientists to sit on peer-review panels for federally funded scientific research. Torres, who is Hispanic, looks for top scientists who represent diverse fields and geographical areas as well as a spectrum of different educational and cultural backgrounds. Diversity among scientists is essential because it provides a broad perspective for finding comprehensive answers, she explains.
Torres herself has created a diverse career that has helped her broaden her own perspective in addressing health care issues. As a health law attorney and nationally recognized expert in women’s health, she has worked in a wide variety of clinical settings and offered her expertise in the development of health care policies.
“I’m an atypical nurse,” she says. “I created a career path that enabled me to assess and impact the full stage of a patient’s life.”
There are many other ways nurses of color can get involved in diversity and equal opportunity efforts without actually holding a formal diversity management position. For example, you can promote diversity in the workplace informally by mentoring other minority nurses. Another option is to reach out to local minority communities. As a Girl Scout leader, for instance, Boyd helped her troop learn about breast cancer and educate the women in their families about the disease.
What skills and qualities must nurses possess to play leading roles in diversity initiatives? “Self awareness is critical,” according to Boyd. “We have to be willing to look at ourselves and examine our own biases in forming relationships.”
Nurses who want to help their employers reach out to diverse communities also need to have patience and a thick skin, she adds. “Just because you have a degree and a title, people aren’t going to automatically trust you.”
Although nurses don’t have to have a human resources background to work in diversity management positions, Alexander says it’s crucial to have an understanding of how the entire health care system works. Other essential qualities include the ability to form trusting relationships and the courage to speak up.
Even though an encouraging number of health care organizations are beginning to embrace diversity issues, Alexander believes much work still lies ahead.
“At the majority of meetings I attend, I’m the only minority person sitting there,” she says. “I will know we’ve made an impact when people are sitting around a table where there is no diversity and someone at that table says, ‘This isn’t right.’”
The nation’s health care needs are growing. Costs are rising. Access is an increasing concern, especially in underserved rural and inner-city communities. Nurses today can be left wondering what to do and how they can make a difference.
Yet the nursing profession holds a promising solution to the U.S. health care challenge. To increase access to high-quality, comprehensive, and affordable care, there is a growing demand for nurse practitioners. Nurse practitioners will play a vital role in reforming health care. According to the U.S. Bureau of Labor Statistics, the number of positions for nurse practitioners is projected to increase by 23% through 2016.
Are you ready to take on the challenge? Two experts—both nurse educators and advanced practice nurses—can tell you how to get started. We asked them to share their insights about the education, role, and potential impact of nurse practitioners.
What are nurse practitioners’ key responsibilities, and what might attract someone to this career?
MORGAN: Becoming a nurse practitioner provides you with an opportunity to expand your role as a nurse. Nurse practitioners can diagnose and treat a wide range of acute and chronic health problems. Nurse practitioners can provide acute and primary care in a variety of clinical practice settings, including subspecialty areas such as dermatology, gastroenterology, neurology, urology, and hematology. These practice settings include some of the following: women’s health, college health, emergency rooms, nursing homes, public health, psychiatric health, and pediatric health. In essence, you will find nurse practitioners in just about all facets of health care now.
Nurse practitioners are also becoming more involved in telehealth. They can evaluate, monitor, and follow up with a patient at home via telecommunication. This is especially helpful in rural areas and for patients with chronic diseases, including diabetes, congestive heart failure, and mental illness, just to name a few. Nurses who become nurse practitioners want to make a difference for their patients at a broader level. They want more autonomy and independence in how they can care for individuals, families, and communities.
How might nurse practitioners impact health care quality, cost, accessibility, and affordability?
TORRES: Our health care system is changing rapidly, and qualified nurse practitioners will play an increasingly important role. Many physicians are choosing specialty practice rather than general practice, and this is creating a shortage of primary care providers. This shortage is magnified given that our aged population is increasing rapidly. Nurse practitioners will be invaluable in filling the gap in providing primary care. This shift in care from physicians to nurse practitioners in the provision of primary care is a goal of the Affordable Care Act; nurse practitioners can provide care that is more accessible and cost effective to patients.
