When it comes to accessibility and quality of health care, people of color who live in remote rural areas are one of the most severely underserved populations in America. One organization that is working hard to address this disparity is the National Rural Health Association. Since 1988, NRHA’s Rural Minority Health Advisory Committee has played a leading role in developing programs and resources for improving the health status of African Americans, Asian Americans, Hispanics and Native Americans who reside in geographically isolated rural communities.
To provide health care professionals, researchers, health policy-makers and community-based organizations with a comprehensive source of health information that can be used to benefit rural minority communities, NRHA is launching a new online resource: the Rural Minority Health Information Warehouse. Scheduled to be up and running by October 1, the Information Warehouse can be accessed through the Minority Affairs section of the NRHA Web site at www.NRHArural.org.
NHRA Minority Affairs Director Rosemary McKenzie tells Minority Nurse that the warehouse will include such resources as:
Listings of rural minority health researchers and research centers
Policy briefs, executive summaries and abstracts of federal and state reports and published manuscripts
A catalog of community programs and services
Maps of rural minority health data by county
Mini state reports of 1862 and 1890 land grant institutions relevant to rural minority populations
A catalog of information based on Healthy People 2010 priority areas
Are you looking for a nursing career that’s different from the “same old same old?” One that offers variety, challenge and opportunities to work in many different parts of the country? A deeply fulfilling career that gives you a chance to make a real difference in addressing some of the nation’s most serious minority health disparities? Then consider a career with the Indian Health Service (IHS).
There are more than 560 federally recognized American Indian and Alaska Native tribes located throughout the United States. The Indian Health Service, a federally funded agency within the Department of Health and Human Services, is the primary health care provider and advocate for approximately 1.9 million of the nation’s 3.3 million American Indian/Alaska Native (AI/AN) people. About 57% of AI/AN people in the U.S. depend on IHS for a wide range of health care services, including hospital care, clinical care, dental and pharmacy services.
These are particularly exciting times for nurses to pursue careers in the Indian Health Service. President Obama’s fiscal year 2010 budget authorized one of the largest IHS funding increases in 20 years. As a result, the agency now has a $4.03 billion operating budget directed at supporting and improving health care services, improving health outcomes, promoting healthy communities and addressing health disparities. Last year the IHS received a $500 million allocation of American Recovery and Reinvestment Act funds to help pay for new health care facilities, health information technology, medical equipment and other improvements in the delivery of health care to AI/AN communities.
A Unique Mission
Although the IHS as we now know it was established in 1955, earlier efforts to provide some type of federally funded health care for Native people date back to the 19th century. By 1921, the Snyder Act authorized the use of federal funds to provide health services to federally recognized tribes, which are sovereign nations that have a government-to-government relationship with the United States. The Snyder Act approved funds “for the relief of distress and conservation of health. . . [and] . . . for the employment of . . . physicians . . . for Indian tribes throughout the United States.
“Today the Indian Health Service provides a comprehensive system of health care services to AI/AN people living on or near tribal reservations, in rural communities and in urban settings. Headquartered in Rockville, Md., just outside the nation’s capital, the agency has 12 local area offices across the country, mostly in the Western U.S. and Alaska. The IHS operates 31 hospitals, 63 health centers, 30 health stations and 34 urban Indian health projects.
During the 1970s, landmark legislation such as the Indian Self-Determination and Education Assistance Act gave tribes the option of contracting with IHS to operate and manage their health care services themselves, rather than receiving services directly from the agency. As a result, there are currently 14 hospitals, 240 health centers, 102 health stations and 166 Alaska village clinics that are run by tribal governments.
Through both federally operated and tribally contracted health programs, the Indian Health Service’s goal is to ensure that all AI/AN people throughout the U.S. can receive health care that is accessible, comprehensive and—most importantly—culturally acceptable.
“The thing that is distinct about working for the Indian Health Service, besides the fact that it is a federal agency with a direct clinical service delivery mission, is the fact that the American Indian/Alaska Native people still have much of their [traditional] culture intact,” says Carolyn Aoyama, CNM, RN, MPH, the agency’s senior consultant for women’s health. “American Indian culture is very different from the dominant culture.” For non-Native nurses, she adds, having the opportunity to learn about and work within a culture that is so different from their own can be a tremendously enriching experience.
