Some rules on physical appearance in hospitals and other institutions can be off-putting to nurses, especially students entering the profession. “Why can’t I wear nail polish?” they might ask, or “Why do I have to cover up a tiny butterfly tattoo on the back of my neck?” Sometimes, these rules are based on concerns about infections, backed by rigorous scientific studies. But in many cases, the rules are based on less definable concerns, such as concepts of nursing professionalism or what is thought to bother patients.
The rules vary widely by institution, and they are evolving as social norms change. For example, a growing number of young nurses wear tattoos and piercings, pressuring hospitals to relax rules. Also, the Civil Rights Act of 1964 protects discrimination against racially based hairstyles such as afros and dreadlocks.
The following is an analysis of some of the most controversial rules, based on dress codes posted on institutions’ websites and nurses’ comments on message boards.
Banning Nail Polish and Gel Some hospitals and nursing schools ban all form of nail polish, which can upset some nurses. For example, a nurse on the allnurses.com discussion forum wrote that a ban on all nail polish would make her seriously consider finding a new job. “I think that ‘no nail polish’ is a pretty ridiculous requirement,” she wrote. “Seeing a cheerful color on my nails brings a smile to my face.”
Such bans are based on studies showing that when the polish chips, infections can lodge inside the crevices. That’s enough reason to ban all nail polish, according to Beverly Malone, PhD, RN, CEO of the National League for Nursing. “Patient safety should be the paramount concern,” she says.
However, many institutions only ban long fingernails and artificial nails, which have been shown to have higher risks of infection than ordinary nail polish. And other hospitals, focusing on the problem of chipping, simply ban chipped nails or require new polish on nails every four days, to reduce the risks of chipping. But this requires strict enforcement.
The problem is that rules that are nuanced may be difficult to carry out, and enforcement relies on frontline managers who may be less than enthusiastic about them. “A policy that says ‘NO…but!’ is no policy at all,” another nurse wrote about nail standards on allnurses.com. “If they make allowances (4 day changes, etc.), they might as well just shut up about the issue and everyone can wear what they want.”
The introduction of gel and shellac nails over the past few years has only complicated matters. These polishes last longer than traditional products and are touted as chip-free. Although they are still too new to be well-studied for infection risks, some hospitals have included them in bans of artificial nails, and this has caused uproar among some nurses.
Tess Walters, a manicurist in Logansport, Indiana, says a ban on gel nails at a nearby hospital brought in six nurses who needed emergency redoes. “Hospital policies lump gel polish together with artificial nails,” Walters says, adding that “sweeping policies make for disgruntled employees.”
Excluding Unusual Hairstyles Many hospitals and nursing schools ban hair in bright, unnatural colors, and some specifically ban unusual styles. “Extreme trends such as dreadlocks, Mohawks, and long spiked hair is not acceptable,” according to the University of Utah Health Care’s dress code. Other institutions are more easy-going: “There are 3 nurses on my unit that have locks and I never heard a problem about it,” according to a comment on an allnurses.com forum discussing nurses with dreadlocks. “Personally, I think if the unit and region is culturally diverse then it won’t be a problem.”
Hairstyles that can be pulled up or tied back don’t appear to present problems with infection control. But, Malone says unusual looks may offend some patients and staff. When hospitals formulate rules, “patients’ views and the professionalism of nurses ought to be major considerations,” she says.
However, Malone doesn’t think the rules should impinge on natural hairstyles, such as dreadlocks, worn by African Americans who choose not to straighten their hair. According to the Equal Employment Opportunity Commission (EEOC), Title VII of the Civil Rights Act makes a distinction between racially based hairstyles and ones that could be worn by anyone, such as Mohawks or green hair.
The EEOC compliance manual, which carries out Title VII, prohibits employers from restricting hairstyles that involve “racial differences in hair textures.” However, a federal judge in Alabama recently denied an EEOC lawsuit against an insurance company that terminated a dreadlocked employee, arguing that African Americans have a choice to wear other hairstyles besides dreadlocks. The case, EEOC v. Catastrophe Management Solutions, is being appealed.
But even hairstyles not protected by Title VII are flourishing in some places—perhaps because employers have no interest in being strict, or because they prize the nurse’s skills and patients don’t seem to mind. Another nurse on allnurses.com says she has worn spiked hair and a rattail in a wide variety of health care settings for about 20 years, and she now works in a rural Appalachian community. “The little old country Baptist preachers’ wives often comment on how much they like my hairstyle,” she asserts.
Curbing Tattoos Hospital rule-makers have had to contend with a surge of young employees with tattoos. A 2012 Harris survey found that 38% of Americans in their 30s had at least one tattoo. Minorities in particular seem to have them. A 2006 study published in the Journal of the American Academy of Dermatology found that 38% of Hispanics and 28% of blacks had tattoos, compared with 22% of whites.
“Tats” were traditionally for males, but the Harris survey found that as of 2012, more women than men wore them. However, most female tattoos aren’t visible. According to a 2010 Pew Research Center survey, only 13% of tattooed women had art that could be seen outside their clothing.
Unlike nail polish, tattoos don’t present safety issues like harboring germs, but they can upset patients and other staff. According to a 2012 study in The Journal of Nursing Administration, patients tend to have negative attitudes toward health care workers—especially women—who have tattoos. Moreover, certain tattoos, such as depictions of demons, may strongly offend some patients.
Hospitals typically prohibit visible tattoos but often allow employees to cover them up under long sleeves, Band-Aids, or larger bandages. “I’m not saying get rid of your tattoos,” Malone says. “Just cover them up when you’re at work. You’re in a professional setting.”
