Professional nursing programs in the United States are rigorous and demanding, particularly for students whose first language is not English. Language, culture, and academic expectations are the most common areas of difficulty for those who teach multicultural students. According to recent research, early academic interventions, tutoring, and culturally sensitive educational practices can foster success and promote a more ethnically diverse nursing community.
Resources and Outreach Center for Research on Education, Diversity & Excellence: http://crede.berkeley.edu National Council of Teachers of English:www.ncte.org Teaching Diverse Learners:www.alliance.brown.edu/tdl “Using Flexible Technology to Meet the Needs of Diverse Learners: What Teachers Can Do,” a PDF from West Ed: www.wested.org/online_pubs/kn-05-01.pdf
Many nursing schools are admitting record numbers of students categorized as English Language Learners (ELL). In fact, the number of ELL students seems to be growing more rapidly than the general student population. The National Center for Educational Statistics reports the U.S. population grew 9% between 1993 and 2003; the ELL population increased by 65% during that same time. Now, ELL students comprise over 10% of all students.
Faced with completing assignments in a language they are not comfortable with, ELL students tend to score lower on standardized tests and receive lower grades than their English speaking classmates. Their teachers even sometimes perceive them to have lower academic abilities, according to research by Moss and Puma, 1995.
In 2002–2003, baccalaureate and graduate nursing program enrollment indicated that 21.6% of nursing students came from minority populations. However, there are no clearly outlined procedures for identifying ELL students in higher education. Determining the exact criteria for classifying the ELL student has been controversial. Poor classification of ELL students results in insufficient annual reporting and inadequate provision of student services.
There has been minimal research associated with the challenges experienced by ELL students. Some researchers have posited that one of the reasons may be that researchers do not have the patience to listen to someone with an accent. Increased diversity in our nation’s college classrooms and communities, including new immigrants from many different parts of the world, requires greater understanding of student education needs.
In order to accelerate nursing academic progress in the next decade, schools of nursing must consider recruitment, acceptance, and graduation of culturally diverse nursing students. This will require change in the current education system, with specific improvements to address challenges faced by international nursing students and students who speak English as a second language. The following research gives a voice to the obstacles encountered by the English language learner nursing student.
Achieving a higher education requires a partnership between student, teacher, and institution. The successes of each entity are interdependent. Ten ELL nursing students enrolled in two separate associate degree in nursing programs in San Antonio, Texas, were interviewed. The goal of the interview was to identify and describe unique challenges experienced by students who speak English as a second language. The group was representative of nine nationalities and fluent in a total of 15 languages. It was concluded that student success was based on four areas: student study habits, student distress, student support system, and student learning tasks.
Student study habits included a tedious, time-consuming approach to reading assignments. Often students reread an assignment several times in order to grasp its true meaning. Additionally, the students described their exam study habits. The single most helpful study method was reviewing the National Council Licensure Exam (NCLEX) practice questions. Personal study habits, including reading practices, note taking, small study groups, use of printed lecture PowerPoint handouts, and reviewing websites, were also described.
Implementation Education Northwest, an organization devoted to improving schools and student outcomes through research, has several suggestions regarding the implementation of educational practices suited to all ELL students. You can fi nd tips like these and more on their website: http://educationnorthwest.org/services/ell. 1. Give language learners many opportunities to read and write in meaningful contexts, in their fi rst and second languages. Draw on effective strategies for increasing literacy skills. Integrate technology to support writing instruction and motivate students to use written language to communicate. Encourage students to develop literacy skills in their native language, then transfer these skills to learning English. 3. Connect with students’ families and culture. Use culturally congruent teaching methods to incorporate culture and native language, introduce multicultural literature, and draw on the expertise of community members. Give ELL students opportunities to teach others about their first language and home culture. 4. Use strategies such as project-based learning, thematic instruction, and cooperative grouping to engage learners. Help ELL students connect words with meaning by using nonverbal clues and nonlinguistic representation of ideas, including multimedia, manipulatives, simulations, and modeling. Give students opportunities to talk about shared learning experiences. Hands-on, experiential learning experiences will develop understanding. 5. Vary assessment strategies. Use wide-ranging assessments, including observations and performance assessments.
ELL students also reported an increase in stress related to their relationship with their instructors, lack of time to complete exams, and anxiety around approaching teachers with questions. More importantly, they felt unable to communicate clearly in English, resulting in a negative self-image.
The study demonstrated that participants had a strong desire for emotional support. First, ELL students valued a positive relationship with their nursing faculty. Second, students showed progress and confidence in the nursing program based on strong emotional support from their family and friends.
Student learning tasks comprised three areas: nursing vocabulary comprehension, confidence to speak publicly in English, and comfort level posing a question during class. The single most important point discerned was the students’ needs to comprehend nursing vocabulary. Use of study guides and Internet tools, along with repetitive verbalization of terms, developed both vocabulary as well as English language confidence. Posing questions in class is something English speaking instructors and students take for granted. ELL students are perceptive and sensitive about their ability to correctly pronounce English terminology. Inability to ask a question in class hinders a student’s learning experience. A silent suffering is taking place as it applies to English communication skills.
By the year 2020, non-white American citizenship is expected to rise by 50%, according to the U.S. Census Bureau, 2000. English Language Learners seek higher education, so institutions of higher learning, nursing instructors, and students must all come together to understand what processes are needed to create success for this group of students. ELL students will become a larger part of nursing classrooms, as is reflected in their demographic advancement.
Said one male participant from Burundi, Africa: “I came to study. And I believe that if I study, I can—I can succeed!”
