“Kuleana means having a sense of place in society such that each person has a right to basic necessities needed to sustain oneself—security of housing, food, health care, transportation, safety, and justice—and in turn has a responsibility to contribute to the sustenance of society,” Boyd says. She likens this sentiment to “client rights and health care ethics” in the Pathway program.
A contrast to the vacation resort paradise with which the continental 48 are so familiar, Hawaii actually experiences a great deal of socioeconomic instability. Pathway out of Poverty helps the impoverished, particularly native Hawaiians, build self-reliance and guides them toward a career in nursing.
Teaching since 1998, Boyd is currently an assistant professor at University of Hawaii, Windward Community College in Kaneohe, in addition to serving as Director of the Pathway out of Poverty program. In her own words, the program is “a curriculum based in Hawaiian values and traditions of healthy living that leads underserved community college students through a nursing pathway from Nurse Aide (NA) to Licensed Practical Nurse (LPN) to Registered Nurse (RN), with inherent increases in wageearning potential.”
Boyd won the Robert Wood Johnson Foundation Community Health Leaders award in 2011 for her commitment to improving health care in her community while overcoming immense personal obstacles. She received $20,000 for personal growth and a $105,000 grant for the Pathway program. The grant’s mission? “To support and sustain the capacity of individuals who demonstrate creativity, innovation, and commitment to improving health outcomes at the community level.” This mission was well served in honoring Boyd’s life and work.
From the ground up
When her guardian grandmother died, Boyd found herself in a much darker world. “My grandmother instilled in me that I was a precious blessing on earth. After she died and I went to foster care I was told that I was fortunate to have food on a plate or a roof over my head,” she says. “I was given old tattered clothes while foster parents bought new clothes for their own daughters. I was made to scrub toilets while other kids played outside. It sounds Cinderella-ish, but it’s true.
Boyd accepting the Robert Wood Johnson Foundation Community Health Leaders award in 2011
“I was warned that if I didn’t surrender I would be put on the street,” Boyd says. “I found myself 13 and pregnant. After my early childhood with my grandmother I was never again told in my youth that I was a blessing. I knew inside that my blessing was to help others.” Through this experience, Boyd says she learned “society treats the havenots as want-nots,” casting them aside. But she convinced her social worker she could live as an independent, and went on to complete nurse training and education up to her Ph.D.
“I was fortunate to have come across folks in my own path out of poverty that held knowledge about supports for have-nots: orphaned, teen mother, impoverished, minority,” Boys says. One of the folks was Kathryn L. Braun, Dr.P.H., Boyd’s Ph.D. mentor and a professor of public health at the University of Hawaii. They met through Braun’s work with `Imi Hale, The Native Hawaiian Cancer Research Training Network, and Braun also served on the University of Hawaii’s dissertation committee throughout Boyd’s doctoral studies.
“I have always been inspired by Jamie, who overcame many obstacles to get where she is today,” Braun says. “The road was difficult, but it has motivated her to help others ascend the path out of poverty through education and service.”
From the early days, when Braun was helping her mentee obtain research funding from the National Cancer Institute, to now, where they support each other’s professional pursuits and even room together at public health conferences, the two women forged a close, supportive relationship. “As a Native Hawaiian I could not have completed my Ph.D. training without her dedication to mentoring NH [native Hawaiians] and other Pacific Islanders,” Boyd says of her mentor. Braun also notes that Boyd is one of the state’s first Ph.D. nurses to come from an indigenous background.
“She declined a [University of Hawaii] research position in favor of [Windward Community College], so she could reach Hawaiian and other disadvantaged students,” Braun says. Originally charged with developing a health curricula that would help get students “done and out,” Boyd recognized the deficiencies and disparities plaguing her vocational students. “They are not eligible for federal financial aid or student health insurance, WCC provided no graduation ceremony for NA graduates, and there were no supports to transition graduates to living-wage jobs,” Braun says. “She worked to convince WCC to approve a ‘pathway’ approach, helping transition NAs to the Associate Degree in Nursing. She worked nights and weekends to secure financial and in-kind resources to reduce barriers facing students, which won WCC and community support.” Boyd also steered the WCC’s administration toward indigenous teaching models.
“I always had the capacity to give and would have to work very hard to earn resources to experience the privilege of helping others,” Boyd says. “I learned that every individual who presents as a ‘have-not’ may hold within the potential to make lasting positive change.”
On the Pathway out of Poverty
Native Hawaiians seem to have the deck stacked against them: they are more likely to hold low-paying jobs, lack health insurance, suffer from chronic disease, and drop out of school. According to Boyd’s 2007 article “Supports for and Barriers to Healthy Living for Native Hawaiian Young Adults Enrolled in Community Colleges,” “in 2000, 72.5% of Native Hawaiians were overweight, 54.4% met national recommendations for physical activity, and about 10% enrolled in college.” They are underrepresented in areas that count, like amongst college students and health care practitioners. Because of these disparities and others, Boyd is taking action.
At the crux of Boyd’s efforts to improve the health and socioeconomic livelihood of indigenous Hawaiians is the Pathway out of Poverty program: “A Values-Based College- Community Partnership to Improve Long-Term Outcomes of Underrepresented Students.”
