In her study of Hispanic victims of intimate partner abuse in the U.S.-Mexico border city of Brownsville, Texas, nurse researcher Nora Montalvo-Liendo, PhD, RN, wanted to learn about the factors influencing the women’s decisions to disclose the abuse and seek help.
She will never forget the story of one mother, who had denied the abuse when questioned by her doctor. Yet years later, sitting in the interview for the study, the woman handed Montalvo-Liendo a business card for a battered women’s shelter, given to her at a health care clinic. The dog-eared card was smudged and wrinkled and looked ready for the trash.
But for the woman, that 2-by-3½-inch piece of paper symbolized a lifeline. She secretly hung on to it for two years before she finally called the number and got herself and her children out of their horrendous living situation. Today the woman keeps the card as a reminder, and Montalvo-Liendo, an assistant professor in the associate degree nursing program at the University of Texas at Brownsville, remembers it as a testament to the impact health care providers, including nurses, can make on patients who are victims of intimate partner violence (IPV), even if they don’t see the effects of that impact immediately.
According to a 2008 report by the Centers for Disease Control and Prevention (CDC), 1,510 people in the United States died at the hands of a spouse or other intimate partner in 2005 and 2 million women suffered injuries from IPV. Besides the immediate physical injuries sustained by victims, IPV can lead to depression, hypertension, eating disorders, substance abuse and other long-term health problems. The estimated annual cost of IPV—including medical care, mental health services and lost productivity—is more than $8.3 billion. And that figure doesn’t take into account the toll on children who witness the abuse.
“It’s not just a personal issue. It’s a real health issue,” says Phyllis Sharps, PhD, RN, FAAN, professor and chair of the Department of Community Public Health at Johns Hopkins University School of Nursing. “The [problem] is multifaceted and cuts across all elements of society.”
Almost one out of every four women has experienced intimate partner violence sometime during her life. The CDC’s definition of IPV includes four types of abusive behaviors:
Physical violence (such as hitting, kicking and beating)
Sexual violence (such as forcing a partner to take part in a sex act to which the partner does not consent)
Emotional abuse (e.g., stalking, belittling, intimidation and controlling behavior, such as not letting a partner see friends and family)
Threats of physical or sexual violence (including the use of words, gestures, weapons or other means to communicate the intent to cause harm).
Women of Color at Risk
Although intimate partner violence can affect women of all races, ethnicities and socioeconomic backgrounds, minority women experience IPV at disproportionately high rates. Consider these statistics compiled by the Women of Color Network, a national grassroots advocacy initiative responding to violence against minority women and families:
African American women experience IPV at a rate 35% higher than that of white women, yet they are less likely to use social services and battered women’s programs or seek medical attention for injuries resulting from domestic violence. They also experience higher rates of intimate partner homicide than their white counterparts.
In a survey conducted by the Asian & Pacific Islander Institute on Domestic Violence, 41% to 60% of Asian American and Pacific Islander respondents reported experiencing physical and/or sexual IPV during their lifetime.
A survey of immigrant Korean women in the U.S. found that 60% had been battered by their husbands.
According to the National Violence Against Women Survey, Hispanic women were more likely than non-Hispanic women to report they had been raped by a current or former intimate partner at some point in their lives (although there were differences among Hispanic/Latino subgroups). Almost half of Latinas in another study (48%) reported that their partners’ violence had increased after they immigrated to the United States.
American Indian and Alaska Native (AI/AN) women experience higher rates of IPV than women from other minority populations. The U.S. Department of Justice notes that IPV is a relatively new phenomenon in tribal communities and is not a traditional part of AI/AN culture.
Nurses can play an important role in addressing these disparities, both alone and in collaboration with other health care providers, social services agencies, community organizations, police officers, attorneys, legislators and educators. And minority nurses in particular can bring cultural knowledge, linguistic competence, sensitivity and passion to the task of creating IPV interventions in communities of color.
Fear of Disclosure
Intimate partner violence is often shrouded in secrecy and shame, so Montalvo-Liendo wanted to learn more about what encourages Hispanic women to disclose abuse and what prevents them from doing so. As part of her qualitative study, she interviewed 26 women served by a shelter and an outreach agency for battered and sexually assaulted women in Brownsville. Nineteen were Mexican immigrants,
12 of whom disclosed that they were in the United States illegally, and seven were U.S.-born women of Mexican descent.
Among the most disturbing findings: Most of the women—17 of the 26—reported that they were never asked about the abuse in their interactions with the health care system. “In my opinion, for that many women to not be asked by a health care provider is not acceptable,” Montalvo-Liendo says.
As for the nine women who did have nurses or doctors ask them about possible abuse, none were willing to admit it. And in many cases, other women in the study shied away from even telling neighbors or friends. Why were they so determined to keep the abuse a secret? The answer, Montalvo-Liendo explains, is that the women were afraid their partners, their partners’ families, the legal system or immigration officials would take their children away from them.
“When it came down to the main reason , it was to keep the family together,” she says.
How can nurses break down these barriers of secrecy and fear? Montalvo-Liendo’s study found that women were more likely to disclose abuse to friends, co-workers or neighbors who asked general questions sensitively and without judgment. Questions such as “Why do you stay?” or “Why don’t you leave him?” aren’t helpful, says Montalvo-Liendo, who recently presented her findings at the 2009 International Nursing Research Conference in Spain.