On January 12, 2011, little seven pound, 10 ounce, 20.5 inches long Carson joined the Samantis family after a fairly easy pregnancy and uncomplicated delivery. Until Carson was born, both his mother, Kristen, an interventional cardiology nurse at Massachusetts General Hospital in Boston, and father, C.J., worked full time. Until four days before Carson was born, Samantis, now 31 years old, was working.
In the 1980s and 1990s, over 80% of women ages 25–34 years old were working, according to the U.S. Bureau of Labor Statistics. Before the Family and Medical Leave Act (FMLA) passed in 1990, around one-third of women never worked while they were pregnant, one-third quit their jobs, and only one-third took a maternity leave that often lasted under a week.1 For employers and employees, today’s culture of working mothers elevates work-family relationships to a high priority. The FMLA allows employees who have worked at least 1,250 hours to leave their jobs for 12 work weeks in a 12-month period, without pay, to give birth and care for a newborn child.
But nurses face particular stressors when they return from maternity or paternity leave, and the Massachusetts Nurses Association and other unions say these benefits could be better. While all working mothers (and fathers) have a difficult time reacclimating to work, nurses generally face grueling 12-hour shifts, so they are away from home for longer periods of time and may feel especially drained by the nature of the work they do caring for patients.
Samantis decided to start a family only after carefully considering the economy and her job. She waited to have Carson until she had earned enough time off to take the full 12 weeks of paid maternity leave. While she has worked at MGH as a nurse for over two years, she has worked at MGH for a total of nine years, with a previous position in health education.
Welcome back
The days when every mom was a stay-at-home mom are a distant memory. New mothers are returning to work in large numbers, and nurses are actually more likely than other moms to return to work full time. According to the U.S. Department of Labor, 20% of nurses work part time, and most of those women are married with young children. At Massachusetts General Hospital, where Samantis works, nurses represent 15% of the hospital’s overall maternity and paternity leave, but most of the new parents return to the full-time 36- to 40-hour workweek, according to the hospital’s human resources department.
“This is where the recent economy has had a larger impact on nurses and this trend [of working mothers],” says Steve Taranto, Director of Human Resources at the Knight Nursing Center for Clinical & Professional Development and the Yvonne L. Munn Center for Nursing Research at Massachusetts General Hospital. “Especially in today’s economy where fewer people have jobs and more nurses are supporting unemployed spouses, this is the career that the marriage or family will turn to as the reliable source of benefits,” he said.
After Carson was born, the Samantis family decided they didn’t want to put the baby in daycare, so they agreed that Kristen would work part-time. How that reduction in income from her career would affect their new family’s lifestyle troubled her.
“I was a nervous wreck when I had to go back to work,” says Samantis. “I kept thinking about it as each week of maternity leave passed by.”
While hospital administrations have streamlined adjusting schedules when nurses take paternity or maternity leave and return, nurses find returning to work particularly stressful because of their own schedules. Nurses often work nights on already minimal sleep as new parents, and they are balancing a baby’s sleeping patterns with long hours and/or night shifts at the hospital.
“Since I was going back to work mostly nights, I was sad that I wouldn’t be the one putting him to bed each night,” Samantis says. C.J., her husband, was handling nightshifts with the baby on his own, and little Carson wasn’t sleeping through the night. C.J. would stay up all night with the baby, then return to work in the morning, and Kristen would work nights, then stay awake most of the day taking care of Carson.
According to research published in Health Affairs in 2011 by Project Hope: The People to People Health Foundation, job burnout or dissatisfaction among nurses is a big problem in hospitals because of risks to patients, work disputes, and turnover.1 The research found much higher levels of burnout with nurses working in hospitals and nursing homes, where lower patient satisfaction levels correlated with more dissatisfied or overworked nurses.
What’s best for you and your family
“There are fewer jobs out there, so the nurses, even if they have just had a baby, have more of an incentive to pick up more hours as they adjust back into work, where their career is often a large source of income for their family,” says Taranto.
While Samantis originally thought she would sleep when the baby took naps during the day, she discovered that Carson napped less as he got older, which didn’t allow her to sleep like she planned. “That makes for a cranky baby and mom!” she says. Immediately after returning from maternity leave, Samantis worked 36 hours a week, but she has since dropped that number to 28. “We are not superheroes!” she says.
Communicate with your supervisor
The nature of nurses’ schedules when taking maternity leave, versus other roles in a hospital, may actually be advantageous. Nurse managers have more freedom and flexibility to adjust schedules to meet a new parent’s needs by offering more hours to part-time workers and per diem nurses.
Before and during her leave, Samantis closely communicated with her supervisor and still does. When she needed to cut back her hours after Carson was born, her supervisor was supportive and checked in periodically to see how things were going. Her manager recently gave Samantis the option to cut back to 24 hours a week, which the new mom is considering now that Carson is five months old and sleeping less while she is at home with him during the day.
Although cutting back working hours is a big decision, as fewer hours means less income, Samantis would only need to be at work two days a week instead of three, a schedule worth considering for a family not using daycare.
According to the Human Resources department where Samantis works, most nurses return from maternity leave at the 36- to 40-hour workweek level, while only a few come back at the 20- to 24-hour workweek level. They attribute this trend to the economic stresses of the past three years. Like Samantis, nurses who are new parents are working on limited sleep and would prefer to be home more often with their babies, but taking cuts in their hours means cuts in their paychecks.
“Mass General’s flexibility with nursing schedules is what leads to the greatest success with regards to retaining nurses post-maternity leave,” Taranto says. The hospital was named a “Working Mom Institution” in 2005 by Working Mother, scoring particularly high in child care options, parenting and child care workshops, and benefit policies that allow mothers flexibility around part- or full-time employment. MGH has a job vacancy rate of 1% and a turnover rate of 3.1%, which represents return for education, nurses becoming stay-at-home moms, or family situation changes. Communication between supervisors and nurses about schedules is key to keeping MGH working mothers happy, Taranto says.