Boyd points to a snowball effect in native Hawaiians’ achievement levels: students do poorly in the K–12 levels and cannot gain entrance to public universities. After years of insufficient grade school support, and consequently poor achievement, they’re also unprepared to enter fields like nursing. “But we naturally give so much to community and have a natural aloha to care for the sick,” she says. “We need for Hawaii universities to stop social exclusion behaviors of our early colonizers and allow Native Hawaiians to selfdetermine entrance criteria to nurse training in Hawaii.” The alternative? “Allow me to create the first Indigenous School of Nursing that is inclusive of Native Hawaiian values and cultural practices.”
Boyd reports 135 students, or 90%, of those who have participated in the first three and a half years of the program graduated and became certified nurses assistants; 77 of those individuals went on to higher education, including 33 entering nursing programs.
“Her vision is to reduce poverty and increase representation of Hawaiians in nursing,” says Braun. “Toward that end, she secured critical partners and more than $1 million to build . . . Pathway out of Poverty.”
What nurses can do
“There are big gaps between resources that slow people’s potential to heal themselves,” Boyd says from experience. “My motivation is to eliminate gaps and create a steady, continual path out of poverty.”
It’s not about handouts, Boyd says. It’s about education. “Don’t give childcare; provide centers for child care co-ops,” she says. “Don’t give food; protect land to grow food or designate certified kitchens where [the] disadvantaged can feed each other.”
To that end, Boyd recently secured funds and began developing a “Seed to Plate” curriculum, says Braun. “Pathway students use the garden as a healthy foods ‘lab.’ Recognizing Jamie’s success in nursing and Hawaiian educational approaches, she was asked to join with faculty in botany and nutrition to build cross-disciplinary learning communities that aim to impart Western knowledge while honoring Hawaiian traditions for healthy living.”
Boyd’s Ph.D. dissertation defense. Committee members (left to right): John Casken, R.N., M.P.H., Ph.D.; Kathryn Braun, Dr.P.H.; Boyd; (chair) Chen Yen Wang, A.P.R.N., Ph.D., Lois Magnussen, A.P.R.N., Ed.D.; Bee Kooker, A.P.R.N., Dr.P.H.
Boyd says those who are working diligently should be awarded with “change credits,” like those given to her by the Robert Wood Johnson Foundation. Boyd’s life’s work, her ultimate goal, is to reduce poverty and health disparities amongst indigenous and minority populations. She intends to do so through education, advocacy, and tapping into native teachings. Her solutions draw upon economic and cultural research. In the end, these people will have brought themselves out of poverty. “Through my volunteerism, peer mentorship, publication, and dissemination I help other underserved, and together we pull ourselves up and in turn again pull up even more.”
Lisa Zick-Mariteragi, A.P.R.N.-R.X., M.S.N., M.P.H., an advanced practice nurse practitioner in internal medicine, worked with Boyd at Waianae Coast Comprehensive Health Center in 1998– 1999. “Jamie was a NP student at the time and knew that I took students who had a vested interest in improving health outcomes for indigenous populations,” Zick- Mariteragi says, who agreed to mentor the eager student. “She had a very clear picture in her mind of where she wanted to go professionally and what she needed to do to get there.” Zick-Mariteragi says Boyd, even then, was focused on the bigger things beyond the horizon of her graduate studies.
“Based on, among other things, the Native Hawaiian principles of ‘Ohana, Aloha (appreciation), Laulima (work), Lokahi (unity), and Malama (service), Jamie has been able to create a venue and provide access for disadvantaged individuals to improve their own lives by addressing their social, cultural, educational, familial, and fiscal needs through her programs,” Zick-Mariteragi says. “She demands commitment from them to pay back— not to forget where they came from—and forward-extend a hand to those in greater need than themselves.”
Sharmayne Kamaka, C.N.A., experienced that demand firsthand. She was one of the first Native Hawaiians to join Boyd’s Pathway program. The two met at Windward Community College, where Boyd served as Kamaka’s CNA instructor. “My first impression was that I thought I couldn’t meet her expectations. She was very strict, yet loving at the same time,” Kamaka says of Boyd. “I felt a magnetic pull toward her ‘mana.'” But over the four years they have known each other, that intimidation gave way to deep admiration and a strong mentoring relationship.
“Without Jamie, I wouldn’t be where I am today,” Kamaka says. A divorced mother of five when she met Boyd, Kamaka couldn’t afford to begin her CNA training, but Boyd helped her do the legwork needed to secure funding. “Four years later, I am on the dean’s list, a Phi Theta Kappa member, and a KCC Practical Nursing Student [graduate],” Kamaka says. “Without all the countless selfless hours of Jamie writing grants and securing contracts and community partnerships, I would have given up. It was always a dream of mine to become a nurse. Jamie is making it possible for my dream to come true.” But Boyd says Kamaka is “fulfilling her own dream….She hasn’t gotten anything she didn’t work very hard for.”
Visions of the future
Zick-Mariteragi says she imagines Boyd will continue to grow the Pathway program; to surprise her colleagues with her unstoppable energy; and to make her kupuna (ancestors), her keiki (children), and her mo’opuna (grandchildren) proud. “All that she is, all that she’s done, she’s truly fought hard for. Determined, focused, passionate, humorous, pressed to improve the outcomes for native peoples by creating models of personal and community development—quite literally from the ground up,” Zick-Mariteragi says. “Though I was her mentor before, she could be mine now.”
Braun says she also imagines Boyd simply continuing her current trajectory: reaching out to the community to engage students and administrators, health care providers and funders alike.