Nurses also need to be aware that different women may have different perceptions of what constitutes abuse. One woman in the study said she hadn’t thought she was “abused.” Her reasoning: “I was only thrown out of a car. He never hit me.”
There is a great need for more nurse-led research to identify other factors influencing minority women’s disclosure of intimate partner abuse. In the meantime, Montalvo-Liendo says nurses should keep in mind the fears women harbor of losing their kids. “We need to assure them that there is help for them and their children.”
And nurses shouldn’t get discouraged if women don’t disclose right away, she adds. Like the woman who kept the battered women’s shelter card for two years, they may absorb the information to use later. “More than anything, by asking you have shown an interest in the safety and well-being of that woman, not just on the physical level but on the emotional level,” Montalvo-Liendo emphasizes.
Culture Is Key
Many resources are available to help nurses and health care organizations develop culturally appropriate IPV prevention, screening and intervention programs (see “Online Resources” sidebar). For example, the CDC’s 2007 monograph Preventing Intimate Partner Violence and Sexual Violence in Racial/Ethnic Minority Communities: CDC’s Demonstration Projects showcases eight successful model programs, targeted to specific minority populations, that nurses can adapt to meet the needs of the communities they serve.
Phyllis Sharps, PhD, RN, FAAN
In the 1980s, Jacquelyn Campbell, PhD, RN, FAAN, a professor at Johns Hopkins University School of Nursing and a nationally recognized leader in IPV research and advocacy, developed the Danger Assessment (DA), a widely used screening tool that assesses the severity and frequency of abuse as well as the risk for intimate partner homicide. The DA’s effectiveness has been validated across a broad spectrum of racial and ethnic groups, she says, and it can be tailored slightly to women’s individual needs.
For instance, recent immigrants may need to be reassured that reporting abuse will not affect their immigration status. In fact, non-citizen IPV victims who are married to or recently divorced from U.S. citizens or legal residents can self-petition for permanent resident status without the help or knowledge of their abusive spouses.
Examples like this demonstrate why cultural sensitivity is so important, Campbell says. “On the one hand, you need to strive to make [IPV] interventions culturally appropriate. Nurses need to find out as much as they can about patients they serve.” But on the other hand, she adds, “you [can’t expect to] be culturally competent in every culture.”
In other words, nurses shouldn’t shy away from addressing the issue just because they are not immersed in the culture of their patient. They can still intervene, using the appropriate screening tools and their knowledge of community resources to refer patients for help.
Nurses can also tap into the expertise of groups like the Women of Color Network that are addressing IPV in minority populations at the community level. Sacred Circle, for instance, is an advocacy organization that provides training, develops policy and provides technical assistance for ending IPV and sexual assault in American Indian/Alaska Native communities.
Sharps believes being sensitive to cultural differences involves more than just issues of race and ethnicity. For instance, a woman living in a small town rather than a large urban area might be hesitant to report abuse because she’s likely to be acquainted with the responding police officer or a staff member at the local social services agency.
Establishing rapport and trust with patients who are in abusive relationships is essential, too. Nurses need to project a non-judgmental attitude when discussing intervention options.
“We become culturally relevant when we start [at the same emotional place] where the woman is,” Sharps says. “We should never, ever start with, ‘What is your plan for leaving?’ We should start with, ‘How can we help you be safe?’”
Protecting Moms and Babies
Sharps has focused most of her research on how IPV affects the health of pregnant women, infants and very young children. She became interested in the topic when she was a labor and delivery nurse who was troubled by the high rate of infant mortality among African Americans. The number of African American babies who die before they reach their first birthday is two to three times higher than the national average, she says. In fact, the infant death rate for white mothers with only a high school education is lower than for black women with college degrees.
Calling for Help Nurses should become familiar with these toll-free hotline numbers and keep them handy for patients who may need them. These hotlines serve all 50 states, are open 24 hours a day and protect callers’ anonymity and confidentiality. National Domestic Violence Hotline 1-800-799-SAFE (7233) 1-800-787-3224 TTY National Teen Dating Abuse Helpline 1-866-331-9474 1-866-331-8453 TTY Domestic Abuse Helpline for Men and Women 1-888-7HELPLINE (743-5754)
“I realized that how healthy a baby is at the time of delivery had a lot more to do with the nine months it lives [in utero] in the community than with [the labor and delivery care the mother receives],” Sharps says. “[The disparity in infant mortality rates] is a very complicated picture for African Americans. Unfortunately, intimate partner violence is part of the [problem], along with other risk factors, such as disparities in access to health care.”
Sharps is currently testing the effectiveness of an intervention called the Domestic Violence Enhanced Visitation Program (DOVE), in which specially trained nurses visit new and expecting mothers at risk for IPV and teach them how to keep themselves and their babies safe. The nurses provide information about breaking the cycle of IPV, risk factors that increase a woman’s danger of being killed by an abusive partner, options for leaving the abuser and safety planning, including phone numbers of local support services. The program is funded by a $3.5 million grant from the National Institutes of Health and will be tested in Baltimore, Kansas City and rural Missouri.