Mark your calendar
According to the Mayo Foundation for Medical Education and Research, returning to work at the end of the week or on a weekend eases new parents back into the work routine. Nurses have the flexibility as well to not schedule themselves two days in a row at first, so they only need to get through one day of work before they can return to their babies.
Of course, returning to work also presents an emotional challenge for new parents. For moms in particular, postpartum hormones are still fluctuating 12 weeks after giving birth, so being back at work may be that much more stressful.
“You haven’t had a chance to wrap your head around taking care of a baby yet,” says Samantis, who says she felt “out of sorts” when she returned to work after her maternity leave. According to the Mayo Foundation, for all new parents, nurses or otherwise, calling to check in with your baby and whoever is taking care of him or her is important for your peace of mind and to stay connected with a shift in your life that is still so new.
Recruit reinforcements for baby and you
Leaving your baby in someone else’s care is one of the most important decision new parents can make. Finding reliable childcare is also one of the most challenging aspects of being a working parent. While MGH provides childcare for their workers 10 minutes away from the hospital, as well as onsite daycare centers for emergencies, the Samantis family decided they didn’t want their baby in daycare but had no one to call to stay at home with him. Working their careers around alternating days and nights at home was the best decision for her family, Samantis says. In this way, her schedule options allowed her family to work through this.
Breastfeeding
Breastfeeding can also complicate the return to work. Some babies have trouble latching, and it takes time to develop a routine. Once moms are back at work, sticking with this schedule becomes even harder.
According to the World Alliance for Breastfeeding Action, for the first six months back at work, employed women should receive support from their workplace to provide private breastfeeding options. Hospitals today have lactation rooms set aside for their working moms, but the commitment presents daily challenges. Finding time during your shift to sit in a lactation room is one thing; you then need coworkers to care for your patients while you’re pumping. But many still make it work.
At MGH, Human Resources and the Employee Assistance Program have been monitoring and keeping track of numbers in the hospital’s lactation rooms, which have been adjusted and their numbers increased based on their volume of use.
“Pumping while back at work is a huge commitment,” says Samantis, who shifted to baby formula for Carson when they returned from the hospital, even though she originally planned to breastfeed until she went back to work. “With that being said, many of the moms I work with do it and are successful!”
Baby yourself and stay positive
Maintaining regular bed times, cleaning out unnecessary commitments, and maintaining a positive attitude are all keys to balancing your work and home life.
The Samantis family has found good routine now, and Kristen says Carson “is sleeping like a champ through the night.” She still doesn’t work two days in a row unless it’s the weekend, so she says her lack of sleep at home doesn’t affect her work too much. She is thankful she can be home with Carson to watch him play and grow while still maintaining her career.
“I’m just now feeling like I can balance everything—home, life, relationships, work. It’s still hard being a working mom, but everyday I feel like it’s getting a little easier!”
More than 9 million people live along the U.S.-Mexican border, a figure so staggering that economists and health care workers view this region as a quasi-country onto itself–neither American nor Mexican, but rather Amexican, as it was recently referred to in a Time magazine cover story.
This huge population–which includes both undocumented U.S. immigrants and legal residents–faces a variety of serious health risks, creating an urgent need for culturally and linguistically competent preventive education and nursing care. Yet with today’s severe shortage of nurses–particularly Hispanic nurses, who currently make up only about 2% of the nation’s RN workforce–the health care situation on the southwest border is in a near-crisis state. All sorts of undesirable health records are being broken at the border, including highest teen pregnancy rate, highest obesity rate, highest diabetes rate and highest rate of car crash injuries caused by not wearing seatbelts.
To complicate matters even further, more than 800,000 people cross the 2,000-mile-long border every day. As a result, says the Southwest Center for Environmental Research and Policy, the Borderlands population is expected to escalate to an unmanageable 24 million by the year 2020.
First Stop in America: The ER
Rudy Valenzuela, RN, MSN, FNP-C
Rudy Valenzuela, RN, MSN, FNP-C, is a family nurse practitioner with Southwest Emergency Physicians at the Yuma Regional Medical Center in Yuma, Arizona. “Last year our hospital received 14 patients who died crossing the desert [to enter the U.S.],” he says. “The increased security on the border has narrowed the cross points to only the most dangerous areas. [Undocumented] immigrants are forced to cross the driest, hottest part of the desert at night, and that’s how they die. Containing the border won’t stop them. The economic disparity between Mexico and America is so great, people will do anything to get here.
“As nurses, we see their health problems every day,” Valenzuela continues. “Heat exhaustion, hypothermia and poisoning. They get so thirsty crossing the desert that they’ll drink anything, including antifreeze. If they make it to the ER, we send them to dialysis.”
When illegal immigrants or undocumented workers show up for emergency treatment, nurses can find themselves caught in an unfortunate political bind. They want to treat the patients, but all too often they can’t, because no one can cover the expenses. Emergency nurses are trained to save lives, no matter what. Yet unless undocumented patients are literally at the brink of death, the hospital must turn them away.
“If patients are diagnosed in Mexico with a terminal illness, they try to come here because they think we can save their lives,” explains Jacqueline Crespo Perry, RN, BSN, president of the Houston Chapter of the National Association of Hispanic Nurses (NAHN) and an ER nurse at the Lyndon B. Johnson Hospital in Houston. “Unfortunately, we can’t do much for them. Some of them have cancer, but we can’t treat them long-term with chemotherapy if they’re undocumented and uninsured. It breaks our heart, but it’s the law.”
In 1985, to ensure that emergency care was available to anyone who needed it, Congress enacted the Emergency Medical Treatment and Labor Act (EMTALA). This law mandates that all patients who present themselves to the emergency department must be given a medical screening examination and be stabilized (if their condition warrants it), regardless of whether or not they have insurance coverage. Once they are screened, however, and are deemed to be in a stable condition, the patient must be released.