Kamaka imagines Boyd establishing Hawaii’s first indigenous nursing school, with buildings named after her. “She is definitely a community leader and should be recognized as such,” Kamaka says.
And what does Jamie Boyd imagine for herself? Her ultimate goal is, indeed, to create a school of nursing for indigenous peoples, she says, combining traditional healing with cutting-edge medical technology—and social justice training to boot. She hopes the disparities affecting native Hawaiians and other underserved populations become a non-issue.
Yet, as long as they persist, and perhaps simply because they persist, disparities and deficiencies make so many people feel helpless—particularly the people living them. Then, someone fights back. Though disparities often prove stubborn, when confronted with individuals determined to eradicate them, they can topple. Jamie Boyd is one such fighter, armed with her cultural roots, her resolve, and her Pathway out of Poverty program.
“For every gain I experienced, I promised to turn back and pull up 10 just like me,” Boyd says. “I’ve already pulled up 10, and I’m still going strong.”
Federally Qualified Health Centers (FQHCs)—the nation’s community, migrant, and homeless health centers—serve over 20 million patients yearly, according to the National Association of Community Health Centers (NACHC). FQHCs provide comprehensive primary health, oral, and mental health/substance abuse services to people across their lifespan. On the front line of these centers, which often serve patients from low-income and medically underserved communities, are nurses. “In a community health center like this one we are moving toward nurse case management,” says Mildred McIntosh, R.N., C.D.E., B.S.N., the Director of Nursing at the Henry J. Austin Health Center (HJAHC) in Trenton, New Jersey.
FQHCs offer affordable, comprehensive, and cost-effective primary and preventive care. In Trenton, HJAHC serves a population of patients who are uninsured or underinsured. “It draws people who always have not had access to health care. They can’t afford [the care] and so when they do come in they have comorbidities, which require a lot of care, and that requires a lot of management,” McIntosh says.
Health centers that fall under the designation of FQHC provide services not typically given in other primary care settings, such as dental care, behavioral health, and pharmacy. The NACHC notes that health centers also help remove barriers to care, such as transportation, case management, interpretation, and home visits. Given the patient population, these additional services are critical. Compared to other providers, the NACHC also reports that health centers disproportionately serve more chronically ill, uninsured, publicly insured, and minority patients, as well as those in poor health.
Designated a FQHC facility, HJAHC patients are 54% African American, according to McIntosh, while Latinos and immigrants from around the world make up a vast majority of the other 46%. As economic and (often, consequently) health care disparities still plague minorities, nurses working in community clinics frequently treat these communities.
The effects of health care reform
Since the health care reform law went into effect, McIntosh says there has been an uptick in patients served at HJAHC. “Absolutely, we have had an increase. We have been trying to enhance primary care,” she says. “[Now] everybody is being given access to care, and that is what we are trying to do, to make sure patients have access and can get an appointment.”
HJAHC is the largest non-hospital based ambulatory care provider in Trenton. It is seeking to become a patient-centered medical home, McIntosh says. Adult medicine, gynecology, pediatrics, HIV treatment, dental care, podiatry, and ophthalmology are the primary health care services offered. Nutrition, social service, substance abuse assessment and intervention, behavioral health, translation services, transportation, and an on-site pharmacy are also provided. Most forms of health insurance, including Medicare and Medicaid, are accepted, and there is a sliding fee scale for the uninsured. The HJAHC provides care to around 17,000 individuals annually, generating over 61,000 visits from three Trenton locations.
“Being in the inner city and being a community health center, we see many [people with] social and behavioral problems,” McIntosh says. “There are not enough funds and social services available.”
The ability to find specialty care is also an issue for the demographic group the center serves. McIntosh notes that many people in underserved communities have used the emergency room as “primary care” in the past because they can’t find specialists who will readily see them. At times, HJAHC will try to facilitate access to specialty clinics. The goal, however, is optimal primary care, health, and wellness. “If we get to the patients earlier, hopefully this will prevent them from presenting further progressions with their problems,” McIntosh explains.
Nurses from minority backgrounds should have major roles in community centers, McIntosh says. “We serve a lot of minorities…and minority nurses have the culture and understanding of care,” she explains.
Working in a center that provides such a wide range of services also means nurses there need to be experienced. “You have to know the specifics across the lifespan,” McIntosh says. “You need a variety of nursing skills, and you have to be very caring and understanding.”
McIntosh believes nurses must also acknowledge what impact their background could have on care provided. “You need to recognize your own culture to understand other people’s cultures….I have to know what problems I have when I approach other people,” she explains. “I have to respect their different views, whether they are religious or social issues. We are working cross-culturally.”
Inside the clinic
Certainly, public health comes with its own challenges, but McIntosh says she couldn’t see herself anywhere else. “The rewards are phenomenal. I love it,” she says. “I would not do anything else. The reward is when a stressed-out patient comes in and at the end of their visit, they say, ‘Thank you for taking the time.’ The reward is I helped someone today, that I brought one person into the health care system.”
McIntosh oversees eight RNs and three LPNs, many from minority backgrounds. “Minority nurses do make a difference; that is the community we serve,” says McIntosh, who is African American. “We are qualified health care providers. We are helping people get access to care, enhancing primary care. We are improving and changing the delivery system [of health care services].”