The DOVE project grew out of an earlier program Sharps developed called Passport to Health, which used the nurse home visitation model to help minority women transition from battered women’s shelters to healthy living situations. Of the nine women in that program, seven were able to re-establish their lives without further abuse.
“The best home visitors are nurses [rather than social services workers], because their professional training and background gives them the ability to look holistically at the situation,” Sharps says.
Widening the Focus
Still other minority nurse researchers are investigating IPV prevention strategies targeted to other vulnerable populations, such as younger women of color, children, and even men who are at high risk of abusing their female partners.
Angela Frederick Amar, PhD, APRN, BC, an assistant professor at Boston College’s William F. Connell School of Nursing, has conducted a variety of studies focusing on dating violence among college-aged women from diverse racial and ethnic backgrounds. The research, she says, is like slowly turning a kaleidoscope. Each study provides one more view into a complex and changing picture.
According to Amar, girls and young women ages 16 to 24 are at the greatest risk for sexual assault and IPV, and those who experience violence are more likely to suffer from depression and other mental health disorders.
Young women living on college campuses are at greater risk for dating violence than their off-campus counterparts, Amar says. The high rate of alcohol consumption among college students is often a factor, as are some young people’s attitudes about sexual consent. Commenting on whether he would ask a woman for permission to have sex, one young man told Amar: “Of course I’m not going to ask, because she’ll say no.”
In her current research as a Robert Wood Johnson Foundation Nurse Faculty Scholar, Amar is exploring the factors that encourage young women on college campuses to report gender-based violence. She hopes to use the results to guide development of campus IPV prevention programs.
Not surprisingly, most IPV interventions focus on the women who are victims of partner abuse, rather than the men who commit it. But there is also a need for more research to establish screening assessments and interventions for abusers, says Christina Cardenas Wei, PhD, RN. Wei conducted a qualitative study of seven Hispanic and non-Hispanic men who were taking part in a batterers’ intervention program in San Antonio, where she recently completed her doctorate at the University of Texas Health Science Center.
Nursing literature makes a correlation between substance abuse and IPV, but Wei found other underlying problems among the men, such as depression and post-traumatic stress disorder. Five of the men reported experiencing trauma or violence in childhood, including parental abandonment.
“I would like to see this work continue and to do [more] research to develop interventions with men,” Wei says, noting that there is no standard screening tool for men who use violence in their intimate relationships.
The most vulnerable and innocent victims of IPV are, of course, children. From the one sample of 26 women Montalvo-Liendo interviewed in her study in Brownsville, 73 children were exposed to domestic violence. Children who witness IPV are likely to continue the cycle as adults or internalize what they’ve seen, unless they get help. While some middle schools have developed programs to help students address the issue of unhealthy relationships, Montalvo-Liendo says, “I feel very strongly that we need to get [this information] into the elementary schools.”
Online Resources
The Centers for Disease Control and Prevention (CDC)’s Intimate Partner Violence site, www.cdc.gov/Features/IntimatePartnerViolence, offers many resources for developing IPV interventions, including assessment tools and a database of evidence-based prevention strategies.
Preventing Intimate Partner Violence and Sexual Violence in Racial/Ethnic Minority Communities: CDC’s Demonstration Projects can be downloaded free of charge at www.cdc.gov/ncipc/dvp/PreventingIntimatePartnerViolence.htm.
Online training in using the Danger Assessment is available at www.dangerassessment.org.
The Women of Color Network, http://womenofcolornetwork.org, offers fact sheets on IPV issues affecting communities of color and provides leadership training, cultural competency training and technical assistance for individuals and organizations working to end violence against minority women.
The U.S. Department of Justice’s Office on Violence Against Women (OVW), www.ovw.usdoj.gov, has many violence prevention grant funding programs, including grants for tribal governments, faith-based and community organizations, and projects that provide culturally and linguistically specific services for victims of IPV.
The Department of Health and Human Services, Office on Women’s Health (OWH), www.womenshealth.gov/violence/programs/index.cfm, offers IPV prevention resources for women in English and Spanish, including information on safety planning, obtaining a court order of protection and how to help a friend who is being abused.
Sacred Circle is a national resource center for ending violence against American Indian and Alaska Native women.
The Family Violence Prevention Fund, www.fvpf.org, provides a wealth of free resources for health care professionals and patients, including culturally sensitive patient education materials targeted to Native Americans, Asian Americans and other minority populations.
The National Asian Women’s Health Organization has developed “Breaking the Silence: Preventing Violence Against Asian American Women,” a free three-module curriculum designed to educate college-aged Asian women about IPV and dating violence. It can be downloaded from www.nawho.org (click on “Issues,” then “Violence Prevention”).
The Asian & Pacific Islander Institute on Domestic Violence, www.apiahf.org/apidvinstitute, is a national resource center and clearinghouse on gender violence in Asian American, Native Hawaiian and Pacific Islander communities.
The Nursing Network on Violence Against Women, International (www.nnvawi.org) encourages the development of nursing practice that focuses on health issues relating to the effects of violence on women’s lives.