“We have patients who come here with end-stage renal failure,” says Perry. “Because they’re undocumented, we can’t put them on regular dialysis, which would be a three-times-a-week schedule. They can only come to the ER when they’re very sick, which is about every seven or eight days. If their potassium level is not low enough, we have to send them away until they get sicker.”
Torn Between Two Cultures
While the plight of undocumented immigrants is the most acute, legal residents living on either side of the border also have their share of health problems. For example, Yuma, a town on the Arizona/Mexican border, has the highest teen pregnancy rate in the state.
Valenzuela, who is president of NAHN’s Yuma chapter, attributes this to the fact that young people in the Borderlands are caught between two cultures. He explains that the parents come from a strict Mexican culture that doesn’t allow for abortion or adoption, yet the children grow up in a more liberal American environment, where teens are likely to be sexually active regardless of whether or not birth control is available.
But the most serious problem of all is that many, if not most, border residents lack access to preventive health care services. “Most of them do not have health insurance benefits, so they have to pay cash for their clinic visits. As a result, preventive care becomes a luxury,” says Maria Salinas, RN, who works at a family practice clinic in Houston.
“The biggest challenge for nurses is trying to educate these patients about why prevention is so important and what will happen if they don’t take care of themselves,” she adds. “For example, we explain over and over again that they need to do something about their high cholesterol or high blood pressure, but they don’t understand it, because they don’t feel sick.”
Furthermore, of the 9 million people living in the 48 border counties, 3.4 million fall below 200% of the poverty level, according to the Health Resources and Services Administration (HRSA)’s U.S./Mexico Border Health Task Force. This means that 38% of the border population is trapped in substandard living conditions and needs special assistance. Specifically, the task force has identified six major health priority areas for this region:
• Environmental health
• Health promotion/disease prevention
• Maternal and child care
• Occupational health (such as protecting migrant farm workers from pesticide exposure)
• Primary health care
• Substance abuse.
“This is all related to the poverty syndrome,” Valenzuela emphasizes. “The worst disease at the border is poverty. It results in unemployment, teen pregnancy, lack of quality housing, domestic violence, diabetes, cancer and more.”
Partnerships in El Paso
Fortunately, Hispanic nurses aren’t the only ones who are deeply concerned about the serious health disparities affecting border populations. In recent years, a variety of organizations–including hospitals, medical and nursing schools, government agencies, and non-profit foundations–have been teaming up in collaborative efforts to close the Borderlands’ health care gaps.
One particularly outstanding cooperative venture was created in El Paso as a partnership between the University of Texas at El Paso (UTEP), the Texas University Medical School in Brownsville, the W.K. Kellogg Foundation and the U.S. Department of Health and Human Services (HHS).
El Paso shares a border with Juarez in Mexico, and the two cities have a combined population of 2 million. The only thing that separates them is a dried-up Rio Grande, which at this point is no bigger than a family-size swimming pool, says John Conway, MPH, PhD, dean of the College of Health Sciences, Nursing and Allied Health at UTEP, where about 70% of the students are Hispanic.
In 1991, the college received a grant from the Kellogg Foundation to build four clinics dedicated to providing health care and medical services to the border population. The school then formed a partnership with the Texas University Medical School to run the clinics jointly. The Brownsville school supplies the doctors, while UTEP provides nurse practitioners.
HHS awarded UTEP’s Family Nurse Practitioner Program an $800,000 grant to prepare culturally and linguistically competent FNPs to work at the border clinics. The students are required to take two semesters of Spanish, says Jane Poss, PhD, DNSc, ANP, C-FNP, director of the program. About 12 nurse practitioner students, half of whom are bilingual, are enrolled in the program each year.
“They learn how to take a health history in Spanish, how to converse about medical issues with their patients and how to provide health care education,” Poss explains. “It’s practically impossible to provide good care to patients if you don’t speak their language.”
The clinics, which are directed by Leticia Paez, BS, MA, MPA, and managed by nurse practitioners, are located about 25 miles outside of El Paso in the Texas towns of Socorro, Montana Vista, Sabens and San Elizario. These are colonias or shantytowns, some without water and most with only dirt roads. Families with typically three children or more buy a piece of land for $200 and build one room as their home–living conditions that foster infections, domestic violence and squalor. The clinics themselves are based in school district buildings which were donated.
“We are training our health professionals to work in the colonias because these communities are terribly underserved medically and the people are extremely financially challenged,” says Paez. “Patients come to us with serious complications, things that could have been managed had they been caught at an earlier stage. They’ve had to go through years of [lacking access to even the most basic health care services] until they got to us.”
Poss notes that border populations have an especially high risk of diabetes, partly because of their diet, which is high in fat, carbohydrates and sugar. There is also a prevalence of obesity, asthma, tuberculosis, hepatitis A and lead poisoning in the colonias, she adds.
Robert Amador, RN, BSN, is a staff nurse at the clinic in Socorro, which sees about 500 patients a month, and he loves the work. “It’s different from working in a hospital, where you only see a patient for one or two shifts,” he says. “Here, you get to know how the people live and what kind of resources they have. You get to meet their families, and to understand the patient as a person.”
He remembers one patient who refused to take Celebrex to alleviate her rheumatism pain because she was seeing a curandero (folk healer) who had already prescribed herbs. Amador spent time talking to this patient, convincing her that his medicine was plant-based as well. Finally, she consented to try the Celebrex and soon felt relief from her pain.