The Brownsville Community Health Center (BCHC), a FQHC in Southern Cameron County, Texas, is also making a difference in a minority community. Brownsville is on the southernmost tip of Texas, and its county population is mainly Hispanic. Originally established in the late 1940s, BCHC opened doors to its newest center in the summer of 2011. Approximately 215 people work for the corporation, including 50 nursing staff personnel.
The vast majority of nurses who work at BCHC are of Hispanic descent, particularly people from Mexico/Mexican Americans, according to Terry Frizzell, R.N., Director of Nursing. “A lot of our nursing staff is from the area. It is important that the people who are hands-on with the patients are from the same culture because they understand the patients and speak the same language,” says Frizzell, a Canadian native who has worked for the Brownville Health Center Corporation for 16 years.
Originally established in the late 1940s, the BCHC Corporation has four fully functional sites (two other smaller sites are pending providers with recent changeover in key positions). The corporation’s newest facility, the New Horizon Medical Center, is a 47,000-sq. ft. building. It offers OB/GYN, pediatrics, internal medicine, behavioral health, dental, and diabetes education, as well as pharmacy, laboratory, podiatry, and radiology services. BCHC accepts Medicaid/CHIP, Medicare, private insurance, and self-pay patients, who are charged on a sliding scale. In 2010, approximately 19,200 patients visited the center and 85,635 encounter visits were recorded.
Carmen Lopez, R.N., is another long-time employee of BCHC, having worked there almost 13 years. Lopez, born and raised in Brownsville, is a clinical resource nurse. She supervises the nursing staff, which includes a large number of medical assistants, for the centers.
“A lot of times when Hispanic people come here, they usually do not come here until they are really very sick,” Lopez says. “Sometimes we get cases where there is nobody else to take care of them or their Medicaid is done. They [may] have cancer and they have all these [other] problems. When they come here, then they do get help. That is one of the things that’s rewarding: to see people getting taken care of who have all these kinds of problems. You see quite a bit of those kinds of people here.”
Frizzell says finances are not the only barrier to care. “In the Hispanic population, especially with males, they to tend to not seek help,” she says. Whether due to male machismo, a desire to stay strong for family and work responsibilities, or an effort to save money, Frizzell says she sees her patients prolonging their avoidance of medical care. “They don’t see care until the point where they cannot go any more and they realize that something is desperately wrong. Then you do have to be very tactful, very convincing,” she says. “We are all part of a team; we try to be the advocate for the patient.”
Lopez agrees; being a team player is very important in this type of setting. “Everybody has to mesh together,” says Lopez, whose job sees her working across the board with doctors and staff from every department, from OB/GYN to geriatrics. Lopez also has significant administrative duties, including doing evaluations for the nursing staff.
Education is a key part of the role the nursing staff provides. Teaching goes beyond the individual patient, Lopez says. Family members must also be educated. In the Hispanic culture, Lopez says, close family friends are also considered part of the family. “I used to do a little teaching for diabetics, and they would ask, ‘Can I bring my mother, father, brother…? I was helping all these people because they are people living with the diabetic and they need to get the information as well,” Lopez says. “Sometimes my classes were quite large.”
Being family oriented is inherent in the Hispanic culture, agrees Angela Hernandez, R.N., a native of Brownsville. She has worked for the BCHC Corporation for almost one year. “Family is just very important,” she says. Hernandez works mainly with adult health and geriatric patients, and she points to geriatric patients as one example where family involvement is paramount. It is very difficult to make the decision to put a parent in a nursing home in this community, she says. Instead, many geriatric patients are cared for at home. “We teach family members what to expect, and about being caregivers. We educate them on things like falls and medication,” she says. “You are treating the whole family.”
Hernandez says she enjoys the opportunity the clinic setting gives her to forge bonds and follow patients throughout the delivery of care. “Here you get to help people who have nowhere else to go and form relationships with them. I think that is the best part of the job,” she says. “You get them in to see a doctor and get the services they need. It is very rewarding.”
Challenges
As with any specialty, community nursing has its ups and downs. One challenge of this type of nursing is trying to accommodate all patients who seek care. “We do get to see just about everybody, but it doesn’t always happen as quickly as we would like it to happen,” Hernandez says. “In some cases, you get patients that have never seen a doctor and they wind up in a hospital, and end up with all these chronic conditions and now…they need to see a doctor. There are so many people that come here. That is the frustrating part, the difficult part, getting them in within a reasonable amount of time.”
Another challenge is making sure the patients are compliant with their own care plan, such as taking their medicine as diagnosed. “Many people who come in here have diabetes, hypertension, and COPD. Because of our culture and diet, we have a lot of that here,” Hernandez says. “For hypertension for example, you have to explain that they need to take the medicine daily and they need time to adjust to the medicine.” Getting patients to discuss details of noncompliance, such as side effects bothering the patient to the point where they simply stop taking the medicine, is critical.
Being a good listener is another important skill for community health nurses. “The patients have stories,” Hernandez says. “Maybe you cannot do everything for them, but if you listen you have done something for them.”
For Hernandez, the rewards of working in this setting are many. “You get to see the difference you are making in a person,” she says. “You see them and then they come back and tell you [what impact you had]. That is a feeling you cannot describe.”
Lopez advises anyone looking into this career field should take the time to visit a clinic. “You need to have a big heart,” she says. “Your heart has to be in to helping people. It can’t be because of money.”