Culturally appropriate nursing care can play an important part in helping to eliminate the severe health disparities that are rampant in AI/AN communities. According to IHS statistics, the life expectancy of AI/AN people is almost five years shorter than that of the general U.S. population, and they have significantly higher mortality rates from tuberculosis, alcoholism, diabetes, automobile accidents, unintentional injuries, homicide and suicide.
“Diabetes is the predominant diagnosis that we see,” says IHS nurse Devon McCabe, RN, a member of the Navajo nation in Leupp, Ariz., who works as an ICU supervisory clinical nurse at the Gallup Indian Medical Center in Gallup, N.M. “My goal is to get these patients out of the hospital and [help them stay] healthy. I stress to my staff that educating our patients is a top priority. Patients need to be self-aware about their diseases and understand their diagnosis.”
Nurses Urgently Needed
The Indian Health Service currently has a nursing workforce of more than 2,500. But like many other health care employers that have been impacted by the nursing shortage, it has struggled to recruit and retain nurses, in in-patient, outpatient and public health/community health settings. Last year the agency’s overall nursing vacancy rate was 26%—compared to 21% for physicians and 11% for pharmacists. Therefore, nurses interested in exploring careers in the IHS will find great demand for their skills and an exciting variety of opportunities to choose from, especially if they are willing to work in rural, medically underserved locations.
A Coast-to-Coast Commitment to Improving INdian Health In addition to its national headquarters near Washington, D.C., the Indian Health Service comprises 12 regional areas:
Aberdeen Area (North Dakota, South Dakota, Iowa, Nebraska)
“Here on the Navajo reservation, hiring is one of our top priorities,” says Jeannette Yazzie, BSN, RN, nurse consultant for the Navajo Area IHS office in Window Rock, Arizona. “I have a nurse recruiter at each one of our facilities. We’re just in the process of reestablishing a region-wide recruitment and retention group which will include not only nursing staff but also physician and pharmacy staff. Our greatest need for nurses right now is in OB and ICU. Medical-surgical nurses are always needed.”
The IHS also needs more advanced practice nurses, including nurse practitioners, nurse-midwives and nurse anesthetists, adds senior national nurse recruiter Celissa Stephens, MSN, RN. “The vacancy rate for APNs has been going up every year for the past four years,” she notes. “Advanced practice nurses have a lot of autonomy and responsibility within the Indian Health Service, and in general the risk status of the population and the patients that they’re going to be serving will be higher.”
IHS nurses have the option of working either for the agency or for tribes. Nurses hired by tribally operated facilities are employees of the tribes, which typically determine their own salary levels and benefits packages. Nurses who work at IHS-run facilities are employees of the federal government and can choose to be either civil service employees or members of the U.S. Public Health Service Commissioned Corps.
According to Stephens, salary rates for federally employed IHS staff nurses are competitive with the national average for the private sector. Nurses will also find plenty of opportunities for professional growth, including training programs, education programs and leadership development.
The agency also offers a loan repayment program as well as a scholarship program to assist staff members who wish to advance their professional education. Each year the IHS awards scholarships to help AI/AN nurses complete their bachelor’s or master’s degrees while maintaining their full salary and benefits. “That’s how I earned my master’s degree,” says Stephens.
Traveling Many Paths
If you thrive on versatility and variety, rather than doing just one type of nursing in one location, then a career with the Indian Health Service is for you. IHS nurses typically handle a wide range of medical and public health situations, and they must be open to performing duties that fall outside those of traditional nursing jobs at private sector health care facilities. Plus, working for the IHS gives you the opportunity to move around the country and work with a variety of different tribes and cultures.
“On most of our reservations, when we’re looking for OB nurses for example, we [want] them to be able to work a whole range [of nursing functions],” explains Yazzie. “We want them to be able to [provide care to the mother] before birth, after birth, and then provide care to the baby.”