In 1909, Lillian Wald, founder of the Visiting Nurse Service of New York (VNSNY) and the “mother of public health nursing,” hosted the NAACP’s inaugural meeting at her agency’s early headquarters, at a time when integrated meetings were forbidden by local ordinance. Last year, the NAACP remembered Wald’s courage and work during its centennial anniversary celebration in New York City. On their website, they refer to Wald as one of the organization’s “first and oldest friends.”
Wald truly set a tone for the agency she established. From its founding in the late 19th century, the VNSNY has served a broad range of diverse communities, played pioneering roles in the civil and women’s rights movements, and blazed a trail for diversity in the workforce.
In the late 1800s, Manhattan’s Lower East Side neighborhood was deemed the world’s most densely populated slum. At that time, Wald was a young graduate of New York Hospital’s nursing program, studying medicine and teaching immigrant women about home health and hygiene. Galvanized by the public health needs she saw among immigrant communities in the area, she and a fellow volunteer launched VNSNY in 1893. Wald and her colleague became the first public health nurses in the country.
Wald championed women’s rights by hiring and promoting women. In fact, the National Women’s History Project included her among its 2009 honorees. She played a prominent role in the women’s suffrage movement and is enshrined with Susan B. Anthony, Elizabeth Cady Stanton, and others in the National Women’s Hall of Fame. From Wald’s 1933 retirement to present day, women have led the VNSNY, culminating in 1989 with the arrival of current President and CEO, Carol Raphael. Ten years ago, the VNSNY staff was composed of over 90% women. Today, that figure stands at about 80%. Because of the agency’s highly diverse clientele, VNSNY has been at the forefront of promoting cultural awareness, developing and retaining a diverse workforce, and creating an inclusive environment—all elements that are crucial to effective service delivery. According to U.S. Census data, nearly 37% of New York City’s population is foreign-born, and 48% of the city’s residents speak a language other than English at home. More than a quarter of VNSNY patients are non- English speaking, and its staff members speak more than 50 languages.
Following their founder’s example, the agency has a proud legacy in the hiring of minorities. In the 1920s, when mortality rates in the black community were 200% higher than elsewhere in New York City, African Americans comprised 15% of VNSNY’s patients. Wald and other agency leaders responded by increasing its African American nursing staff from one supervisor and four nurses to two supervisors and 18 nurses, a number commensurate with their patient load. In her 1933 book Windows on Henry Street, Wald noted that VNSNY was the first organization to hire black nurses on equal terms. Today, roughly a quarter of its patients and more than half of its employees are descendants of the African diaspora, including African Americans, Afro-Caribbeans, and colleagues from Nigeria, Sierra Leone, Togo, and other African nations. VNSNY has also been caring for Asian and Hispanic immigrant patients and hiring staff of the same descents.
For most of its history, VNSNY also has been caring for patients in a number of other ethnic communities, while employing clinicians who share their cultures and heritages. In recent years, VNSNY developed multicultural home care programs dedicated to serving New York’s Hispanic, Asian, and Russian communities. Patients often feel more comfortable and, in some cases, recover more quickly, when they receive care from nurses and other caregivers who speak their language and have in-depth knowledge of their culture.
Currently, VNSNY employs the largest pools of Asian and Hispanic caregivers in the New York area, offering home health care teams trained in providing culturally sensitive care to patients in their native languages, incorporating their customs and values. Staff tailor comprehensive home health care and community-based services to the more than two million Spanish-speaking residents of New York City, who trace their heritage to 35 nations worldwide. Patients from these communities make up approximately 20% of active cases, a fi gure that mirrors the 20% of VNSNY colleagues who self-identify as Hispanic/ Latino.
Features offered include a Spanish-language telephone hotline for referral and information; nutritional diet plans specifically designed for Hispanics; patient forms and educational materials in Spanish; partnership programs with key Hispanic community organizations and referrals to community resources; and a close alliance with Hispanic community agencies, doctors, hospitals, and managed-care organizations. In late 2008, VNSNY was honored with a special institutional award from the New York chapter of the National Association of Hispanic Nurses for extraordinary outreach in that community.
The composition of VNSNY’s workforce and patient populations also reflect a spike in Asian immigration to New York City over the past decade. The staff now includes more than 700 colleagues of Asian descent, including Chinese, Filipino, Indian, Korean, Pakistani, and other nationalities. These colleagues speak several dialects of Chinese, Tagalog (Philippines), Korean, Hindi, and other Asian languages. They provide home health care familiar with the cultures, values, and customs of many different Asian groups. VNSNY also administers the Chinatown Community Center, which has served more than 65,000 community residents since it opened in 1999. The facility administered hundreds of free fl u shots last year, and it regularly provides free cholesterol, diabetes, and blood pressure screenings; health classes; community outreach; and other services to residents, particularly seniors, of New York’s Chinatown. VNSNY also runs the Chinatown Neighborhood Naturally Occurring Retirement Community (NNORC) program, launched in 2006. In addition to the public health services offered at its Chinatown Community Center, the Chinatown NNORC nurses and social workers visit homebound seniors to assess their individual needs and provide culturally sensitive care.
To serve the more than one million émigrés from the former Soviet Union now residing in the New York area, VNSNY has hired more than 200 colleagues who immigrated from Russia and former Soviet republics, including Ukraine, Azerbaijan, and more. The agency also employs escort translators who speak other languages, ranging from Korean and Japanese to Haitian Creole. In addition to the VNSNY Multicultural Home Care Programs, the agency makes a number of smaller, less formal arrangements to coordinate caregivers and patients in New York’s many other diverse communities. VNSNY also regularly sponsors events tailored to recruit nurses and other staff members from various multicultural NYC communities.