The Family Health Center of Worcester is a community Federally Qualified Health Center founded in 1970. It is a full-service health facility open to all residents of Worcester, Massachusetts, the second-largest city in New England, and its surrounding areas. Family Health Center of Worcester’s mission is “to improve the health and well-being of traditionally underserved and culturally diverse populations in the greater Worcester area by providing accessible, high-quality, comprehensive primary care, dental care, and social services to individuals and families regardless of their ability to pay.”
While the Family Health Center’s history goes back over four decades, it made a big move in the early 1990s when it rented space on property that once housed Worcester City Hospital. That acute care facility closed its doors in 1991, making services offered by community clinics even more important.
In its quest to fulfill its mission, Family Health Center offers a wide range of services: family medicine, maternal child health, behavioral health, dentistry, nursing, a walk-in center for urgent and primary care same-day visits, pharmacy, lab, radiology, school-based health centers, refugee/immigrant health services, teen health clinic, ADHD clinic, INS clinic, flu vaccine clinics, health education and promotion, HIV counseling and testing, and public health programs for the early detection and prevention of disease. Additionally, Family Health Center administers the Women Infant Children (WIC) nutrition program at four sites in the Greater Worcester area.
Opened in 2010, the Center offers patient support to help its clients fully access necessary health care and other needed benefits. These include medical interpretation in over 30 languages, care coordination for patients with chronic illness, patient advocacy and navigation services, homeless families case management services, Ryan White HIV/AIDS Early Intervention Services, a 24/7 telephone nursing line, financial assistance for prescription drugs, food stamps enrollment assistance, exercise and wellness programs, and community health education. Family Health Center also runs a number of satellite offices, many in the city’s schools. It also offers dental services in the nearby town of Webster in its public schools.
Grace Hicks, L.P.N., has worked for Family Health Center at the main clinic for the past two years. A native of Kenya, she has lived in the United States for the past decade. Daily, she performs a variety of tasks for the patients the Center sees, many of whom are Hispanic. “I do triage, pediatric shots, wound dressing, blood pressures, as well as stitch and staple removal,” she says. “I do pretty much anything that comes in the door that needs to be addressed.”
One attribute Hicks sees as necessary in community nursing is empathy. Nurses act as patient advocates, she says, and sometimes help them find a social or economic link to their health problems. “They may come in not feeling well, but they have other areas that need to be addressed, like their housing [situation] or a lost job,” Hick says. “Sometimes you have to explain that they are depressed and why they are stressed out.”
The center has a rich cultural mix of health care staff on hand as well. “I love it because we get all the different cultural diversity,” Hicks says. “And wherever the patient comes from…they all get taken care of, their needs are met, and they are satisfied with what we did for them.”
The nursing coordinator for infection control and employee health at the center is Emmanuel Okrah, R.N., M.S., who has been installed as a Ghanaian Chief. He notes that the largest concentration per capita of Ghanaians is in New England. They make up part of the population that the Family Health Center serves, Okrah says. The Center also sees many patients with Albanian backgrounds. “It is immigrant populations that are underserved,” he says.
Having a multicultural staff at the Center helps them relate to their clientele. “It is important because as a patient, you feel more comfortable,” he says. “You can open up better to a person you relate to. That is one of the [positive things] I see about minority nurses working in community settings.
“Using my situation as an example, when a medical issue arises with someone from my [native] area, there may be a need for a translator for an English speaking provider. I am a qualified nurse and I can interpret,” he adds. “There is a trust there, and they can feel confident.”
Likewise, cultural barriers can be erected, Okrah says. “If a person doesn’t feel at home or there is a communication issue and that person cannot be able to explain the issue to the provider, then that is a barrier. It is very important to understand the cultural underlining of one’s condition.”
Health care reform has had a positive impact, Okrah says. “It is a big plus for community health centers. In a sense it has allowed our clients, who are underinsured or not insured, to use us as a conduit to meeting their health needs. It is a very important role in providing health care.”
If there is one thing surgical nurse Rochelle Scott has learned from her patients, it is to assume nothing. No matter how well she might think she understands a culture or a tradition important to her patients, Scott learned through repeated interactions that each patient, no matter what his or her heritage, will interpret and use cultural norms in slightly different ways.
“Giving the culture respect, and honoring that when it is appropriate, shows the patient they can trust you,” says Scott, who is midway through her master’s degree in the nurse practitioner program at Mount Saint Mary College in Newburgh, New York.
When you care for patients of Southeast Asian descent, with cultures that may include but are not limited to Hmong, Vietnamese, Chinese, or Thai people, learning a bit about the cultural norms and traditions can positively impact health care outcomes. But the languages and traditions of this group are incredibly diverse and have many nuances that impact literacy, child-rearing practices, elder care, and self-healing. Thankfully, nurses are in a great position to do some research, interact frequently, and discover the individual subtleties of their patients’ heritages.
When Dr. Madeleine Leininger introduced the idea of transcultural nursing in the 1950s, the idea was outside the norm. As cultural diversity and the promotion of cultural competence in health care settings becomes more mainstream, the idea continues to take shape in nursing programs. Dr. Priscilla Sagar, R.N., A.C.N.S.-B.A., C.T.N.-A., professor of nursing at Mount Saint Mary College, says nurses are often called on to lead the journey, bringing cultural competence standards into practice in academic settings, health care practices, and research.
“One of the biggest barriers is the lack of research about the populations,” says Sagar, referring to Southeast Asian patients. “Usually [research] has lumped them in saying ‘Asian/Pacific Islanders’ instead of separating them.”