In her 25-year career with the IHS, Yazzie has journeyed both geographically and professionally. “I initially started as an ICU nurse in 1983,” she says. “Being Navajo and growing up for part of my life on the reservation, I always knew I wanted to work there and assist my people in whatever way I could. Working for the IHS has been very rewarding for me. It has taken me many places and given me numerous opportunities [to advance in my career].”
Over the years, Yazzie has worked in Washington state with the Yakama tribe, at the Whiteriver Indian Hospital on the White Mountain Apache reservation and at Indian Health Service facilities in Phoenix, Ariz., and Alaska.
Similarly, Stephens, who is a member of the Choctaw nation of Oklahoma, has worked for the IHS since 1989 and has held a variety of positions, including ICU nurse, manager of a med-surg unit, clinical nurse specialist, clinical nurse consultant and chief nurse consultant.
For nurses who love the outdoors, the IHS offers opportunities to work in some of the country’s most beautiful, unspoiled natural settings, from the spectacular landscapes of Alaska to the Big Sky Country of Montana. In Arizona, for example, there are plenty of activities for an outdoors person, including walking, biking, hiking and many national parks and monuments to explore. If, on the other hand, you’re someone who prefers to live and work in a city environment, there are IHS urban Indian health programs in metropolitan areas like Chicago, Denver, Dallas, Los Angeles, Minneapolis, San Diego, Boston, Milwaukee and Tucson.
All Nurses Welcome
Unfortunately, many non-Native nurses fail to even consider the possibility of pursuing a career in the Indian Health Service because they mistakenly believe that only American Indians and Alaska Natives are eligible to work for the agency. This perception, though common, is not true. While the IHS is federally required to give hiring preference to AI/AN people first, nurses of all races and ethnicities are encouraged to apply. Currently, only about half of the IHS nursing staff is American Indian or Alaska Native (see below).
Who are today’s Indian Health Service Nurses? Source: Indian Health Service, August 2009
Aoyama is an example of a non-Native nurse in a leadership role within the IHS. “For me it’s been fabulous,” she says. “I love working in this agency. It’s a mission-driven organization that is very clear about its purpose. There’s never any mistake about what the purpose of your work is and who you are serving, and I thrive in organizations like that. I find the people to be very generous in helping me understand the culture.”
Being open to learning about, adapting to and embracing AI/AN culture is definitely a key requirement. Yazzie says that the non-Native nurses she hopes to recruit are always offered the chance to come and visit the Navajo reservation, or any other reservation, because the culture and lifestyle is so different from the majority culture.
“It’s not like the big city,” she warns. “Some of our reservations are pretty isolated and remote. Some people [who have never been to a reservation] are quite shocked at the distances we [have to] drive and the fact that we still have homes with outdoor [bathroom] facilities, no indoor plumbing and no electricity. People will ask me how far away the nearest Walmart is and I tell them that it’s 60 miles away.
“The realities of reservation life are nothing like what is portrayed in Hollywood “cowboys and Indians” movies, Yazzie emphasizes. “I think some people out there in the world still believe—and I’m hoping that this stereotype is lessening—that Native Americans are like the people they see on their television set,” she says. “[Sometimes non-Native nurses come into IHS] thinking that they are going to ‘rescue’ us. We certainly don’t need to be rescued.”
Stephens agrees. “Despite the Anglo cultural view that not having [modern amenities like] heating and plumbing is a detriment, these communities choose to maintain their lifestyle and culture. Another benefit of working for the IHS and working out in the field is that you have the opportunity to be embraced by the community. You learn so much about that community.”
For some IHS nurses, learning about AI/AN culture and traditions may also mean learning a new language. Some tribes maintain their original languages to keep this part of their cultural heritage from disappearing.
Who are today’s Indian Health Service Nurses? Source: Indian Health Service, August 2009
“[Language barriers] are definitely a concern that some [potential nursing employees] have,” says Yazzie. “I’ll have people call me and talk about wanting to come and work with the Native American population, and oftentimes they [ask] if they have to be Native and do they have to speak the language.”
“I remember when I worked with the Navajo nation in 1975,” says Aoyama. “I had to have an interpreter because I couldn’t speak Navajo. It’s very different and [extremely difficult to learn]. You [really] have to learn the language as a child.”