Some hospitals soften the rules on covering up. The radiography school at Akron Children’s Hospital calls for covering up “to the extent possible,” and Rochester General Hospital calls for covering “inappropriate” tattoos.
A few, though, have stricter rules. For instance, the nursing school of Missouri Southern State University not only bans visible tattoos but won’t allow students to cover them up, either. In 2009, the policy drew many protests from applicants, according to The Joplin Globe. A spokesman for the school told the Globe that a bandage put over the tattoo “could become wet or soiled, and there is the potential for cross-contamination.” The school’s 2014-2015 student handbook shows the tattoo rule is still in place.
Like employees with green hair or a Mohawk, people with tattoos basically don’t have any Title VII protections either, according to Robert G. Brody, an employment attorney in Westport, Connecticut. In a 2010 analysis, he wrote that the law “does not include ‘tattooed’ as a protected classification.”
Rules on Body Piercings and Earlobe Gauges Body piercings are now common among younger women in particular. According to the 2010 Pew Research Center survey, 35% of women and 11% of men under age 30 have a piercing somewhere other than in an earlobe.
The eyebrows, nose, top of the ear, lips, and tongue may be pierced. In addition, holes in the earlobes can be stretched and fitted with round ornaments, or “gauges,” which are as much as 1½ inches in diameter. Piercings don’t seem to present much of an infection hazard for patients, but items like large nose rings could be grabbed by patients, and the sight of these adornments can be off-putting to some people.
Basically, piercings don’t have Title VII protections from employers’ actions. Hospital rules typically state that “visible” piercings are prohibited, but it’s not clear what that means exactly. Does it mean that piercings will be allowed if the jewelry is removed and replaced with clear or skin-color pieces—the equivalent of a Band-Aid over a tattoo? Or, does it mean that only piercings under the clothing will be allowed?
Children’s of Alabama, a hospital in Birmingham, meant the second interpretation, according to Deborah Wesley, RN, MSN, the hospital’s chief nursing officer and coauthor of its rules. But some institutions specifically allow some camouflaging. “Ear gauges must be covered/non-conspicuous,” according to the nursing student guidelines at Tarrant County College. Alternatively, Lancaster General Health in Pennsylvania allows gauges that are solid, don’t exceed ¼ inch in diameter, and don’t have jewelry connectors.
Rulemaking and Enforcement When making rules on appearance, hospitals have to balance the conflicting demands of patient safety, patient satisfaction, and employee satisfaction, says Wesley. To make sure employee satisfaction has a role, staff nurses at Children’s of Alabama develop the first draft of the dress code, which is then sent to leadership for approval, she adds.
This process produced a rule on tattoos that is unusually tolerant. “Tattoos that consist of nudity, profanity, or are racial in nature are not allowed,” the Children’s of Alabama rules state. As a result, tattoos “have not been an issue for us,” Wesley says. “We understand that newer generations have evolving views on this.”
For rules to be respected by staff, they have to be enforced in an equitable way, she argues. Management has to understand the rules and believe in them. At Children’s, “the rules are managed at the unit level,” Wesley said. “Our frontline leaders know these policies and procedures.”
“We have really tried to find a balance,” she says.
Leigh Page is a Chicago-based freelance writer specializing in health care topics.
Do you work at one of the more than 400 Magnet-recognized hospitals around the world? It has been said that minority nurses who work at these recognized facilities have the benefit of flourishing in a positive environment with employers who value their skills and career goals.
However, the results of Minority Nurse’s 2014 best companies survey suggest that nurses value other qualities far more than Magnet status when it comes to selecting an ideal employer. The survey, which was conducted late last year, asked nurses how important certain qualities (such as salary, benefits, and flexibility of hours) were to them when considering an employer. The results revealed that Magnet status ranked near the bottom of the list, only ranking ahead of one category: workplace size.
For some health professionals, the question of whether or not Magnet status is important can’t be fully answered until they know more about the designation, and that includes those nurses who work at Magnet-designated facilities, says Kristin Baird, RN, a hospital consultant.
“In some programs, people talk about ‘Magnet’ but people don’t understand it,” she says. In turn, they may be less likely to advocate for it or share its benefits with their colleagues. If a facility has already achieved the designation by the time a nurse is hired, then the nurse who didn’t go through the certification process may have a harder time understanding its importance and impact, especially when speaking with fellow nurses, Baird argues.
“If it’s just part of who [their hospital] is and people stop talking about it, and they don’t embrace what it means, they’re not going to be promoting it,” she says.
However, many nurses who work at Magnet hospitals and who do understand the program believe that it is a very important ideal. “Having Magnet status heightened our visibility in the community and state for being a leader for health care,” says Cabiria Lizarraga, RN, manager of telemetry at Sharp Grossmont Hospital in San Diego, California. Sharp Grossmont Hospital first received Magnet status in 2007.
Other hospitals likely receive positive coverage in their communities as well, Lizarraga adds. In fact, according to the American Nurses Credentialing Center (ANCC), 15 of the 18 medical centers on the 2013 US News Best Hospitals in America Honor Roll and all 10 of the US News Best Children’s Hospital Honor Roll for the same year are recognized by the ANCC as Magnet-recognized organizations.
“It’s very important to have because it shows we are committed. When people see we are a Magnet facility, they know the employer is committed to nursing excellence,” says Lizarraga.
Patients who are seeking hospitals may also look for the Magnet designation as an objective benchmark to help them choose where they’ll do business, says Nick Angelis, CRNA, MSN, a nurse anesthetist in Pensacola, Florida. Angelis has worked at Magnet and non-Magnet hospitals throughout his career.
Understanding the Magnet Designation
According to the ANCC, which is the Magnet credentialing organization, there are three goals for the program:
• Promote quality in a setting that supports professional practice;
• Identify excellence in the delivery of nursing services to patients/residents; and
• Disseminate best practices in nursing services.