MORGAN: Nurse practitioners are trained to provide safe, competent, comprehensive, and cost-effective health care. You will find many nurse practitioners who provide care in rural and indigent areas where they can serve vulnerable and underserved populations.
Nurse practitioners can prescribe medications. They are also able to provide treatment for acute minor illnesses. That’s very important because when you look at the demands on hospital emergency rooms, you see an influx of patients who should be going to an outpatient or acute care clinic instead of the emergency room.
In addition to teaching at Walden University, I work at a retail clinic where nurse practitioners provide care for acute minor illnesses such as strep throat, urinary tract infections, otitis media, and sinus infections. Patients are very grateful to have a clinic like this. When they need care, they don’t have to go to the hospital emergency room or take time off from work to go to the doctor’s office.
Some patients have reported that they prefer a nurse practitioner as their primary care provider because they say we listen, we’re comprehensive, and they like the follow-up care we provide. Of course, some people say they prefer to see a physician because that’s what they are accustomed to. As the country seeks to make health care more accessible and affordable, we have an opportunity to educate the public about the roles of nurse practitioners.
TORRES: As the demand for health care services by nurse practitioners increases, it is important that barriers to practice also be removed. The scope of practice for nurse practitioners can vary significantly from state to state. In some states, nurse practitioners have more autonomy to practice, whereas in others, nurse practitioners are not able to prescribe a controlled substance such as pain medication. A key recommendation from the Institute of Medicine’s (IOM) 2010 report The Future of Nursing: Leading Change, Advancing Health was that outdated barriers to practice should be removed and nurses should be allowed to practice to the full extent of their education and training.
With health care reform increasing the need for nurse practitioners, what practice areas are in the highest demand?
TORRES: Currently, some nurse practitioner specializations are in higher demand than others. For example, there is a high demand for family nurse practitioners (FNPs). FNPs have the most options as to where they can practice and the populations to which they can provide care. FNPs practice in all types of settings, including private or public clinics and hospitals, and they can provide care across the lifespan. Nurse practitioners who focus on the care of adults and the elderly are also in demand.
Is there a particular need or demand for nurse practitioners from minority communities?
MORGAN: There’s both a need and a demand. There’s a lack of minority representation among nurses across the board. For example, among advanced practice nurses, it’s very low because less than 1% of all African American nurses have earned a doctorate. Yet research has provided evidence demonstrating that it helps the patient-provider relationship when a patient who is a member of a minority group has a provider who is a member of the same minority group.
The Health Resources and Services Administration (HRSA), a federal agency, is looking at how to increase workforce diversity in nursing. It’s providing funding opportunities for minority nurses— either RNs or advanced practice nurses—to earn graduate degrees, which could help increase minority representation among nurse practitioners.
What are the education requirements and experience needed to become a nurse practitioner?
TORRES: For certification as a nurse practitioner, you need at least a master’s degree. Often, someone who already has a master’s degree and then decides to become a nurse practitioner will complete post-master’s certificate courses to prepare for certification to practice.
If you already have a Bachelor of Science in Nursing (B.S.N.), you can go into a master’s program and become a nurse practitioner in two years, or you can go directly into a Doctor of Nursing Practice (D.N.P.) program and complete a degree in three years. The American Association of Colleges of Nursing is proposing a shift that would make the D.N.P. the professional standard for all advanced practice nurses, including nurse practitioners.
Whichever degree program a prospective nurse practitioner chooses, its content needs to include separate courses in the “three Ps” of nursing—pharmacology, physical assessment, and pathophysiology—plus other content based on the population the nurse practitioner will serve. Some degree programs offer specializations in practice related to particular populations, such as family nurse practice and adult-gerontology nurse practice. At least 500 hours under a preceptor in a clinical area is also needed before you take the certification exam through the American Nurses Credentialing Center or the American Academy of Nurse Practitioners.
For those who have jobs and families or who live in remote areas, an online program can be a good option to help make this education more accessible.
MORGAN: Nurse practitioners come from a variety of backgrounds. Among students in Walden’s advanced practice nursing program, we’re seeing experienced nurses as well as people who are starting a second career. A student might be a health care administrator, someone who’s worked as a pharmacist, or someone who hasn’t been in health care at all. They’ve been in marketing or computer science, and they want to give back to society in a different way by incorporating their first career with a new career in nursing. For example, they are combining computer science and nursing and specializing in nursing informatics, or blending business and nursing for a career in nursing administration. It’s very individualistic
What career paths and advancement opportunities are available to experienced nurse practitioners?