Even though the IHS is working to attract more nurses from diverse racial and cultural backgrounds into its workforce, it will always have a particularly strong need for more American Indian and Alaska Native nurses who are culturally knowledgeable and deeply committed to improving the health of other AI/AN people, especially in their own tribal communities.
“If a [non-Native] nurse wants to work for us, they have to be open-minded and want to learn more about people in general,” says McCabe. “The people that I care for are part of my tribe and that’s the catalyst for what I do.”
To learn more about nursing career opportunities in the Indian Health Service, including current job openings, visit www.ihs.gov/MedicalPrograms/Nursing.
New nursing technology has opened endless opportunities for superior care, says Susan R. Stafford, R.N., B.S.N., M.P.A., M.B.A., Associate Chief Nursing Officer of Nursing Informatics at the Cleveland Clinic Stanley Shalom Zielony Institute for Nursing Excellence. The Zielony Institute oversees the practice and education of more than 11,000 nurses in all aspects of the Cleveland Clinic health system, including inpatient, outpatient, rehabilitation, and home care fields. “From recently introduced innovations to those that are on the horizon, enhanced technology gives nurses the ability to integrate so we can focus on delivering quality, safe, world-class care,” Stafford says.
Nurses have always been information managers at the center of a wheel, according to Patricia Abbott, Ph.D., R.N., associate professor and Co-Director of the World Health Organization/Pan American Health Organization Collaborating Center for Nursing Knowledge, Information Management, and Sharing at The Johns Hopkins University Schools of Nursing and Medicine, and chair of the 11th International Congress on Nursing Informatics in 2012. Everybody touches base with the nurse to get the latest information on a patient, says Abbot. “We’ve always had technology in our lives.”
“Our students come in with every piece of technology known to man hooked on their belt. Sometimes it’s like Jeopardy—we’ve got the answer; now what’s the question?” Abbott says. “We’ve got the technology; now show me how to apply it.” Abbott says the younger generation was raised with technology, impacting the way they communicate and conceptualize. “It’s fundamentally changing the way you think and your belief networks,” she says. “What’s happening is a lot of people are starting to look at this and see they have to adapt or leave.”
As U.S. Secretary of Veterans Affairs General Eric Shinseki once said, “If you dislike change, you’re going to dislike irrelevance even more.”
What follows are some of the top trends in nursing technology today, from the macro-level, government-funded changes to the little gadgets you might soon find in your hand.
Nursing informatics is a growing field that supports nursing processes through technology, including telehealth, home health, ambulatory care, long-term care, education/research, acute care, outpatient settings, software development, and work flow redesign.
“Technology has been growing and work has been done for 40 years, but people didn’t know about informatics education and it was not that widely available,” says Bonnie Westra, Ph.D., R.N., F.A.A.N., associate professor and Co-Director of the International Classification of Nursing Practice Research and Development Center for Nursing Minimum Data Set Knowledge Discovery at the University of Minnesota School of Nursing. She says she’s suddenly seeing informatics classes that previously attracted three people grow into classes of 25. “Now programs are crawling out of the woodwork,” says Westra, also co-chair for the Alliance for Nursing Informatics (ANI).
The Healthcare Information and Management Systems Society (HIMSS) 2011 Nursing Informatics Workforce Survey reported that nurse informaticists play a critical role in the implementation of various clinical applications, including clinical/nursing documentation and clinical information systems, computerized practitioner order entry (CPOE), and electronic health records (EHR). The 2011 data also suggests a substantial increase in salary for nurse informaticists, which is up 17% from 2007.
Kathryn H. Bowles, Ph.D., R.N., F.A.A.N., associate professor of nursing at the University of Pennsylvania School of Nursing, says there are a few programs in the United States for nurses holding a master’s or Ph.D. She added the American Medical Informatics Association (AMIA) is doing a lot of work to promote nursing and medical education in nursing informatics, and the Technology Informatics Guiding Educational Reform (TIGER) Initiative is transforming informatics.