The nurses quickly learn that many patients are being treated herbally for susto or fear (e.g., fear of dying from cancer), which the curanderos consider a symptom or even a separate disease. Several different herbs are prescribed for susto, depending on the curandero, so the nurses must keep up with the latest folk remedies and be mindful of adverse reactions that can occur when the American drugs interact with the Mexican ones.
Each of the four clinics also has promotoros (promoters), community outreach workers who visit the patients in their homes or other places in the community to educate them on the importance of visiting the clinic. Although the clinics do charge for their services, the cost is relatively low.
Guadalupe Ramos has been a promotora for the clinic in Sabens for 10 years, and she has seen and heard many stories. “A lot of people don’t believe in mental illness or depression,” she says. “They think it’s something they can control, rather than a disease that needs to be treated. I’ve learned a great deal about humanity in this job. The people I work with keep me grounded. Every day, I see life, death and resurrection.”
Many other health professionals who work with border populations are similarly passionate about what they do and have seen their efforts make an immediate impact in the lives of their patients. They feel gratified to be helping people who are so desperately in need, and they only wish that more could be done.
As Paez puts it, “The patients are so appreciative of our services. Nobody helps them but us and God. As Hispanic health professionals, we have a cultural understanding and sensitivity to these patients’ needs. The border is an exciting place with great opportunities to work with wonderful and courageous people who have tenacity and pride.”
What Can You Do to Help?
If you’re a nurse who wants to get involved in serving the urgent health care needs of Hispanic populations on the U.S.-Mexican border, here are three organizations that are worth looking into. They are involved in a variety of Borderlands outreach programs that can provide rewarding career opportunities for nurses.
US/Mexico Border Health Association
Institute for Border Community Health Education http://chs.utep.edu/KelloggProject/index.htm
HRSA Border Health Program http://bphc.hrsa.gov/programs/BorderProgramInfo.htm
New Initiatives to Improve Health in the Borderlands
Factors such as lack of health insurance, a shortage of culturally competent Spanish-speaking nurses and limited opportunities to receive preventive care and screening have all been identified as factors contributing to unequal health outcomes between Hispanic border populations and the Caucasian majority. Here’s a look at several innovative new Borderlands initiatives in California that are making strides in addressing these issues.
To close the insurance gap, Blanca Ramirez Brown, RN, CQI, CCM, cross border medical management manager at Blue Shield in San Diego, has designed the first HMO for the cross-border population in California. This program, which lets patients choose health care providers from Mexico or the United States, currently has 1,300 enrollees, many of whom still cross the Tijuana/San Diego border every day, although they are legal U.S. residents. They work for American companies who are willing to pay their health insurance premiums.
“Many patients have difficulty understanding the plan,” Brown reports. “I tell them to make an appointment with the doctor for preventive care, but they’re only used to walking into a doctor’s office when they’re sick.”
To recruit more Hispanic nurses into Borderlands health programs, Pablo Valez, RN, MSH, chief nursing officer at Chula Vista Hospital in San Diego, is working with the University Iberoamericana in Mexico to help nurses studying there become eligible for licensing in America. “Preparing these nurses to pass the U.S. licensing exam will be a long process,” he says, “but our goal is to recruit more Hispanic nurses from Mexico because there’s such a big shortage on this side of the border.”
Another U.S.-Mexican collaborative initiative, hosted by San Diego members of the National Association of Hispanic Nurses, is a binational health fair, now in its second year. The fair is held in April in Tijuana, Mexico. Nurses from Tijuana and San Diego participate in the event, performing physical exams (including measurements of weight, blood pressure, sugar, hearing and vision) and providing preventive education about diabetes management and diet control.
“The people in the community were so hungry for information about the management of difficult disease processes,” recalls Valez, who participated in last year’s fair. “It was a rewarding experience, because I know I really made a difference in the lives of many patients.”
Hispanics are the fastest-growing segment of the United States’ population—they currently comprise 16% and are expected to grow to 30% by the year 2050, according to the U.S. Census Bureau. However, Hispanic nurses make up only 3.6% of all registered nurses in this country, as reported by the 2008 National Sample Survey of Registered Nurses (NSSRN).
While other minority populations experience problematic underrepresentation in nursing, it is especially apparent in the Hispanic community, and the gap widens every day. In 2008, only 5.1% of all RNs spoke Spanish, according to the NSSRN. There are not enough Hispanic nurses to deal with the health care issues facing this growing population, and the language barriers and lack of cultural understanding created by the void lead to substandard health care for the entire community. In fact, a July 2006 article published by USA Today pointed out that the lack of English language proficiency in patients directly contributed to diminished health care for those individuals.
A 2008 workforce survey showed that Hispanics were 28 years old on average when obtaining their initial licensure compared to an average age of 25 for whites. The most common type of initial R.N. education among Hispanics was the associate degree in nursing (55.1%) followed by the bachelor’s (39.4%), and then a hospital diploma (5.5%). Why does the associate degree come out ahead? The reason may be financial. The A.S.N. provides earning power earlier than a four-year bachelor’s program in nursing. Hispanics were also more likely to pursue a bachelor’s degree after obtaining the initial R.N. (41%), but were less likely to pursue graduate degrees (11%) than white, non-Hispanic RNs (39% and 14.5%, respectively). Hispanic nurses comprise only 3.5% of all nurses in advanced practice fields.
The vast majority of Hispanic nurses (68.8%) work in hospitals and then in ambulatory care (6.9%). Hispanic nurses also hold only 10.9% of all nursing management jobs, possibly due to the low number of Hispanic nurses with graduate degrees. Finally, there are fewer Hispanic mentors in higher education and nursing leadership positions who can guide other Hispanics. Attracting and retaining nursing students from racial and ethnic minority groups can’t be accomplished without strong faculty role models. According to 2009 data from American Association of Colleges of Nursing member schools, only 11.6% of full-time nursing school faculties come from minority backgrounds, and only 5.1% are male.