The process to achieve Magnet status is identified by the ANCC as the “Journey to Magnet Excellence.” Facilities have to show that they have strong nurse leaders who are able to guide teams, develop professionally, take the lead in research efforts, and can show good empirical outcomes and the impact of those results. The certification lasts for four years, after which time the facility can re-apply.
Angelis, who has served on several committees on hospitals seeking Magnet status, says it is an expensive and time-consuming process, but it’s a good way for hospitals to prove that they value nurses. “A Magnet designation can be a hint that a hospital has a culture that respects the contributions its nurses make,” he explains.
“Nurses want to work for an organization that really strives to empower them, one that has opportunities in place for them to do research or advance their degrees,” says Lizarraga. Facilities that have Magnet status can attract some of the best nurses available, she adds. “It is used as a recruiting tool because nurses would know about Magnet nursing excellence.”
Angelis says that if a hospital has low morale among nurses, achieving Magnet status can provide positive motivation. “It’s an opportunity for the hospital to change their culture,” he says. “Facilities that empower their nurses can improve morale, and that can help with job recruiting and retention.”
Some Nurses Left Behind?
Having an environment that encourages professional development among nurses is a positive, but there is a concern among some professionals, particularly those who don’t have advanced degrees, about where they fit in under a Magnet facility, explains Lizarraga.
Will the jobs be there for LPNs and for associate degree and diploma nurses? “There is some concern about whether or not they’d be able to practice in an acute care hospital or Magnet facility,” says Lizarraga. It may be understandable why many Minority Nurse survey respondents viewed Magnet status as only “somewhat important.”
But that issue is bigger than Magnet certification, Lizarraga argues. In 2011, the Institute of Medicine released a report recommending that the proportion of nurses with baccalaureate degrees be increased to 80% by 2020. This recommendation affects all nurses, not just those at Magnet hospitals, she adds.
However, many nurses who have more advanced degrees obviously have an advantage, states Baird. “It’s not to say there’s not a place for LPNs, but if you’re a Magnet hospital you’re looking at advancing nursing as a profession and making sure you’re finding nurses who want to be at the peak of the profession,” she explains.
Find the Best Match
So what’s a nurse to do? According to Baird, nurses of all education levels should first identify their career goals and factors that are personally important, such as career growth potential, flexibility options, and income. Then, identify an employer that seems to offer the best environment.
“I’m a big advocate of hiring for fit and choosing a job for fit,” says Baird. “Identify your core values, then find an organization that’s in alignment with those values.”
If you plan to obtain an advanced degree or would like the opportunity to go into research or academia, working at a Magnet facility may be able to provide you with more opportunities than a non-Magnet facility, she says.
However, if a potential employer is not a Magnet facility, but has other benefits that may be important to you—such as more flexible scheduling or a generous tuition reimbursement program—that could be the way to go, says Baird. Whether nurses work at Magnet hospitals or not, identifying employers aligned with their values puts them in the best position possible to benefit their patients and their careers.
Margarette Burnette is a freelance writer based in Georgia.
Good nurses are professionals who strive to make a positive impact in their organizations. Some are able to make this impact by working in planning with hospital administrators.
The minority nurse who works in planning is in a pivotal role for making sure patients are safe, says Evelina Echols-Sutton, BSN, RN, nursing director of Women and Children’s Services at Methodist Charlton Medical Center in Dallas, Texas.
These professionals often have leadership titles, such as nurse manager or nurse director. Or they may be in specialty roles, such as nurse statistician and nursing informatics, she says. But one common theme is that they are called on to share ideas with their organization’s leadership.
“They are in those key meetings where decisions are made on the policies that we adopt, the equipment that we eventually bring in to our facility, and the streamlined workflows that will make sure our patients and family are safe,” says Glenda Totten, RN, MSN, CNS, director of nursing services at Kaiser Permanente Los Angeles Medical Center in California.
On an average workday, a nurse who works in planning may interact with the director of pharmacy, information technology, environmental services, human resources, risk management, and legal departments, says Echols-Sutton. “My typical day is probably about four hours of meetings, four hours of office work, and then four hours of follow-up on all these activities.”
“Meetings are also a constant variable in my day,” says Sylvia Williams, RN, MSN, director of education and inpatient nursing services at La Rabida Children’s Hospital in Chicago, Illinois. “They range from brainstorming meetings on quality initiatives to troubleshooting staffing concerns. On average, I would say I am in meetings a good five to six hours per day. They are important to keep morale high and ensure everyone works together harmoniously.”
Kanoe Allen, RN, MSN-CNS, PHN, ONC, is chief nursing officer at Hoag Orthopedic Institute in Irvine, California. She says that nurses who work in planning have to juggle meetings with idea generation. “One of the challenges is carving out time to sit quietly and think through the issues and to have time to develop solutions,” says Allen.
Unsurprisingly, nurse leaders are better compensated for their efforts. The median pay for a nurse manager is $77,988, while it’s only $55,447 for a registered nurse, according to Payscale.com.
Hospitals in turn get someone who engages in positive relationships within nursing, and with managers, supervisors, staff nurses, and executive leaders, says Totten. “It takes all that to make it work and have a world-class facility.”
Managing Inside and Out
In addition to working with leadership, minority nurses in hospital planning also have to help manage their organizations’ external pressures, says Totten. There are numerous outside factors to consider, such as working to meet the standards established by the Joint Commission. As an example, Totten regularly conferences with a stroke performance improvement committee to help her facility earn a comprehensive designation from the Joint Commission.
“It’s ensuring that for any [stroke] patient that goes to our emergency room, or any that are inpatients, we react immediately. We get the neurology resident in there and get the team in there within seconds,” she says.