The TIGER Initiative aims to identify information/knowledge management best practices and effective technology to help practicing nurses and nursing students make health care safer, effective, efficient, patient-centered, timely, and equitable. “Nurses are out doing 50%–80% of all care in the globe, and many times they are in the field or in the bush,” Abbott says. “As technologies have gotten smaller, powerful, and more mobile, if we combine a huge workforce with more powerful technologies, we are enabling nurses, birth attendants, and midwives to practice better. When you do that, you improve care to an entire community.”
Telehealth promotes lower-cost health care through mobile communication and video. Laptops, tablets, and smartphones offer video conference capabilities that allow face-to-face visits without travel costs and complications, and provide vital signs and medical history for remote diagnosis and monitoring.
“Telehealth provides specialty services on the turn of a dime without the patient being shipped off to another facility,” Westra says. Telestroke robotics is one example, where practitioners use robotic technology to manage stroke victims in remote areas. Telehealth also is being used for psychiatric consults in prisons, a less expensive and equally effective treatment option.
Abbott worked on a National Institutes of Health–funded study involving implementing telehealth services for minority patients suffering from congestive heart failure. The program placed telehealth monitors in patient homes for remote monitoring, allowing patients to Skype with nurses regarding their health concerns. “Some of my patients are geriatric African American folks with heart failure, and they don’t have transportation, and they might be in the only occupied house in an area of burned-out homes,” Abbott says. Telehealth also can be a lifeline for entire communities, scaling up knowledge levels of community health workers in low-resource areas without a formally trained nurse on site.
“We know there are not enough doctors to go around, and also not enough nurses,” Abbott says. “In reality, when you start looking at the large provider groups that exist around the world, you look at ways you can reach and teach. Many of these folks, both nationally and internationally, cannot travel to the bricks and mortar model of a school to get additional training.”
Gartner Inc., a Connecticut-based information technology research and advisory company, says mobile health, or mHealth, is one of the top 10 consumer mobile applications for 2012. According to the 2009 American Academy of Nurse Practitioners (AANP) Membership Survey, 60% of respondents indicated they used a PDA or smartphone in clinical practice. Applications do not require a large, up-front investment and are simple to download. Health diaries, medication reminders, exercise tips, and applications to track food intake, pain levels, and sleeping habits are helping people monitor their own health.
Cell phones facilitating mHealth are proving to be powerful tools in the Latino and African American communities, particularly with illegal aliens afraid to participate in a formal health care system. Abbott says she’s involved in a movement surrounding texting for health, in which nurses reach out to minority populations with health tips and reminders concerning maternal health, HIV/AIDS, and drug addiction. The National Healthy Mothers, Healthy Babies Coalition text4baby’s Hispanic Outreach program, for example, supports mothers by providing 140 characters of health information and resources to a pregnant woman’s cell phone.
“They don’t have home phones—a lot don’t even have a home—but they have a cell phone,” Abbott says. “We are getting messages to them about appointments and medication refills. We let them text in questions or problems they have because they won’t come to the clinic. It’s a way to reach people through something so many people have these days.”
Over the past two years, the University of San Diego’s Hahn School of Nursing and Health Science has required an iPod Touch for incoming RN pre-licensure students. Instead of carrying multiple books to clinical sites, the iTouch provides clinical reference tools and pharmacology manuals with the tap of a finger.
“They find that having those clinical reference tools available to them very quickly while seeing patients is easier than having to look something up in a book,” says Karen Macauley, D.N.P., F.N.P.-B.C., Director of the Simulation and Standardized Patient Nursing Laboratory and clinical associate professor. The school developed an nTrack application for the iTouch with Skyscape Medical to help students document clinical experiences in hospital sites. Once they graduate, students can compile the data into an e-portfolio for potential employers.
“We decided to require it because it forces students to really embrace technology,” Macauley says. “Once they get into the hospital sites, you’re really looking at the best evidence-based practice and how to apply it to their clinical practice. Without having something at their fingertips to look at right away, they are at a loss.”
Another mobile tool growing in popularity is the electronic tablet. “The whole iPad application, how it will affect patient teaching and patient interaction, will be huge,” Westra says.