As the U.S. population becomes more diverse, leaders in multicultural segments, including Hispanic communities, must encourage minorities—and minority nurses—to become leaders themselves, so when they continue to build upon their skills and advance their careers, they will help themselves and their communities. Health care for this underserved population should ultimately improve if it helps members of the Hispanic nursing community become leaders in health care, experts in the growing field of nursing informatics, and trained nurse educators.
Taking advantage of the online learning environment
Many factors promote successful career development and mobility among Hispanic nurses, and one of the most important is the opportunity for educational advancement. Online higher education programs in the field of nursing help students develop critical leadership skills that, in turn, lead to improvements in their overall community. The online format provides flexibility, providing students the opportunity to take courses while meeting their professional and personal obligations, contributing to multiple other benefits of studying nursing online.
Minority students at all educational levels can see graduates from these programs as role models and examples of how they, too, can achieve success. In cases where students may be struggling, it’s especially important when they can point to a nurse in a leadership position—someone who looks and sounds like they do—as an inspiration to keep going, whether it’s toward getting a Bachelor of Science in Nursing (B.S.N.), a Master of Science in Nursing (M.S.N.), getting a promotion, or taking on an important social change initiative to help a group in need.
Many of these minority students seek out mentors in school, possibly other minority nurses, and often go on to become mentors for the next generation of nurse leaders. For example, many of Walden University’s graduates work and teach in associate degree nursing programs, which have a large representation of Hispanic nursing students, and they help in retain these students through mentoring.
In some ways, online education “levels the playing field” for minority students, fostering increased participation and confidence that may lead to their greater success in the classroom and workplace. Many Hispanic students speak English as a second language and may write better than they speak. Since writing is integral to online learning, it adds a level of confidence that Hispanic students may not feel when sitting in a traditional, bricks-and-mortar classroom. There is no sitting in the back of the room or far from the action and dialogue up front. Consequently, minority students who may struggle in a traditional setting often thrive in online classes, which provide a unique venue for students to have a new voice, speak up, and become leaders in the classroom and beyond.
Increased participation in the online classroom has additional benefits for Hispanic and other minority nursing students. These students not only have the opportunity to hone their personal and professional skills and talents, but they can also develop relationships and network with other nurses across the country. A nurse working in the Cuban American community in South Florida may share best practices with a nurse working with the Mexican American population in Southern California. Or perhaps non-Hispanic nurses working with Hispanic patients may consult with their Latino classmates online for advice regarding how to provide the best care for these patients. Online higher education gives students a special way to connect so they can enhance their education and make a difference in the lives of many.
Making strides toward improving access
As a minority fellow of the American Nurses Association and a current board member of Ethnic Minority Programs for the organization, I work with my colleagues to develop proactive strategies to train, recruit, and retain more minority nurses, especially Hispanics. As Associate Dean of Walden University’s School of Nursing, I lead an experienced, dedicated, and talented team of faculty and staff focused on creating the next generation of leaders in the minority nursing community. Through programs like our Master of Science in Nursing and Bachelor of Science in Nursing Completion Programs, we can make great strides toward increasing the number of Hispanic nurses who serve as role models for the larger minority community.
Online Education in Nursing Informatics By Dr. Kathleen Hunter and Dr. Toni Hebda, Online Master of Science in Nursing Program Faculty, Chamberlain College of Nursing It’s hard to believe, but online education has been around for some time now. Many early online classes were largely text-based, inconsistent in quality, and less than dynamic. Today, the quality of instruction continues to improve, as schools integrate audio and video to meet different learning styles and provide robust student support structures and resources. With nursing informatics, it makes sense to use information technology to teach nurses about how that same technology can support them in a clinical, administration, or educational setting. Nurses must develop their informatics capabilities to understand how to use automated record systems to document care and to retrieve information on individuals as well as patient populations in order to track quality and identify potential problems. As patient advocates, nurses need to be involved in the design of this technology to ensure it promotes patient safety, is easy to use, and supports the caregiver. Increasingly, nurses will be involved in the delivery of care at sites heavily reliant on such technology, including home monitoring and virtual intensive care units. Many online education programs offer informatics, exploring core concepts of data, information, and knowledge in depth. Students gain experience in data management, health care information systems, and project management. The courses prepare nurses to combine their knowledge of information technology, health information exchange, and legal and regulatory issues with their clinical background. Nurses trained in informatics can:
Make the transition to a technology-rich health care delivery system smoother, more efficient, and safer for nurses and patients.
Help design information systems to optimize practitioner decision making.
Design, develop, and test tools for consumer health care, such as health-related websites, home care management systems, remote monitoring, wearable monitoring devices (smart technology), and telenursing (remote nursing via telephone, computer, and/or television).
Promote health literacy through the design and development of information tools that bring health information to diverse populations.
Teach patients using mobile technology (cell phones, notepads, etc).
For many M.S.N. and B.S.N. students, the training they receive in their online courses is put to work directly in their own communities. During their practicum or capstone course, M.S.N. students can choose projects that are inclusive of the needs of their workplace or neighborhoods. Often, these projects involve working with underserved populations to solve problems in community health care. B.S.N. students undertake similar projects in their community health practicum. They can all tap into their nationwide network of fellow students to come up with the best solutions for problems they encounter.
I especially recognize the importance of recruiting faculty members at the doctorate level from minority groups. Since there already is a shortage in the number of Hispanic nurses, you can only imagine how few in this population have earned their doctorates. Yet, they do exist, and when they teach, they make a difference.