Totten also works on a nursing quality improvement committee to assess nurse sensitive measures, such as interventions that help prevent falls in the hospital. Her teams are responsible for coming up with tools to communicate with nurses so that they are quickly informed about any relevant changes within the medical facility.
“We plan for our 1,200 or so nurses to make sure that everyone, including the per diem nurses, know what’s coming, what’s changing, how they can get more education, and the kinds of tools they need so that they’re up-to-date with the changes,” explains Totten.
Another planning team is responsible for providing constructive criticism to nurses on meeting patients. This involves communicating the best ways to exhibit caring behaviors, such as pulling up a chair and sitting eyeball to eyeball with those they serve, says Totten.
“It’s evidence-based and proven that you don’t want to stand over [patients]. You want to be as close to them as possible,” she notes. “We’re trying to standardize how we greet our patients when they come in on admission and also while they’re here.”
These issues are important because of the new value-based purchasing environment, says Shawana Burnette, OB-RNC, MSN, CLNC, a nurse manager in High Risk Post Partum and High Risk OB at Carolinas Medical Center in Charlotte, North Carolina.
A portion of reimbursements received from the Centers for Medicare and Medicaid Services will be based on the patient’s value perception of the care they receive, she explains. This means nurses in planning have to encourage their teams to not only help the patient heal, but to also have a good bedside manner.
Another area where nurses who work in planning are called on to help is to find ways to improve infection rates. The Centers for Disease Control and Prevention as well as the Institute for Healthcare Improvement review these rates, and of course, the goal is to have them as low as possible, says Totten. “You have to plan how you can show that you have a stellar place.”
Medical centers also compete with other health care centers in the community. “The consumer is more astute nowadays, and they are open to shop for the best medical facility, best health care facility, and the best insurance,” she notes.
This means nurses who work in planning often need to represent their medical centers to the community. “We have a foundation that does fundraising. In order to help them, I have to go out and speak,” says Echols-Sutton. “You want to talk to those that you serve, and find out what’s important to them.”
Improving Soft Skills, Leveraging Clinical Skills
First, health care is a highly regulated industry. Second, reimbursements are based upon the customers’ perceptions of “soft” skills, explains Allen. “Putting the two together is a change for this industry.”
Fortunately, nurses are usually well-prepared. “Nurses, by their calling, have a set of innate behaviors of putting people and solutions to the front,” says Allen. “It is a team spirit, not an individual-only spirit. That is key to the success of multidisciplinary patient care.”
People come to nursing with a big heart and a desire to help others, and it serves them well in collaborative environments where they have to work together to find the solutions, she adds.
Allen notes that being successful in nurse planning requires emotional intelligence, meaning the ability to understand and have a sense of another person’s views. To achieve success in planning means being a team player, using that emotional intelligence to understand the interplay between various personalities and departments, and working in a collaborative manner to solve regulatory and other issues, she says.
Minority nurses who work in planning can also help bridge multicultural gaps. Multicultural environments are a challenge to blend and the goal is to bring out the best attributes, says Allen.
“We serve patients from many backgrounds and having a diverse staff allows us to better anticipate and understand their cultural needs,” notes Williams.
Soft skills are necessary in higher levels of planning, but practical experience is also important, explains Totten. “One thing you can never take away from a nurse is her clinical skills. It’s handy when you’re working in a clinical setting. The more you move up in your career, [the more] those clinical skills are key.”
It all comes down to ensuring that staff members have the correct resources to care for patients, says Allen. Providing the right resources allows the staff to provide strong patient care. “Staff who do not have to worry about resources and administration support provide great customer service,” she adds.
The Career Path
Minority nurses who want to work with hospital administrators, or who want to be in administration themselves, have multiple options.
“The best thing about the profession of nursing is you can pretty much take any path. You can be in a clinical track and still move up to administration. There is also the education track, nurse practitioner track, and advanced practice nursing,” says Totten. “All these elements can secure you a good position in administration.”
Totten’s own background is as a clinical nurse specialist, but she emphasizes there are many ways to advance.
As a first step, Burnette suggests becoming a bachelor’s-prepared nurse. “They have the four-year preparation that includes handling more professional issues and critical thinking,” she explains. “The classes prepare you to be in a leadership role.”
But you should also have your sights set on earning a master’s degree. “Years of experience on the nursing unit are critical, but I would strongly recommend to anyone that is interested in this path to pursue an advanced degree in nursing,” says Williams.
“Nurses who work in planning need knowledge-based skills like budgeting and financials, experience you don’t necessarily receive on the floor,” she continues. The more educated you are regarding the area you’re going in, the more prepared you will be.
Another important means for having a successful career in hospital planning is to find a mentor who can show you the ropes in a real life environment, notes Williams.
“There are many ups and downs in nursing. There are plenty of wonderful days, and there are days in which nothing seems to go right. Being able to balance the good with the bad is essential to having a long career in nursing,” argues Williams. A good mentor can instill these lessons to their mentees and help them find their way, she adds.
Mentoring is intended to help nurses develop their skills and grow within the nursing profession. “The mentor accomplishes this by sharing their years of experiences—warts and all—to help them see nursing in its true light,” explains Williams.
Mentoring also helps a person explore who they are and how they can achieve more in their career, says Allen. In some cases, it opens doors for opportunity as well. “I have had a mentor who challenges my thoughts and plans, refocuses me when I am at a loss and then cheers me on,” she continues.
Having a mentor can also help nurses develop critical work skills, such as priority setting, stress management, people management, and good communication, says Echols-Sutton. She hasn’t had an “official” mentor, but she has had role models she patterned herself after. Other nurses who aren’t in employee-sponsored mentor programs can do the same, she notes.