MORGAN: Experienced nurse practitioners can serve as administrators for hospitals or clinics. Some nurse practitioners work for the National Institutes of Health (NIH). When the NIH conducts clinical trial studies, advanced practice nurses are needed for the clinical protocols or to oversee the research projects. Many nurse practitioners work at four-year institutions, where they teach or serve as project directors for grants funded through NIH.
TORRES: We’re starting to see more nurse practitioners open their own practices in collaboration with physicians. There are also nurse practitioners who are able to teach. The beauty of being a nurse practitioner is that you can teach and do clinical practice. There’s an opportunity to give back to the profession through both roles.
Hypertension is a major health concern for African Americans. They develop high blood pressure more often and at an earlier age than other ethnicities, including Caucasians and Mexican Americans. The Centers for Disease Control and Prevention (CDC) reports that more African American women than men are affected by hypertension.1 According to Demede et al., African American adults have the highest rate (44%) of hypertension in the world and are more resistant to treatment.2 Hypertension is often called “the silent killer” because there are no symptoms, so it frequently isn’t detected until routine medical visits. The only way to know if one’s blood pressure is high is to have it checked regularly.
Compounding these problems, noncompliance to antihypertensive medication in African Americans is common and leads to complications like strokes, heart attack, heart failure, and chronic kidney disease. These complications affect African Americans at alarming rates. Noncompliance can be intentional or unintentional, but the causes tend to remain the same. Lack of knowledge, misconceptions about the disease, heath beliefs, and education level are all factors that can affect medication compliance. Noncompliance often occurs because patients are unaware of the consequences of failing to take their medication as prescribed or are unable to afford the cost of the medication. Patients frequently report that they feel fi ne, which leads them to believe they no longer need their medication. But in reality, they need to continue taking it consistently, even when their symptoms don’t exist.
Not so surprisingly, patients often associate the idea of “feeling better” as an expected result of taking their prescribed medication. Therefore, the patient will stop taking the antihypertensive medication because they do not experience any improvement. Side effects also play an important role towards noncompliance, while many patients are simply unable to afford the medication. For some, there is no other choice but to feed their families and pay rent, especially when they don’t see any improvements in their health.
Health care professionals often fail to remind patients of the importance of continuing to take their medication, even when their blood pressure is normal and they feel fine. Explaining a medication’s side effects is also essential so patients will not become alarmed if they experience any—often resulting in patients discontinuing the use of their medication. Many patients have reported that they stopped taking their blood pressure medication because their health care team has repeatedly told them their blood pressure is fine, so they didn’t feel the need to continue the medication.
Odedosu et al. agreed that emphasis should be on patient education, particularly addressing misconceptions about hypertension and promoting adherence to antihypertensive therapy.3 In teaching patients how to manage their disease and how to be compliant with their medications, clinicians need to go much further than just reminding patients of the ramification of not taking medication as prescribed. Reminding patients to take their prescriptions— even though their blood pressure is normal—should be part of the conversation at all visits. Interventions specific to each patient must be addressed and include the following: patient education, behavioral counseling, lifestyle modification, and home self-monitoring. It’s in the hands of health professionals to educate African American and other minority patients as much as possible on the medications themselves and the necessary reasons for continuing to take them.
References
Centers for Disease Control and Prevention, “High Blood Pressure Facts,” www.cdc.gov/bloodpressure/facts.htm.
M. Demede, A. Pandey, L. Innasimuthu, G. Jean-Louis, S.I. McFarlane, and G. Ogedegbe, “Management of hypertension in high-risk ethnic minority with heart failure,” International Journal of Hypertension, (2011), 1-8, doi: 10.4061/2011/417594.
T. Odedosu, A. Schoenthaler, D.L. Vieira, C. Agyemang, and G. Ogedegbe, “Overcoming barriers to hypertension control in African American,” Cleveland Clinic Journal of Medicine, 79 (2012), 46-56, doi:10.3949/ccjm.79a.11068.