One example is Patti Urso, Ph.D., A.P.R.N., C.N.E., Specialization Coordinator of Nursing Education, who currently teaches nursing education courses at Walden. Dr. Urso, a Cuban American originally from Miami, is a nurse practitioner who now lives in Hawaii and works with other underserved populations from Polynesian and Micronesian communities. In Hawaii, she engages with Hispanic patients through community churches and is involved in forming a new chapter for the National Hispanic Nurses Association. She hopes to inspire her students to reach out to underserved communities, and she mentors Hispanic students in the capstone course of the nursing education program.
One of the ways Dr. Urso works to connect with Hispanic nurses is through contact with alumni such as Lydia Lopez, one of the first graduates from Walden’s M.S.N. program in 2007. As a nurse and mentor, Ms. Lopez is committed to being a role model who recruits and retains minority nurses, keeping them interested in their course work and giving them the necessary tools and strategies to facilitate academic success. “True role models are those who possess the qualities that we would like to have and those who have affected us in a way that makes us want to be better people,” she says.
The nursing profession needs both men and women from all ethnicities to meet the needs of society. Minority nurses—especially Hispanics—with bachelor’s degrees and, eventually, master’s and doctoral degrees—who are prepared to educate and lead a new generation of minority nurses—will help improve this critical situation and provide essential health care for all.
Correction: “First Generation Education,” a feature published in our fall 2010 edition, referenced Glen G. Galindo as CAMP’s Executive Director. He is the Executive Director of CAMP’s alumni association, an independent organization. For more information on CAMP, visit www.hepcamp.org.
With college costs constantly on the rise, there’s no denying that pursuing higher education is a massive undertaking—the academic, financial, and emotional elements strain not only students, but their parents and guardians too. So how big of a dent can $750 make in a $10,000 tuition bill? How about a few hours of academic counseling in a jam-packed class schedule? For first-generation students, it makes all the difference in the world.
The College Assistance Migrant Program, or CAMP, is a government-sponsored college outreach and scholarship program for students from migrant and seasonal farmworking backgrounds. Established in 1972, a product of President Johnson’s War on Poverty campaign, it has grown from five school branches to 38, with a multimillion dollar backing. From advice on admission and navigating financial aid applications to transitional counseling, CAMP supports students who often cannot turn to their families for help. The program focuses primarily on helping students get into college, but they also offer mentoring through the college years. About 2,000 students benefit from the program each year, joining an alumni network of well over 20,000. Executive Director of CAMP’s alumni association Glen G. Galindo reports a college freshman retention rate of approximately 90%.
Galindo was recruited to CAMP as a freshman at California State University in Sacramento in 1986. Since then, it seems he’s held practically every position in the organization, from student assistant to his current role. He speaks quickly and passionately about the organization and what it does.
“CAMP will provide students with assistance during the application process and support during their freshman year in college. But, ultimately, preparation during high school is a student’s best friend,” he says. “All high school students greatly improve their chances of reaching their educational goals if they earn a high GPA, take the correct college preparatory courses, and take their SAT/ACTs more than once. Unfortunately, most first-generation students lack in one or all of these key points.”
CAMP is not a political organization, Galindo says. It’s funded by federal grants; as such, it can only support U.S. citizens and legal residents. “We would like to see the Dream Act legislation pass so as to give greater opportunity for youth to pursue higher education,” Galindo says. “CAMP students typically have parents with an elementary-level education. Most are U.S.-born citizens, and as first-generation students, simply need guidance and mentorship to reach and succeed in higher education.”
What follows are the stories of three CAMPers. Each student is the first in his or her family to attend college, but the similarities don’t end there. They all appreciate their families and their education. They know they are role models, and they take that responsibility seriously. They understand they’ve been given an opportunity that’s not to be squandered.
Ana Laura Meza
Born in Jalisco, Mexico, Meza moved to Oregon with her family about 15 years ago. She spends her time outdoors, when the Northwest weather allows, and she loves being with her family, listening to her parents’ stories or playing what must be a massive game of Uno—she’s one of seven children.
Meza discovered CAMP as a volunteer at a Cesar Chavez Workshop in Independence, Oregon when the program offered a class that caught her interest. “I did not know much about what I was going to do financial-wise to pay for school,” she says. A CAMP representative named Isabel met with her to explain the program and what she had to do to apply. “We got a bit side tracked dancing and laughing because of the band that was playing outside,” Meza says. “Isabel not only helped me that day to get the application, but she offered her friendship.”
Meza says CAMP gives students a chance to slowly transition from high school to college. “It gives them a small push of motivation to continue to school, to achieve their goals.” Whether it’s a little extra money or life-changing mentoring, CAMP provides essential support at a key transitional point in students’ lives.
“I loved everything about CAMP, from the borrowing of books for your classes to the mentors who kept you updated every week, and the field trips to the local universities,” Meza says. “But the most memorable thing is the people that you meet along your first year.” They bonded over potluck dinners each Wednesday, she says. “The bonds you make with other CAMP students and staff you will keep for the rest of your life.”
Meza faced a number of obstacles in achieving her education, including the price of tuition. “Every person attending college knows that books and tuition are expensive and being unemployed does not help at all,” she says. While the lack of money is a common problem for students from all walks of life, first-gen students also deal with some lesser-known, unique obstacles at home. Never having experienced college or dealt with a child in higher education, Meza’s parents did not always understand all the things she had to do to get good grades, she says. “But no matter what they were always supportive.
“I want my parents to be proud of me, see that I am taking the opportunity of living in the U.S. and not just throwing it away,” she says. “I also want to be a role model for my younger brother who is in high school. I want to show him that if I can do it, so can he.”
Meza just started her second year at Chemeketa Community College in Salem, Oregon, but she hopes to transfer to Western Oregon University in the spring and work toward her bachelor’s degree in nursing. “When I was a little kid. I always enjoyed playing ‘doctor’ with my dolls, setting up scenarios where I had to fix their broken leg, or they were sick and they needed some soup,” she says. “I remember cutting my old shirts and using them as bandages or pencils as needles. As I grew I still had the interest to help people out, and what better way than to be a nurse.”