“I didn’t have just one person. I tried to learn from everybody, including coworkers, bosses, and even people out in the community,” says Echols-Sutton. “They were available for me to pick their brains.”
Burnette advises nurses to find mentors who are not necessarily in their departments. If you talk to someone who works in another area of the hospital, they can give you a more global view of your organization. It’s important to surround yourself with people who have different perspectives but who are committed to achieving the same goal of providing patients with the best possible health care, she adds.
Whether a nurse joins a formal preceptor program or starts an informal mentoring friendship, anyone who wants to work in planning should reach out to a health care professional with more experience to help them along, argues Totten. “It’s not just enough to sit in your position.”
Working with Administration
Hospital administrators face many challenges from staffing to budgeting, and it is impossible to have a “go alone” mindset, says Williams. That’s why nurses who are in planning are a vital part of the team. Nurses who work with hospital administration report that their careers are fulfilling, and they have a large say in improving their hospitals.
“When you’re working in planning, you’re able to communicate with all the various staff as well as patients. It gives you a love for the ways you can improve the care that’s delivered to patients,” says Williams. “That’s where you can make the biggest impact.”
Despite advances in recent years relating to cancer prevention, detection, and treatment, many minority groups in the United States continue to bear a greater cancer burden than whites.
According to the National Cancer Institute’s Center to Reduce Cancer Health Disparities, while one in three Americans will develop some form of cancer, it continues to be the number one cause of death for many minorities in the United States. Nationwide, African Americans have a higher rate of death from cancer than Caucasians, and cancer has surpassed heart disease to become the leading cause of death among Hispanics and Asian Americans in the United States.
While the statistics are sobering, researchers say minority nurses can play an important role in working to reduce cancer disparities in their communities.
“Nurses are at the forefront of care and can have a major impact in eradicating cancer disparities by educating patients about the importance of cancer screenings, early detection, and access to care,” says Kimlin Ashing-Giwa, PhD, professor and director of the City of Hope’s Center of Community Alliance for Research and Education in Duarte, California. Ashing-Giwa’s work focuses on addressing the disparities in treatment and outcomes between patients with different access and cultural approaches to medicine.
How Breast Cancer Affects African American and Latina Women
“Although African American women are less likely than white women to be diagnosed with breast cancer, they are more likely to be diagnosed at a later stage and to die of their disease,” says Ashing-Giwa. “Despite the decline in overall breast cancer death rates in the past 20 years, black women continue to have higher death rates.”
A 2012 report from the Centers for Disease Control and Prevention (CDC) says that mammography may be used less frequently among black women than white women. It’s also more common for a longer amount of time to pass between mammograms for black women. Additionally, Ashing-Giwa notes that African American women commonly have subtypes of tumors that are harder to treat, especially an inflammatory form called triple negative breast cancer.
The CDC report also stresses the importance of educating women about the preventive benefits and coverage provided by the Affordable Care Act, including coverage of mammograms without co-pays in many health plans and, beginning in 2014, expanded access to health insurance coverage for 30 million previously uninsured Americans.
“Additionally, a woman’s best overall preventative health strategy is to reduce her known risk factors for breast cancer as much as possible by avoiding weight gain and obesity, engaging in regular physical activity, and minimizing alcohol intake,” says Ashing-Giwa, who encourages nurses to talk to patients about their risk of breast cancer and the importance of getting mammograms and doing breast self-exams.
If women can’t afford a mammogram, there are many free resources available that nurses can recommend to patients (see sidebar). In addition, black women are less likely to get prompt follow-up care when their mammogram shows that something is abnormal. Waiting longer for follow-up care can lead to cancerous tumors that are larger and harder to treat.
Follow-up care after mammograms is also a problem for Latinas. “While Latinas have lower incidences of breast cancer than white or African American women, breast cancer is the leading cause of cancer death for Latinas,” Ashing-Giwa says.
A March 2013 study conducted at the Institute for Health Promotion Research at the University of Texas Health Science Center at San Antonio and published in SpringerPlus found that it took Latinas 33 days longer to reach definitive diagnosis of breast cancer than non-Hispanic white women. Researchers found that Latinas with abnormal mammograms benefitted significantly from the help of trained professionals called “patient navigators,” who were trained in providing culturally sensitive support. Patient navigators were also helpful in providing transportation, language, and childcare solutions.
“We need to move toward more prevention, screening, treatment, and follow-up that speaks to people in a language they understand,” says Ashing-Giwa.
Despite Being Preventable, Disparities Still Exist With Cervical Cancer
Also of concern are the large differences in rates of new cases and deaths from cervical cancer among African American and Latina women. “Latina women have the highest rates of cervical cancer, followed by African American women,” says Ashing-Giwa. “This is troubling because most cases of cervical cancer are largely preventable and treatable with regular Pap tests and follow-up.”
Mortality rates are also higher for women over 50.
“Many women believe that since they are single and not sexually active, they don’t need a Pap test,” Ashing-Giwa says. While stressing the need for older women to get regular Pap tests, she notes it’s also important for nurses to encourage younger women to get the human papillomavirus (HPV) vaccine and to use condoms. HPV infection is the leading cause of most cervical cancers.
“Cervical cancer should have been eradicated 30 years ago with the invention of the Pap test,” argues Ashing-Giwa. “Most women who are diagnosed with cervical cancer today are those who have never been screened for it.”
Minorities Less Likely to Get Screened for Colon Cancer
A 2012 study conducted at the Center for Health Policy at the University of Nebraska Medical Center College of Public Health and published in the public health journal, Health Affairs, found that minorities are less likely to be screened for colon cancer. The data revealed that 42% of Caucasians were screened for colorectal cancer, compared with 36% of African Americans, 31% of Asian and Native Americans, and 28% of Hispanics.