In 2009, CATALYST, a global organization dedicated to promoting diversity in the workplace, added VNSNY to its roster of “case studies”—models of inclusive practices in the workplace.
Comfortable with their knowledge of other cultures, VNSNY staff often act as the organization’s ambassadors to various New York communities and teach coworkers about their cultural heritages. VNSNY has carried its 117-year-old inclusive, multicultural approach well into the 21st century, a philosophy suited to a highly diverse workforce and its patients.
After spending four decades climbing the stairs of New York City’s tenement apartments to deliver compassionate, expert home care to hundreds of Spanish-speaking patients in the South Bronx, Washington Heights, and other communities, Elsie Soto, R.N., a veteran public health nurse at Visiting Nurse Service of New York, may be forgiven for enjoying 2011 as the year she became something of a nurse “celebrity.”
In recognition of contributions made during her lifelong career in home care nursing, Elsie was named “Clinician of the Year” nationwide by the Visiting Nurse Associations of America, an award presented at VNAA’s annual meeting in Baltimore, Maryland, in April. In May, Elsie was honored by the Home Care Association of New York State with a prestigious statewide “Caring Award,” for which all Empire State professionals, paraprofessionals, and family caregivers are eligible. This award goes to one “who has exhibited the compassion, skills, and service that set their contribution apart, or whose actions on a particular day, or over a period of time, exemplify outstanding compassion,” according to the award website. Rounding out a trifecta of recognition, Elsie was also recognized by NursingSpectrum magazine with a 2011 “Excellence in Nursing Award” as a regional finalist in community service.
“I want to thank my familia at VNSNY—including many coworkers, past and present—and my patients for allowing me to enter their homes and do my magic,” Elsie said in her acceptance speech. In my life, I’ve always been surrounded and guided by three important and influential women: mi mami Elena for caring, Florence Nightingale for commitment, and VNSNY founder Lillian D. Wald for service.” Elsie also acknowledged her fivebrothers “who were [her] first patients,” her husband and children, and the early support received from a priest and nun (“long before the word ‘mentor’ became popular”) who encouraged her to pursue a career in nursing, even though it took Elsie away from Catholic high school in the Bronx.
“Mi casa es tu casa“
Bilingual in Spanish and of Puerto Rican heritage, Elsie has long played a leadership role in providing culturally sensitive care to VNSNY’s Latino patients in NYC—a population that in sheer numbers is second only to Los Angeles among Spanish-speaking communities nationwide. In addition to the exceptional care Elsie has provided most recently in the predominantly Dominican neighborhood of Washington Heights, she also serves among VNSNY’s key representatives in the New York chapter of the National Association of Hispanic Nurses. Several years ago, when NAHN honored VNSNY with an “Institutional Award” for the agency’s efforts to “raise awareness of health care disparities and increase diversity in nursing practice,” Elsie was asked to personally accept it.
Elsie is no stranger to accolades and recognition. In 1993 and again in 2008, Elsie was nominated by VNSNY colleagues and went on to win ESPRIT Awards, the organization’s highest honor. (ESPRIT Awards are named for VNSNY’s values: Excellence, Service to Customers, People, Fiscal Responsibility, and Teamwork.)Elsie and her patients were also the focus of a 2007 cover story in ADVANCE for Nursesmagazine entitled “Mi Casa Es Tu Casa: Culturally Sensitive Home Care for Hispanics at VNSNY.” She has also been featured in news articles about VNSNY’s agency’s longest-serving veteran nurses.
Since joining VNSNY as a 20-year-old LPN, Elsie has striven to stay as “flexible as a willow,” relying on a sense of humor to help patients through the tough times. Colleagues cite her stellar commitment to patient care and praise her willingness to always go above and beyond.When nominating Elsie for an ESPRIT award, one coworker wrote, “Elsie is knowledgeable regarding all dimensions of her patients’ conditions, including both clinical and social aspects.”
Elsie shares a memorable patient story from her vast trove: “I was asked to pre-pour meds and informed that my patient’s front door would be open. It was evening when I arrived. To my dismay I found the patient waiting for me in the dark. I immediately turned the lights on. Finally, sitting down to pre-pour his meds, I realized that he was blind. I apologized for not being mindful. He started to laugh, and told me stories of others who had been guilty of the same ‘crime.'”
Elsie still remembers one of her very first home care patients, “Anna,” who lived alone in the South Bronx back in the 1970s. For more than nine months, Elsie provided daily care for Anna’s breast cancer wound. As a new nurse, Elsie remembered feeling silently skeptical when Anna said the wound would heal. Eventually, it did heal, and Elsie recalled feeling a mixture of joy and sadness when she said goodbye to Anna on her final visit.