The distinctions are vitally important when trying to determine something like typical growth and development for instance, says Sagar. Growth and development in a Filipino child might look delayed to some when, in fact, it is normal for that group, she says.
On the job
When on the job, though, cultural competence may not be as well defined. For instance, Dr. Margaret Andrews, R.N., F.A.A.N., C.T.N., Director and professor of nursing at the University of Michigan-Flint, cites instances of health care practitioners suspecting child abuse when children have shown up at doctors’ offices with red marks from the Asian practice of coining. Coining—the custom of rubbing coins over the skin (especially ribs of children with a cold) to create friction and warmth to rid the body of what is assumed to be bad winds or to fight off a cold—also leaves red marks on the skin. If you are not aware of the practice, it might raise suspicions of maltreatment.
The idea of coining, says Andrews, is not so different from Western practices of trying to restore balance to the body. The outcome looks a little different, but it helps if the medical staff is aware of the practice and any other practices of the cultures they frequently treat. They can then respectfully and effectively treat the patient without seeming to dismiss their beliefs. For example, if a child’s cough really is pneumonia, more intervention is necessary. If any herbs have been used for self-treatment, there has to be enough trust so the patient will share what has been used without fear of rebuke. Andrews recommends nurses reference the National Center for Complementary and Alternative medicine’s website at nccam.nih.gov for more in-depth information.
For many nurses, the desire to understand other cultures is the first step toward effective change. “Without the desire, it would be difficult for health care providers to embark on this journey,” Sagar says.
For instance, many cultures in Southeast Asia are family focused and oriented, Sagar says. In the United States, where medical decisions are generally made independent of the extended family, a medical decision that weighs the opinions of many family members might seem different. “But in many of these cultures, the family is involved,” she says.
And while the health care providers have to recognize that, they also have to gain a sense of any underlying factors. Sometimes, especially for immigrants, there is a sense of being in two worlds, both of which might have conflicting values, Sagar says. “If they are second generation and if they were born here and have grown up here, their values may be more Western than Eastern,” while the family values remain decidedly Eastern. The opinions can create a real family conflict.
For nurses, it is a matter of figuring out how it all reflects on the patient’s care. “When you first get educated, it is all about retaining it and incorporating it into the health care with the patient,” Scott says. Even something as simple as being aware of major holidays for that culture can make a patient feel recognized and feel his or her culture is respected. No one wants to schedule a procedure around a major celebration if it is not necessary.
Perform cultural assessments and learn about the top three or four cultures you work with, even small details like how to address the patient, Andrews recommends. In some Asian cultures, the first and last names are in reverse order from Western usage. “Ask them, ‘By what name may I call you?’” Andrews says. “Generally, it is better to address more formally and wait to see if they give you permission later to call them something else.”
Andrews also recommends being aware of the tradition of wearing an amulet to bring good luck or a talisman to ward off bad luck that many Southeast Asian populations honor. “That may give a signal to the nurse that they have spiritual beliefs they are bringing to a health care setting,” Andrews says. “You need to respect those.”
When traditions or beliefs that are important to the patient are not recognized, it can set up a rocky start to a relationship between nurse and patient. “It is the little things that can be frustrating for the patient,” Scott says. “Then the patient feels neglected or disregarded.”
According to Guadalupe Pacheco, Senior Health Advisor at the Office of Minority Health, there is a disconnect that exists between the demographics of the nation and that of health care professionals. Pacheco says that while various ethnic groups compose nearly one-third of the population, the nursing population does not mirror that proportion.
When the patient and provider come from a similar cultural background, the common factor often inspires trust Pacheco, says, but even the most radically different backgrounds can still work well. “It is all about communication,” says Pacheco. “If you establish that rapport with a provider and patient, they will come back to you. They are going to trust the diagnosis you make and the treatment you are prescribing.” And while health care professionals work hard to overcome any language barriers, understanding the cultural barriers as well will ensure that a patient not only trusts a provider, but also understands what is being prescribed and why it is important to follow through.
Think like your patient
Imagine being in your patients’ shoes, says Pacheco, where the system may seem very foreign and difficult. Creating a calm environment is a big step toward putting a patient at ease, he says, despite the difficult time and pressure nurses are under.
Sometimes thinking like your patient, even briefly, gives clues as to how to proceed. Eunice Lee, Ph.D., G.N.P., a UCLA School of Nursing associate professor, had success in implementing change to get more Korean American women to have mammograms. Even the cultural differences between Korean and Korean American women can be vast. “I am struck by how cultural norms impact women’s behavior,” Lee says. “Korean American women do not tend to take care of themselves. Women prioritize family needs first with husbands and children. They are at the bottom of the list, especially if they have no symptoms.”
In the late 1990s, only 10%–20% of Korean American women were getting mammograms, says Lee. The number has since doubled but is still very influenced by the cultural context.
Lee implemented a program where she used a popular Korean vegetable dish as the program’s acronym, KIM-CHI (Korean Immigrants and Mammography: Culture-Specific Health Intervention). By presenting mammography as a normal, routine health screening and educating the husband and the woman together, screening rates jumped 15% in Lee’s intervention group.