“The death rate for colon cancer has increased among African Americans and Hispanic people despite it being one of the most preventable forms of cancer, and if caught early, one of the most curable,” says Durado Brooks, MD, MPH, director of prostate and colorectal cancers for the American Cancer Society.
“Although many people of color are aware of colon cancer, they don’t always see how it applies to them,” says Brooks. “If they don’t have a family history of the disease or have symptoms, such as blood in their stools, they often don’t see the need to be screened.”
Only 10% of colon cancer cases are tied to family history, and by the time warning signs are apparent, the cancer has often progressed to an advanced stage where it’s harder to treat. And while it is currently recommended that regular colon screenings begin at the age of 50, it’s recommended that screenings for minorities begin at 45 since many colorectal cancers have been caught in African Americans and Hispanics at younger ages.
“Many people are unaware of the benefits of colorectal screenings,” says Brooks. “There’s the perception that cancer is a death sentence, yet up to 90% of colon cancer cases are preventable with screening.”
Brooks praises Kaiser Permanente for being proactive about screening its health plan members for colorectal cancer. “Rather than waiting for people to ask to be tested, Kaiser Permanente sends out fecal immunochemical testing kits, a type of fecal occult blood test, in the mail to their members who are 50 and older,” Brooks says. “Not all health care providers are as proactive with their approach.”
And while colonoscopies are still considered the gold standard for detecting colorectal cancer, they also require rigorous preparation—a point that prevents many people from getting tested. In an effort to increase testing for colon cancer, Brooks notes that it’s important to let patients know they have choices and that there are other screening options available.
A study published in the April 9, 2012 issue of Archives of Internal Medicine confirmed this by noting that patients were less compliant with screening for colorectal cancer when colonoscopy was the only option offered. Yet when patients were given a choice between a colonoscopy and fecal occult blood testing, 69% completed one of the two exams.
Latino Men at High Risk of Prostate Cancer
According to the American Cancer Society, prostate cancer is the most commonly diagnosed form of cancer among Latino men, and they are also the most likely to be diagnosed with later-stages of the disease.
A new study conducted by researchers at the University of California—Los Angeles (UCLA) and published in the March 2013 issue of Qualitative Health Research concluded that a combination of financial, cultural, and communication barriers play a role in preventing Latino men from accessing the care and treatment they need.
“These obstacles require a new focus on not only adequate health care coverage, but also on the array of hurdles that limit patient access,” says Sally L. Maliski, PhD, RN, FAAN, associate dean for academic affairs at the UCLA School of Nursing and senior author of the study.
Maliski cites inability to afford medical insurance, difficulty understanding insurance policies, a lack of health literacy among the men, and their limited proficiency in English as barriers throughout the entire prostate cancer-care process.
“Our findings made it clear that we need a system where not only is care affordable, but where we use a multi-faceted approach to improve access, increase health literacy, and greatly improve care coordination,” says Maliski.
Focusing on Cancer Disparities in the Asian Community
“The cancer burden in the Asian American community is unique because cancer has been the leading cause of death among Asian Americans for the past 13 years,” saysMoon Chen, Jr., PhD, MPH, principal investigator for the National Center for Reducing Asian American Cancer Health Disparities headquartered at the University of California-Davis Cancer Center. Chen adds that hepatitis B induced-liver cancer is the greatest cancer health disparity for Asian Americans.
“All Asian American immigrants and their children should be screened for hepatitis B to lead to earlier detection,” Chen says. “And Asian Americans who do not have hepatitis B immunity should also get the hepatitis B vaccine, [which is] the best way to stop the spread of hepatitis B.”
Chen and his colleagues have received a federal grant to increase screening for hepatitis B. Since December of last year, screening events have been held in Northern California at Asian health clinics, local churches, temples, health fairs, and community organizations.
Many Asian Americans don’t get regular cancer screenings, which also adds to poor cancer outcomes. “Until they have symptoms, many Asian Americans aren’t really concerned about cancer and don’t think screening is necessary,” Chen says. “Vietnamese women have the highest rates of cervical cancer, which can be detected and treated early through Pap smears.”
Chen says cigarette smoking is also a big problem among Asian American immigrants and that they are the racial group least likely to be counseled on smoking cessation.
“Smoking is the leading cause of death worldwide and it’s a preventable risk factor,” Chen says. “It’s a complicated message and often language can be a barrier. There’s a great need for smoking cessation programs that are culturally tailored to Asian populations, both in language and intent.”
Stomach cancer is also prevalent in Asian Americans and Chen attributes this to chronic infection with Helicobacter pylori bacteria, which is common in developing countries. In Koreans, diet is also to blame, specifically foods that are preserved with nitrates and nitrites, such as kimchi.
Since prevention and early detection are key components of cancer control, Chen recommends that nurses who work with different Asian American populations either learn the specific language of their demographics, or have cancer education materials readily available in different languages such as Vietnamese, Korean, Mandarin, and Tagalog.
“Nurses who can accommodate differences in language fluency, dietary practices, and cultural beliefs can help to remove some of the barriers that exist in screening and treating minority patients,” Chen says. “Nurses who have this expertise are often the bridge between health care systems and minority communities.”
There are people who are not satisfied with the status quo in their careers and instead help shape their vocations. They are the leaders in their professions. Nurses are no different. There are many movers and shakers within the nursing ranks, and Minority Nurse selected five such individuals to highlight.