Abbott says mobile technology is especially important for nurses, who are incredibly mobile themselves. “We are running from bed to bed to bed, from unit to unit to unit, from clinic to clinic to clinic, from house to house to house,” Abbott says. “Records never seem to go with us, which has caused a lot of errors, redundancy, and wasted effort. Now when you put mobile technology in a nurse’s hand or in her pocket, it allows her to do her job, help her patient, right at the patient’s side instead of running back to the nurses’ station and grabbing a chart or looking on a computer.”
Mobile technology can also be a lifeline for remote nurses in “frontier environments” with less than seven people per square mile, Abbott says. A mini clinic with connectivity enables nurses to provide more services, find the help they need when they need it, and quickly connect through Skype with a specialist to find an answer.
Electronic health records
The federal government set aside $27 billion for an incentive program, as part of the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, to encourage hospitals and providers to adopt electronic health records systems (EHR). Policymakers continue to work toward establishing a Nationwide Healthcare Information Network to standardize EHRs, which would provide a seamless exchange of data among physicians, hospitals, laboratories, pharmacies, and other health care organizations.
At the Cleveland Clinic, electronic documentation includes computerized provider order entry (CPOE), nursing care documentation, medication dispensing and administration, and results reporting. The technology improves access to patient information at the point of care and enhances the ability to benchmark, monitor, audit, and report quality measures while offering quality data to support nursing-led research.
The Cleveland Clinic has been implementing EHR technology in stages over the past six years. The most recent implementation was the ICU nursing documentation with device integration. With this implementation, vital signs go directly from the cardiac monitor at the bedside into the EHR.
At the University of Pennsylvania, Bowles’ is examining decision making supported by information technology to improve care for older adults. Her ongoing study, funded by the National Institute of Nursing Research, focuses on the development of decision support for hospital discharge referral decisions. Using an electronic record, patients are asked a series of questions, ranging from their ability to walk to whether they have a caregiver available at home. Through statistical analysis of the answers and information already contained in the EHR, clinicians can make an informed decision regarding a patient’s needs. “Decision support, in general, is a new phenomenon,” Bowles says. “As we start using electronic records, more and more patient data will be available electronically and more developed to remind clinicians of the right thing to do.”
In May 2010, the Office of the National Coordinator for Health Information Technology (ONC) estimated an additional 50,000 health information technology workers will be needed over the next five years to satisfy meaningful use criteria. Abbott is the principal investigator on a HITECH grant to create a six-month, non-degree program for the unemployed to be qualified to build, upgrade, and maintain the implementation of health information technology programs, including EHR systems, at hospitals and clinics.
Centralized monitoring of intensive care units in remote areas is the health care delivery of the future. FHN Memorial Hospital in Freeport, Illinois, is collaborating with the University of Wisconsin e-Care team of intensivist physicians and critical care nurses in Madison, Wisconsin, on eICU care. Small microphones and cameras in each ICU patient room provide a constant link to the e-Care team at UW Hospital. Patient vital information, including heart rate, blood pressure, medications, and test results, are monitored in the FHN ICU and shared in real time with the e-Care team.
If a patient’s condition suddenly changes, the FHN physician and nurses can touch a button and activate a two-way visual and audio link for an immediate consultation with e-Care specialists.
The Mayo Clinic health guide used to be the go-to guide at everyone’s bedside. But the introduction of social media has both patients and caregivers logging onto sites like WebMD and Patients Like Me for health information, advice, and forums to share experiences.
A 2008 Edelman Health Engagement Barometer found the Internet has become the “new second opinion.” Patients with a diagnosis are barely out of the exam room door before typing status updates on their smartphones and searching for support groups via social media.
Many nurses have taken to Facebook and Twitter to promote accurate medical information to help the general population make healthy lifestyle choices, as well as to promote their profession.
Virtual reality simulations
Imagine being in the operating room and making a devastating decision that risks the life of a patient. Now imagine being given a do-over and figuring out the best way to proceed.
Such is the scenario in Second Life, a 3D virtual world becoming popular in nursing education. Westra says universities are buying islands and creating communities in which students develop avatars and run through different scenarios to see the consequences of their decisions. She’s even seen a virtual theater set up where students in their avatar personas can “attend” an author interview on a virtual theater stage. “It’s a chance to have people practice skills and make decisions and study consequences and not kill patients,” Westra says.