“When you educate the woman, you need to consider and evaluate her support system and how they can help her, rather than have it purely focused on the individual,” Lee says. Health care providers might want to encourage the husband to support the woman in taking time off from work or family obligations to get screened. Lee also expressed the strong cultural resistance to getting treated, even in a screening manner, for illness in the absence of any symptoms. “When you don’t have symptoms, you are not ‘sick,’” she says of some patients’ beliefs.
Use your resources
At Lowell General Hospital in Massachusetts, Brenda Murphy, R.N., a med/surg float, works closely with the hospital’s cultural interpreters to give her patients the best care. In addition to taking advantage of work-sponsored cultural education and training, she picks up appropriate behaviors within each culture from observing and asking questions.
Murphy, who works with Lowell’s extensive Cambodian population, says she always put her hands together to give an elderly patient a small bow as a sign of respect when leaving. At the advice of a cultural interpreter, she adjusted the height of her hands, as hands that are placed too low can be seen as insulting, rather than respectful. Murphy also says she is careful when touching the head of a Khmer patient as the cultural traditions of some Khmer say the soul resides there. If it is possible to ask permission, she always does. Eye contact might be unnerving to Khmer patients as well, who sometimes avoid it as a sign of respect. They may prefer also very limited physical contact.
Many hospitals prefer to use medical interpreters to ensure accuracy in translation of complex medical terms and to protect a patient’s privacy. In their absence, nurses might have to rely on more rudimentary methods like flash cards or pictures to help both patient and nurse. Pacheco discourages the use of family members as interpreters, especially children. “Sometimes you have no choice, but it is best to introduce a bilingual neutral party who also understands medical terms,” he says. Family members can help fill in the missing information about symptoms the patient is experiencing or treatments used.
Moving forward
“It is encouraging,” Sagar says of the progress being made. In the next couple of decades, as minority populations grow, cultural competence in nursing will become much more crucial to quality patient care. “I am passionate about cultural diversity and the promotion of cultural competence,” she says. As an immigrant herself, Sagar says she knows the experience of “being different from the rest.”
When Lowell General Hospital was forming plans for diversity training, staff recognized that diversity was as much of an essential component of patient care as medicines and procedures, says Deborah Bergholm-Petka, Manager of Training and Development. Nurses have the opportunity to learn about cultures through monthly celebrations in the hospital. The staff is also encouraged to reference the book Culture & Clinical Care,which gives general summaries of many cultural beliefs and attitudes. Use what your work environment offers and know a little bit about the cultures served. “Know who your resources are and how to access them,” Murphy suggests. “Now we are more proactive and aware of who makes up our communities.”
Be ready for all situations when you work with many different cultures. Continually ask yourself reflective questions, suggests Venus Watson, chair of Lowell General’s Diversity Council. For instance, how will you navigate various cultural wishes and accommodate a patient while ensuring the best care and follow up? If family members want to speak for a patient, how can you best introduce an interpreter?
“It is not about the nurse,” Scott says. “It is about the patient. You can offend people when it comes to culture.” Never assume you know what a patient wants, she says. Rather, gain knowledge, be aware, and ask the patient—the solution is often that simple. “People do pass judgment on beliefs,” Scott says, “but it is education that will change the system.”
Today’s nurses face the challenge of how to position themselves to be most effective in orchestrating policy changes in their surrounding communities and workplace. But we can look to one of our most effective leaders and political activists for inspiration: Florence Nightingale. We should emulate and develop the skills practiced by Nightingale and other leaders of the past, and with their collective power, modern nurses can make a huge difference in our society’s health care system by participating in policymaking.
Because of persistent high unemployment rates and reform, the health care industry has had a tumultuous past few years. Families that once had commercial insurance are faced with difficult choices regarding compliance with primary, dental, and preventative care decisions. Many nurses recognize the severity of the problem, yet, due to lack of experience in the political realm, often take a backseat on such issues. Nurses can draw strength to make bold attempts at policy change by following Nightingale’s (and many other nurse leaders’) example.
Nightingale became an activist when she recognized the need for reformation in the prisons, hospitals, army, and English workhouses in Europe and India. When she went to the Selimiye Barracks hospital in Scutari (Istanbul) during the Crimean War, she encountered staggering fatality rates, but started developing the theories of sanitation and organization that eventually reformed health care. Although exhausted, and at times ill herself, she fought for humanity and the education of future health care advocates. As a mentor, Nightingale taught her students proper observation and assessment skills. How did Nightingale—a frail, young, inexperienced activist—make the kind of difference that continues to be recognized today? She relied on what she knew and maintained her commitment to humanity. As a nurse, she recognized the need for change and set an agenda to put those changes in motion. When engaging with military commissions, Nightingale used the power of listening and observation, recognizing body language and conversation stoppers. She became a leader, respected not only because of her caring spirit, but also because of her brilliance in tackling problems. Nightingale also became well known and influential in her new uses of applied statistics to bring about social change, presenting data to politicians and government officials through visually stimulating graphics.
Florence Nightingale wrote countless letters, 147 books and pamphlets, and even more reports concerning sanitation and health. She is an example of how we can use writing and communication skills via networking and by forming coalitions of people with common interests to support our goals. Nurse practitioners must become passionate about the issues they find in their communities, giving a voice to the voiceless and advocating inside the health care system.
We must recognize the issues in society today and imitate the examples of past nurse leaders, those who have accomplished their goals in changing policy and procedures. We must realize that we may face rejection, that implementation of policy is generally unpredictable, and that change does not happen overnight. We must be incremental in our attempts to implement new policies, by positioning ourselves in positions of authority, such as agency leaders in government offices. Though we may encounter resistance, such as when convincing an organization to try a pilot plan, we can arm ourselves with evidence and examples to illustrate to others the effectiveness of the innovations being introduced.