Maria Gomez, RN, MPH
Maria Gomez, the founder, president, and CEO of Mary’s Center, is no stranger to the spotlight. She has won a plethora of awards, perhaps none bigger than the nation’s second-highest civilian honor. Gomez was selected by the White House as one of 18 recipients of the 2012 Presidential Citizens Medal. “It was a great honor coming from a president like Barack Obama because I think it is very clear that his priorities are very much aligned with our priorities at the health center,” says Gomez.
Gomez was also quick to point out the role the center’s staff had in her receiving the award. “I received the medal for the collective and extraordinary work of my colleagues and our partners in the community,” she explains. “My role is to make sure that all the administrative pieces are in place and that there are sufficient funds to meet our goals. The issues that the president is diligently working on, such as health reform, early childhood education, economic equity, and immigration reform, are issues that we are dealing with day in and day out with the community that we serve.”
Gomez, along with a group of nurses and social workers, founded Mary’s Center in 1988 on an initial budget of $250,000. It served 200 participants a year at its inception. “There were so many community needs around the indigent population that were not being met,” she says. The vast majority of patients served was Hispanic women, and at that time, a small cohort of African women, according to Gomez.
Today, the center has an annual budget of $40 million and is projected to serve over 70,000 participants at six sites throughout the District of Columbia and Maryland in 2013. The Hispanic population still makes up about 75% of whom the center serves with an ever increasing number of African Americans. “But depending on the areas we are in, we serve individuals from over 110 countries throughout the world who have become uninsured, either because they lost their jobs or because they just cannot make ends meet,” says Gomez.
The center provides comprehensive primary care, intensive social services, and—in partnership with Briya Public Charter School—it provides family literacy classes and job skills with the goal of keeping families healthy, supported in their communities, and moving up the economic ladder.
“My education at Georgetown School of Nursing made me very conscious of the interconnectedness of health and the environment in which people live,” explains Gomez. “In order to keep people healthy, individuals need to be supported in the basic necessities of life, such as housing, food, and employment, before they can tackle their diabetes. This model of comprehensive care is very hard to establish within a health department where I was working, so that was our motivational factor to start Mary’s Center.”
Edward Halloran, RN, FAAN, PhD
Although he didn’t start out to be a trailblazer, Edward Halloran has traveled the road less taken. In a predominately women’s field, his career spans back almost 50 years and has seen him take on many leadership roles—a result he says goes back to a book he read at the beginning of his career.
“At that time, it was much more common for every other nurse to just want to be a nurse and just do your thing. But this book said if you are not visible no one will ever know that there is such a thing, so that is what started my interest in being more visible,” says Halloran. “It is not so much that I had any personal interest in it as much as if there were ever going to be more men in the field, it had to be because the ones that were there were more visible. That prompted my involvement over the years in the American Assembly for Men in Nursing [AAMN].”
The 2012 recipient of the AAMN’s Lee Cohen award, Halloran was selected to receive the award by the Board of Directors of AAMN to recognize his significant contributions to the organization. “I was kind of surprised by that,” says Halloran. “I was very pleased [and] delighted that the people that I have been working with for the last three or four years acknowledged that.”
Halloran is a long-time member of the American Nurses Association and the American Academy of Nursing as well as the former vice president of the National League for Nursing and past president of the AAMN. He is currently finishing his second term as vice president of the latter organization.
Halloran spent a significant amount of time in hospital management. Among his management positions, he was the coordinator of special studies and projects at the Veterans Administration Hospital in Hines, Illinois; the director of nursing at the Gottlieb Memorial Hospital in Melrose Park, Illinois; and the senior vice president, director of nursing and corporate nurse executive at the University Hospitals in Cleveland, Ohio.
“I thought there might be better opportunities to do more in a public way by writing about things or researching them then on a day-to-day basis performing them,” he says about his decision to move into academia. “I had been there and done that so the academic world offered opportunities to do something different.”
Since 1989, Halloran has been an associate professor of nursing at the University of North Carolina and UNC Hospitals at Chapel Hill. During this time, he taught two years in Hong Kong. From 1991-1992, he was a senior clinical nurse on the research unit at UNC Hospitals. He practiced involved care of patients who volunteered for experimental treatment for chronic illnesses, including cancer, HIV, end-stage renal disease, heart disease, sickle cell anemia, diabetes, and other diseases.
Halloran says the highlights of his career include changing the patient care environment. “That gave me the biggest satisfaction,” he adds. “We improved care, and this is very difficult to do from the inside-out of a major teaching hospital or even a suburban hospital or even a rural hospital.”
Halloran says he feels privileged to be considered a leader in the field of nursing. “In many ways I had … the opportunity to do these things over the years, which has been an honor, and then the second piece is to shape [nursing],” he says. “I have done that through practice and through the teaching I have done.”
Mi Ja Kim, PhD, RN, FRCN, FAAN
Mi Ja Kim is one of four nursing educators in the United States named a 2012 Living Legend by the American Academy of Nursing. Since 1994, the Academy has named just 86 Living Legends in the United States. The award honors the distinguished careers of those who have made notable contributions to nursing practice, research, and education.
Kim is a professor, dean emerita, and the executive director of the Global Health Leadership Office at the University of Illinois at Chicago (UIC), College of Nursing (CON). She is known internationally for her leadership in research, scholar training, administration, and policy development. She has published 116 scientific papers and made over 260 research and scholarly presentations at national and international conferences. She has also secured over $6 million in training and research funding from the National Institutes of Health (NIH) and other sources.
Kim served as the dean of the UIC CON which prides itself as a top 10 college in the country, and was the first nurse to be appointed as the vice chancellor for research and dean of the graduate college at UIC. She earned her PhD in physiology at UIC and—with the exception of one year as a Senior Fulbright Scholar at her alma mater, Yonsei University, in Korea—has spent her whole career at the university. “UIC really has been an incredible place for me,” Kim notes. “It is open to anyone who is accomplished in her/his field, regardless of race or ethnicity.”