In addition to using her prized bilingual ability in Spanish to care for VNSNY’s huge numbers of Hispanic/Latino patients, Elsie has also provided home care to patients in many other immigrant communities in New York City, one of the world’s most diverse megacities. From caring for culture-shocked Vietnamese refugees in the Bronx in the wake of the Vietnam War to Russian, Chinese, East Indian, Pakistani, and patients from other ethnic groups, Elsie has personally carried on the mission of VNSNY: “caring for all New Yorkers.” In an example of such service, in the aftermath of Hurricane Katrina in 2005, Elsie was one of fewer than 50 VNSNY nurses to be recognized for aiding Katrina evacuees at Disaster Assistance and Welcome Centers set up by the New York City Department of Health.
Today the nation’s largest nonprofit home health care organization, VNSNY was founded in 1893 by Lillian Wald, the “mother of public health nursing,” to serve the teeming immigrant population of New York City in the 19th century. Through the work of clinicians like Elsie and some 2,600 other nurses on staff, the agency has continued this role into the 21st century.
“The Bronx is burning!”
New York City is home to the nation’s second-largest Latino community, comprised of Spanish-speaking peoples from more than 20 nations. Collectively, they comprise more than a quarter of the city’s population, according to the U.S. Census Bureau. By contrast, Elsie is among a small minority—one of the estimated 2% of U.S. nurses who speak Spanish—and among approximately 4,500 Spanish-speaking nurses serving an estimated 2.5 million Latino residents of New York City. Elsie’s role as a coordinator of care and public health nurse has kept her on the front lines at VNSNY, which employs New York City’s largest pool of Spanish-speaking health care providers.
Born to parents who immigrated to New York City from Moca, a town in the mountains of Puerto Rico, Elsie is the only girl in a family with five younger brothers. They grew up in the South Bronx. During this period, the borough was plagued by crime, drugs, and frequent arson fires. “The Bronx is burning,” the saying went. Elsie credits her parents and Catholic schoolteachers with providing a bulwark against the devastation and modeling responsibility to one’s community.
Elsie became an LPN through a program at Jane Addams Vocational High School and then went on to become a registered nurse at Bronx Community College in 1974 (later pursuing B.S.N. studies at Mercy College). She became involved in home care early and worked in her own neighborhood for 14 years. The needs in this area were especially great in the 1970s and 1980s. Elsie recalls a litany of problems with “riots, job losses, crime, decay, drugs.”
“I personally witnessed the arrival of heroin in the Bronx and watched how it decimated people in droves,” she says. For two years in the mid-1980s, Elsie’s treatment area included the Webster Projects, scene of the highest homicide rate in New York City, with approximately one killing per week. Elsie personally cared for one of the four young men shot in 1984 by notorious “Subway Vigilante” Bernhard Goetz. She recalls needing security escorts on nearly every visit in those days.
Being a Spanish-speaking Latina is an asset in her community, Elsie says, “because even though they know I’m not Dominican, or Cuban, or Mexican, I do speak the language. We have that basic cultural identity. Automatically things are clearer and more relaxed and they think ‘you may not be of my origin, but you speak my language.'” As in any culture, nonverbal communication in the Hispanic culture is as crucial as verbal communication.
These days, with a caseload of about 15 patients a week, Elsie serves patients in mostly Dominican neighborhoods of Washington Heights in upper Manhattan. Although Elsie essentially shares the same language as her predominantly Hispanic patients, she expresses appreciation for the subtle and not-so-subtle differences among various communities. Elsie notes that Hispanics are defined as “persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish cultures.” The term Latino encompasses Brazilian, Asian, and African cultures as well.
“We may share the same town name (there is a Moca in the Dominican Republic too) and ways of connecting,” Elsie says, “but we’re diverse. That’s what makes us so unique. Because of my accent, Dominican, Cuban, and Mexican patients will know that I am from Puerto Rico, but we’re all connected. I try as much as I can to learn about their culture from them and to let them learn from me.”
La familia and culturally sensitive care
Elsie notes that to deliver culturally sensitive care, home care nurses must be mindful of the importance of la familia in Hispanic culture. “You have to include the family as part of the healing process,” she says. “Whoever it is—abuela (grandmother), aunt, godmother—you have to incorporate them because they have wisdom to offer, and so that you can be successful.” She adds that religious and cultural beliefs also play important roles in caring for the Hispanic patient. Many believe pain is an expected part of life and a consequence of immorality.
Elsie Soto with fellow ESPRIT winners in 2008
“Some people will say ‘I’ll take the pain because this is part of my punishment,’ and coming from the Hispanic culture, I can identify with the idea of paying for something I did wrong years ago,” Elsie says. “You have to give respect to the notion of pain as a punishment from God. I tell patients that I understand, but I think you have been forgiven, and now I am here because God is telling me to facilitate your pain and let you go more peacefully.”
On a daily basis, Elsie deals with the fact that Hispanic Americans suffer one of the highest rates of diabetes in the United States, with a prevalence that is more than 50% greater than among average New Yorkers. “As a Hispanic, I implement this knowledge that we have in my work at VNSNY—and on a personal level, I share that my mother and father died very young and that diet plays a role in their heart disease and diabetes,” Elsie says. “But I’m also flexible and do not completely try to demoralize my patients because it’s not going to work,” she adds. “I try to modify the diet but not completely take away their food.” Elsie is drafting a Spanish-language publication on this topic for the Alzheimer’s Association of New York.