Nurses must recognize the influence they can be in current health care dilemmas by exposing themselves to policymaking opportunities. Imagine a world in which Florence Nightingale failed to act on her beliefs—critical changes regarding sanitation and hygiene could have been delayed, and many lives might have been lost. Nightingale was a force in the nursing profession and in society. Today’s nurses must use her as our example, imitating her dedication and tenacity to influence changes that will improve our health care system.
Among the many electrolytes, potassium stands out. It is perhaps the most prescribed electrolyte, followed by magnesium and phosphorous. In cardiac units, it is one of the staple drugs twinned with digoxin. Brand-name orange juice and milk products are now advertised as “potassium rich” to lure not only consumers concerned with heart health, but also the general public.
The health benefits of potassium
When patients ask why they are given potassium, the standard reply is “it’s good for your heart.” But there is more to it than that. According to the National Council on Potassium in Clinical Practice, evidence supports high-potassium diets can reduce the risk of stroke by combating the effects of sodium.1
When teaching patients about dietary sources of potassium, most nurses stop at bananas. The New England Journal of Medicine published the following categories of excellent potassium sources: Highest Content (>1000 mg [25 mmol] per gram) • Dried figs • Molasses Very High Content (>500 mg [12.5 mmol] per gram) • Dried fruits, nuts • Avocados • Bran cereals, wheat germ • Lima beans High Content (>250 mg [6.2 mmol] per gram) • Vegetables: spinach, tomatoes, broccoli, winter squash, beets, carrots, cauliflower, potatoes • Fruits: bananas, cantaloupe, kiwis, oranges, mangos • Meats: ground beef, steak, pork, veal, lamb
Studies also show reduction in blood pressure after potassium supplementation is three times higher in African Americans than in Caucasians.2 Research suggests that when one’s potassium level is below 3.5 mmol/L, supplementation is essential, even in asymptomatic patients with mild-tomoderate hypertension.3 For patients with a history of arrhythmias, the threshold for potassium replacements is higher: 4.0 mmol/L. The Journal of the American Medical Association reports the risk for ventricular fibrillation in acute myocardial infarction is significantly higher in patients with a potassium deficiency (less than 3.9 mmol/L).
The effect of digoxin is enhanced in the presence of hypokalemia. Hypokalemia predisposes a patient to digoxin toxicity by reducing renal clearance and promoting myocardial binding of the drug.4 Maintaining a normal potassium level is important in preventing digoxin toxicity and minimizing the potential side effects.
The daily minimum requirement for potassium in the average adult is 1600–2000 mg (40–50 mEq). It is interesting to note that across racial lines, it is reported that urban whites consume approximately 2500 mg of potassium per day while African Americans take in only 1000 mg per day on average.5
So what can your patients (and you) eat or drink to get an adequate amount of potassium? For starters, eight ounces of orange juice supplies 450 mg of potassium. Milk and vegetable juice (such as V8) are also rich in potassium but, unfortunately, can be loaded with sodium. Additionally, some of these potassium-rich foods can be costly and potentially cause weight gain. But don’t limit yourself to bananas; seek diverse foods to supplement your potassium intake.
Potassium replacement
In the hospital setting, compliance with potassium replacements or therapy can be a challenge. Tablets are better tolerated than the liquid form for patients who do not have any difficulty swallowing. Compliance is also enhanced by the dosing schedule; the more infrequently the patient takes the pill, the better the compliance. Instead of giving 20 mEq BID, you can ask the doctor to order it as 40 mEq once a day as clinical condition allows. In patients taking diuretics, dietary consumption of potassium-rich food is not enough and must be coupled with a potassium supplement.
Mixing potassium liquid with juice or ice makes it easier to swallow. To prevent the occlusion of feeding tubes, give the liquid form to the patient instead of crushing the pills. Lastly, it is important to note that magnesium is an essential cofactor for potassium uptake and maintenance of intracellular potassium level.1 Potassium supplementation works best when the magnesium level is within a normal range (1.5–2.5 mEq/L).
Nurses must be particularly keen on improving potassium intake in vulnerable groups such as the elderly, those who live alone, and persons with disabilities or functional limitations—they are most at risk for low potassium intake.
Resources
J. Cohn, P. Kowey, P. Whelton, et al., “New guidelines for potassium replacement in clinical practice,” Archive of Internal Medicine 160 (2000): 2429-2436.
P.K. Whelton, J. He, J.A. Cutler, et al., “Effects of oral potassium on blood pressure: meta-analysis of randomized controlled clinical trials,” Journal of the American Medical Association 277 (1997):1624-1632.
P.V. Caralis, B.J. Matterson, E. Perez-Stable, “Potassium and diuretic-induced ventricular arrhythmia in ambulatory hypertensive patients,” Miner Electrolyte Metabolism 10 (1984): 148-154.
A, Bielecka-Dabrowa, D.P. Mikhailidis, L. Jones, et al., “The meaning of hypokalemia in heart failure,” International Journal of Cardiology (2011) doi:10.1016/j.ijcard.2011.06.121
A.K. Mandal, “Hypokalemia and hyperkalemia,” Medical Clinics of North America 81 (1997):611-639.