Kim’s extensive list of accomplishments only reaffirms her status as a leader in her field. She is an Honorary Fellow of the Royal College of Nursing in the United Kingdom and has received the Lifetime Achievement Award from the Asian American Pacific Islanders Nurses Association. She was one of 18 charter members of the National Institute of Nursing Research’s (NINR) study section as well as a member of the NIH’s National Advisory Council. Kim has been named one of the 100 Most Influential Women in Chicago by the Chicago Tribune; has received the Recognition of Outstanding Contributions to Nursing (The Public Women’s Award), American Nurses Association Minority Fellowship Programs and the Cabinet on Human Rights; two awards for “Meritorious Service in the Fight Against Heart Diseases – Public Policy and Government Relations” from the Chicago Heart Association; and two American Journal of Nursing Book of the Year awards for the Pocket Guide to Nursing Diagnosis and Classification of Nursing Diagnoses: Proceedings of the Fifth National Conference.
Her research interests include pulmonary physiology/nursing, cardiovascular health disparities in Korean Americans, and the quality of nursing doctoral education involving seven countries. Her career documentary has been filmed by the Korean Broadcasting System, which is the largest TV network in Korea—an accolade she finds a high honor.
The students appreciate Kim. She lists two “Golden Apple” awards she received from the junior and senior undergraduate students as highlights of her career. Since 2013, she has been the program director of the Bridges to the Doctorate for Minority Nursing Students, which is funded by the NIH. Eleven PhD students have graduated under this grant and 23 are in the Bridges program currently. This program is one of the largest ones in the country that have educated and trained underrepresented minority nursing students pursuing a doctoral degree.
Omana Simon, DNP, RN, FNP-BC
Omana Simon is an advanced practice nurse who serves as the facility telehealth coordinator at Michael E. DeBakey VA Medical Center (MEDVAMC) in Houston, Texas. A native of India, Simon came to the United States in 1983 and began her health care career with a BSN before diligently working her way up the ladder.
Today, she works on the cutting edge of technology. Simon provides primary, secondary, and tertiary prevention strategies to the veteran population. For her efforts, she was the Gold Award winner in 2012 of the Good Samaritan Foundation’s Excellence in Nursing Awards in the Clinical Practice in the Large Hospital category and a recipient of the 2012 Nursing Excellence award in the Advancing and Leading the Profession category for the Texas region.
As the facility telehealth coordinator at MEDVAMC, Simon is responsible for a program that allows vets to receive home telehealth, store and forward, and clinical video telehealth (different modalities of telehealth). “Telehealth in Veterans Affairs is a huge project,” says Simon. “We can provide health care through the use of telehealth devices, video conferencing equipment, or Jabber/MOVI.”
Simon is a true leader in her field, implementing a number of clinical video telehealth programs at her facility, including telepreop, telerehab, and tele-epilepsy, to name a few. These programs connect the veterans in the rural areas where health care is not easily available to a provider at a distant site.
She also oversees telehealth equipment and telehealth programs. “I never thought when I went into nursing I would be on the forefront providing care to the patients using telehealth technology,” says Simon.
Under her direction, the home telehealth program at MEDVAMC received three hospital-wide recognitions. “She is very hard working, very intelligent, and very insightful,” says Nicholas Masozera, MD, the primary care director atMEDVAMC.
For her part, Simon says she gets her inspiration from the veterans she serves. “It is truly an honor to serve the nation’s heroes by providing exceptional 21st century health care that improves their health and well-being,” she notes. Simon exemplifies excellence in her role as a family nurse practitioner as well as a mentor and teacher of future caregivers. Simon upholds the tradition of nursing by being a caring, compassionate nurse who settles for nothing but health care excellence for veterans and the community she serves.
Ora Strickland, PhD, RN, FAAN
Ora Strickland is a nationally recognized leader in women’s health, minority health, and nursing measurement. Not only has Strickland won nine American Journal of Nursing Book of the Year awards, but she was also the first person to hold an endowed professorship in the Nell Hodgson Woodruff School of Nursing at Emory University in Atlanta, Georgia. Formerly a professor at Emory, Strickland is now the dean and a professor at the College of Nursing and Health Sciences at Florida International University in Miami.
Strickland began her writing career early. “Writing is storytelling but on paper. If you are excellent at writing, your work will last a long time; its imprint will be longer,” notes Strickland. “You can build and extend on knowledge and present problems and their solutions in new and unique ways.”
Strickland says she recognized that she could write textbooks when she was a student herself. “You can blaze trails [writing],” she adds. “You can really make a difference if you are good at writing textbooks. You can have an impact on how people are taken care of.”
Strickland is the founding editor and served as senior editor of the Journal of Nursing Measurement for 20 years. She has been on a plethora of prestigious editorial boards and panels, including Advances in Nursing Science, Research in Nursing and Health, Nursing Outlook, Journal of Professional Nursing, Scholarly Inquiry for Nursing Practice: An International Journal, Encyclopedia of Nursing Research, Health Care for Women International, Nursing Leadership Forum, and the American Journal of Public Health.
Strickland has been recognized by many groups and organizations. She was the youngest person inducted into American Academy of Nursing at age 29 and has won the “Trailblazer Award” from the National Black Nurses Association (NBNA). She also earned the Mary Elizabeth Carnegie Award from the Southern Council on Collegiate Nursing for her contributions to health and nursing. Additionally, she was inducted into the NBNA Institute of Excellence.
“I don’t think about the awards I won. It isn’t important,” says Strickland. “I get joy in what my students have produced, the research and work they are doing. That is where I find my joy and that is where my rewards come from.”