Eight years ago, Elsie was one among a small group of VNSNY staff who joined together to revive the dormant local chapter of NAHN, founded in 1975 and committed to improving the health of Hispanic patients and communities and increasing educational, professional, and economic opportunities for Hispanic nurses. Thanks to such efforts, the NAHN chapter is vital once again.
Elsie is involved in a pilot program called the Hispanic Leadership Project, to develop such skills among Hispanic nurses. Elsie notes that the project sprang from a yearlong nursing course called the Minority Leadership Program that she took some years ago at Rutgers University. Elsie also attends NAHN’s national conventions. In summer 2009, she presented a poster on diabetes and comorbidities among Hispanic patients at NAHN’s annual meeting in San Antonio, Texas. She and others presented on the pilot Hispanic Leadership Project.
“Home care has been my ‘second home’—an amazing journey for me,” Elsie says, when asked how her profession and role as a home care nurse has changed in the past 40 years. “The fundamental care of nursing has not changed. What has changed is the introduction of technology in the home and in our manner of communicating. My journey has been filled with much love for the work I perform and the people I work with…”
Capt. Evangelina Montoya, RN, MSN, is reading aloud from a report on migrant farm workers. “‘We work from sunrise to sunset,’” she recites, “‘and my body gets so tired it’s hard to walk. My uncle has to park the truck so far away, and I get so cold and tired when I walk back to the truck.’”
This experience is all too familiar to Montoya, who grew up as the daughter of migrant farm workers in Visalia, Calif. “I can put my face on this story,” she says. “For me it isn’t just statistics—it was a fact of life.”
When Montoya started attending community college, she realized that she wanted to go into the health care field. “I chose nursing because it reflected my values,” she explains. Her interest in providing health care to an underserved population in a rural community, along with her desire to travel, drew Montoya to public health nursing. Now a commissioned officer in the U.S. Public Health Service, she is a public health analyst for the federal Division of Community and Migrant Health, where she helps develop health care policies affecting migrant workers.
Another former migrant worker who is dedicating herself to improving health conditions in migrant communities is Aurora Hernandez. Growing up in Texas, Minnesota and Wisconsin, Hernandez worked the fields while other kids rode their bikes and went to Disneyland. Every year, her mother took her to a migrant health clinic for a checkup. When she was 12, Hernandez was examined by a nurse—an experience that made a lasting impression on her young mind.
“The nurse could probably tell that I was unhappy,” Hernandez recalls. “I wasn’t looking up and I didn’t talk much. She was concerned about me, and I noticed how nice she was. She was very sincere and kind.”
When the young girl asked the woman what she did, she replied that she was a nurse. “That was my first experience meeting a nurse and seeing how their work involves helping people,” says Hernandez. “I realized that [as a nurse] I could have a good job, be able to talk with kids and families and spend my day inside a building! From that day on, I wanted to be a nurse and work with migrant kids.” Hernandez is now a nursing student at Georgetown University in Washington, D.C., and the first Hispanic president of the National Student Nurses’ Association.
At a Greater Risk
Migrant farm workers are the people who pick the fruits and vegetables that you and your family eat every day. There are three to five million of them in the United States and their average income is less than $7,500 a year. Eighty percent of these migrant farm workers are Hispanic, and two thirds of them are under 35 years of age. Sixty-six percent of migrant worker parents have their children with them as they work.
The migrant worker community is divided into three “streams.” The West Coast stream stretches from California to the Pacific Northwest; the Midwest stream starts in Texas and extends north, while the East Coast stream reaches from Florida to Vermont and New Hampshire.
A migratory lifestyle and harsh working conditions create a myriad of health problems for these workers. “They have more complex health problems than those of the general population,” Montoya notes. “They suffer more frequently from infectious disease and they have more clinic visits for diabetes. Contact dermatitis is also common because of the exposure to pesticides.” Other common ailments affecting migrant workers include cancer, hypertension and asthma.
Many of these health problems stem from poor nutrition. “Migrant farm workers have extremely low incomes, and they work six days a week, 10 to 12 hours a day,” explains Hernandez. “When things are really terrible—when the weather’s bad and the crops aren’t growing well—the result is malnutrition. People working 10 to 12 hours every day in 95-degree weather have tremendous nutrition needs.”
The health of migrant workers’ children is another area of concern. These children often suffer from Vitamin A deficiencies or ear infections that can lead to deafness if left untreated. Pesticide exposure is another serious health issue. One recent study revealed that 48% of migrant children had worked in fields when the plants were wet with pesticides and 36% had been sprayed either directly or indirectly by pesticide drifts. Thirty-four percent of children’s homes had been sprayed in the process of crop-dusting the fields.
“As the planes sprayed the fields, you could feel the drifts,” remembers Montoya. Hernandez has similar memories. “Every morning, the crops were sprayed,” she relates. “[It mixed with the dew] and when it dried, the pesticide residue would be on your clothes and your skin. It looked like a white film.”
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Such exposure is particularly dangerous for children because their higher metabolic rates and lower body weights make them more susceptible to the toxic effects of pesticides than adults.