Jump at the chance to become a CAMPer, Meza advises students considering the program. “One thing for sure is do not take this opportunity for granted, because so many students who live here in the U.S. don’t have the same opportunity as we do,” she says. “Chances like this might only come our way once.”
Jose Arrezola
Health care translators bridge the language gap during some of life’s most difficult and stressful moments. In the public health sector, it’s especially trying work, but it’s Arrezola’s passion. CAMP played a prominent role in getting him there.
Arrezola had already participated in a high school program geared toward migrant children before he learned about CAMP. When he discovered there was a similar program at CSU Fresno, he made an appointment to meet with the director and soon found himself involved as a CAMPer. “I read and learned a great deal about CAMP, and it made a significant impact in my life. I say this because right then I learned that I was going to be part of a group of students that were migrant like me and that also shared many cultural practices like mine,” he says. “That made me feel like I was going to have a family away from home.”
The eldest of five siblings in a family from Amacueca, Mexico, Arrezola came to the United States at 17 years old. He did not speak English, but he learned during night classes after full days at high school.
He credits his parents for their constant support and motivation, but he also struggled to relate the college experience to them. “Because I am of a migrant background and my parents did not go to school, they do not understand the educational system,” he says. “My parents always knew that school will prepare their kids for a better future, but it is not comprehensive.” He says he’s met many other CAMPers with similar problems. “Unfortunately, for various reasons, our migrant parents are not educated about the school system, whether it was poverty, machismo, lack of guidance, or role models.”
Another all-too-common barrier was money. His parents couldn’t afford his tuition, but with financial aid, determination, and help from CAMP, he was able to obtain his bachelor’s degree. “[My parents] did not have the opportunity to go to school like I did. It is my priority to also be a role model to my younger brothers and sisters, because I would also like for them to have a life full of opportunities to enjoy life to its fullest extent.”
Arrezola says college was always part of his plan; he didn’t consider it “optional.” “I was going to be one of those individuals that was going to have guidance in school and also was going to represent the minority in our community,” he says. “Education for me has been my inspiration to make a positive impact in the life surrounding me. I have always believed that an educated community cannot become perfect, but an educated community for sure can make better choices and make a difference.”
Arrezola is currently pursuing a master’s degree in public health at California State University, Fresno. “I always knew that I wanted to stay in the medical field,” he says. “After I graduated from college and became a health educator, I saw the necessity and the need to educate our communities about preventative care.” At 30 years old, he’s already worked as a bilingual health educator, leading one-on-one and group sessions throughout California, particularly in rural areas, for United Health Centers, and he’s served as the Administrative Leader of HealthCare California. As a volunteer, he’s worked as a bilingual spokesperson for the American Cancer Society. “This experience has given me the option to understand that, in our society, we have different groups of the population that need a lot of help finding guidance to medical access,” he says.
Arrezola has seen the health disparities in rural communities with limited access to health care. “I felt a close connection and could relate to the concerns of these individuals from personal experience,” he says. “I also felt the need to promote awareness about cultural sensitivity because there are a great deal of barriers, such as language, religion, and communication, etc., that retain people from seeking medical care.” He plans to finish his master’s degree and pursue a doctorate in public health with an emphasis in education.
To Arrezola, if any program can help students through the college experience, it’s CAMP. “I am still involved in the program because I see that new students have the same questions that I had when I was beginning my education at the university, and I want to be able to help them in the same way that program helped me,” he says. “I am proud to say that I am still a good friend with many of the students that I met at the CAMP program. Now a lot of them are professionals in the workforce, and the network that we have built has been a great help to continuously grow in our careers.
“I would like to tell students to take advantage of a program such as CAMP,” Arrezola says. “Be serious about wanting to pursue a college education and not feel discouraged.”
Benita Flores
“My parents are from Jalisco, Mexico, and although I was born in San Diego, I’m proud to say I’m from Jalisco, Mexico, too,” says Flores. Now enrolled in her fifth year at California State University, San Marcos (CSUSM), she first learned of CAMP as a senior in high school, after being accepted to the University. “I had heard the program would help me in my first year at CSUSM,” she says “Students need someone to guide them throughout the first year of college. It’s wonderful to know someone out there cares and wants you to succeed.”
Flores also came from a low income family. Her father and brother shared the family car, and she had trouble getting to her college classes. “I desperately needed a job to cover my expenses, which included my textbooks for college,” Flores says, so she got a job as a tutor at her old high school and took their bus. “At times it was embarrassing, since students that knew me would ask, ‘Didn’t you graduate already? What are you doing here?’ But being embarrassed was nothing compared to my determination to overcome financial and transportation obstacles.”
Flores wrote about her dreams of becoming a doctor when she was a little girl, she says, but she decided she wanted to become a nurse in high school. Sometimes I would fake being sick because I wanted to go ask the school nurse about nursing,” she says. “Volunteering at Palomar Hospital for two years helped me notice the great satisfaction I would feel when I would receive a smile from the patients I helped. I realized how privileged I was to be able to help the less fortunate.”
And, like the other CAMPers, Flores credits CAMP for providing the support necessary to not only attend but thrive in college. “I thank the CAMP staff for the help they gave me through these past years; if it wasn’t for them, my path in school would have been full of obstacles,” Flores says. “Once you become part of the CAMP family, they guide you through your college years and the road to success becomes more visible.”
*Correction: This article originally referenced Glen G. Galindo as CAMP’s Executive Director. He is the Executive Director of CAMP’s alumni association, an independent organization. For more information on CAMP, visit www.hepcamp.org.