Some migrant worker health disparities have a devastating effect on both parents and their children. “There is a very high rate of depression in both mothers and fathers in migrant families for a variety of reasons,” says Mary Lou de Leon Siantz, RN, PhD, FAAN, who teaches at Georgetown University and is the current president of the National Association of Hispanic Nurses. “Depressed parents are less able to interact and communicate with their babies, and that places a child who’s already at a substantial risk for health problems at an even greater risk.”
Siantz has received funding from the National Institute for Nursing Research to study the prevention of developmental delays in Mexican migrant infants. She is also actively involved in getting migrant babies prepared for school in the Migrant Head Start program and is working with the University of Washington to develop a culturally and linguistically sensitive intervention program for Spanish-speaking migrant workers.
Still another factor that contributes to increased health risks for migrant workers is substandard housing. “Whatever the farmer [whose fields you are working in] provides is where you live,” says Hernandez. “Our family lived in houses that had been condemned.”
Nurses who work in migrant communities can attest to the health problems poor housing can cause. “We see increases in infectious diseases, gastrointestinal disorders and emotional distress in people exposed to those living conditions,” Hernandez explains. There are increased risks of accidental injury as well, she adds. “People can fall through holes in the floor. At one home I lived in, I fell into a well that was covered up by grass and dirt.”
Working Without a Net
Even though they face disproportionate health risks, most migrant farm workers don’t have the peace of mind of health insurance. Because they are always on the move, they rarely reside in one place long enough to qualify for insurance. As a result, routine medical exams account for only 1.4% of all visits to the Division of Community and Migrant Health’s clinics—39% below the national average.
“By the time they show up in the ER or at the clinic, their health problems have become very severe, because [nurses] don’t see these patients until they’re too sick to work,” says Montoya.
Then there’s the issue of lack of access to health care. Migrant families tend to work in regions that are even more remote than typical rural communities, and these areas often lack clinics and medical professionals.
The Division of Community and Migrant Health is attempting to address these problems through a national nursing voucher program that is instituted in regions where migrants work for only a few months and then move on. Under this program, migrant workers can receive vouchers to bring to participating clinics to “buy” health care services. The program also allows nurse practitioners to provide primary health care, and RNs can refer workers to a physician or another nurse for advanced medical care. Currently, there are 21 such voucher programs providing health care to migrant workers in the United States, serving some 56,000 patients per year.
“Nursing voucher programs are an area where nurses can really take the lead in filling gaps in migrant workers’ access to medical care,” says Gloria Torres, RN, MS, assistant clinical director of Community Health Partnership (CHP) in Aurora, Ill., an organization that serves migrant farm workers exclusively. Another nurse who grew up in a migrant worker family, Torres administers a nursing voucher model that is used at six CHP sites in Illinois.
Imagine trying to comprehend health care information from a doctor who speaks only Swahili and you’ll understand why language differences are another major barrier to providing effective health care to migrant farm workers. “My parents spoke Spanish at home, so I didn’t learn English until I started school,” says Montoya. Hernandez also has experience with the language barrier: “When I was a young child of 11 or 12, I went with my parents to the doctor to translate for them.”
Cultural barriers may have an even stronger effect on health care providers’ ability to treat migrant workers. “My father had hypertension and diabetes,” Hernandez recalls. “He would say ‘yes, yes’ at the clinic, but at home he would not do what they told him to. I came to realize that he didn’t trust them, because they didn’t understand his culture. When you’re discussing food with a migrant worker who is diabetic, you need to understand that they eat tortillas, beans and rice because they work 10 to 12 hours a day, and they need food that will help them do all that work.”
How Nurses Can Help
These cultural and linguistic competency issues help explain why the field of migrant worker health care urgently needs more Hispanic nurses. Sara Erlach, a retired nurse who received a Lifetime Achievement Award from the National Association of Hispanic Nurses last year for her pioneering work in migrant worker health care, emphasizes that “[minority nurses] are in demand everywhere. Only 2% of the RN population is Hispanic.”
The demand for nurses who speak the language and who are familiar with (or are willing to learn about) the needs of migrant farm worker communities is especially great. Nurses need these qualifications to earn the trust of Hispanic patients, Hernandez explains. “When my father finally met a nurse who spoke his language and came from his background, that’s when [the health care advice] really clicked,” she says. “Everything that nurse said was like the Bible to him. He felt that she understood his life and he believed everything she told him.”
There are many opportunities available for nurses who want to enter the field of migrant worker health care. “If you’re working at a migrant health clinic, you can work as an LVN as well and do some of the technical aspects that are done in traditional clinics,” says Siantz. Other opportunities include making home visits in migrant communities, teaching health awareness, developing public programs and creating public health announcements for Spanish-language radio.
Research on migrant health issues is another important career path. “If we had more [nurses] interested in research, we could develop better policies and have more advocates and clinicians,” says Hernandez.
Some of the most rewarding career opportunities for nurses in migrant health care are with the federal government or other nonprofit national organizations, such as the National Center for Farmworker Health, the Migrant Clinicians Network, the Pan American Health Organization and the U.S. Department of Health and Human Services’ Office of Minority Health (OMH). To find migrant worker clinics that may be looking for nurses, contact the OMH and ask for information about clinics in your region of interest (see “Resources”).
When asked what qualities a nurse needs to become involved in migrant worker health care, Siantz lists only three things: “Good communication skills, an understanding of the culture and a good heart.”
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