Radio frequency identification
Radio frequency identification (RFID) has been traditionally used for tagging equipment, but it’s starting to replace bar coding for patient identification. Westra says she is seeing RFID in nurseries to prevent kidnappings and tagging breast milk to ensure it goes to the right baby. Alzheimer’s units are using it as well to monitor patients prone to wandering.
Experimentally, it also is showing up in operating room equipment. A wand with an RFID reader is replacing X-rays to pick up any sponges or instruments left in patients before they are sewn up. Another experimental use is with intubating patients to check placement rather than using X-ray.
Judy Murphy, R.N., F.A.C.M.I., F.H.I.M.S.S., Vice President of Information Technology for Aurora Health Care in Wisconsin and co-chair of ANI, says RFID is a lot like Global Positioning System (GPS), but added there isn’t a lot of penetration of the technology at this point due to the expense. But it may be something more institutions turn to down the road.
Almost every IV these days is connected to a smart pump integrated with a computer that handles drug infusion calculating. Computerized infusion pumps with dose error reduction systems were developed to alert nurses if a programmed fusion dosage exceeds the hospital’s best practice guidelines.
Some organizations are integrating the pumps with EHRs, allowing physicians to enter information electronically and pass it along via computer to the pump, Murphy says.
Cleveland Clinic is rolling out new IV digital smart pumps designed specifically for high-volume medication infusions. This imitation will be completed and fully implemented in 2012. The Clinic will also be using new smart syringe pumps and smart pain pumps.
Wireless voice-over-IP phones
Through wireless voice-over-IP phones—voice carried over Internet protocol networks—nurses can be more easily reached when they are caring for patients in various rooms throughout a unit. This technology eliminates the need for unit secretaries to make announcements over a loudspeaker. The phone, according to the Cleveland Clinic, helps with noise control, improves efficiency in communication between staff and patients, and streamlines processes.
Electronic patient tracking boards
Similar to wireless voice-over-IP phones, electronic patient tracking boards facilitate ease of communication and coordination of patient care with a quick status display of current activity on a unit. A combination of wireless communication, barcode, and Internet technology, electronic patient tracking boards are replacing white boards in many settings.
Cleveland Clinic first used patient tracking systems in the emergency department and operating room areas. In 2010 the hospital system rolled out a new patient tracking board system to all of the main campus inpatient units.
Electronic patient tracking boards, according to Stafford, decrease the need for phone calls or meetings to find information about patients as they are coming and going. The systems give nursing units a one-stop shop for critical information on patients. A nurse, for example, can easily see if patients are at risk of falling or need extra precautions in isolation.
Point-of-care technology offers access to patient records, labs, medication information, and even second opinions, all from the patient’s bedside. A wireless network and computer allow nurses to access and receive a wide array of information without leaving the patient’s side.
Wireless point-of-care glucometers, for example, submit blood glucose results to the electronic medical record as soon as the clinician checks a patient’s blood sugar level. This technology offers completed reporting and documentation immediately upon the docking of the wireless device into its cradle. The information transaction can also be sent into the electronic medical record.
Workstations on wheels are also used for bedside and point-of-care documentation and information retrieval. Cleveland Clinic has one workstation on wheels for each caregiver working a shift on a nursing unit, providing instant access to a patient’s medical records at the bedside. The Cleveland Clinic finds the system helps nurses confirm all patient information is accurate, including medical history and medications, and improves patient safety for medication administration.
Cleveland Clinic is also rolling out a new Web-based self-scheduling platform for all caregivers. The system offers nursing caregivers convenience and flexibility through the ability to select shifts based on competencies. Nurse managers can now spend less time filling shifts and making phone calls. This technology is relatively new and still uncommon among most health systems, but it is a growing trend and anticipated to be coming to more health systems over the next few years.
“We look at the opportunities that are possible because of technological advancements,” Stafford says. “The common thread is that many of these advancements were developed to help nurses give the patient a positive experience. An enhanced patient experience is very valuable, creating a healing environment that contributes to overall positive patient outcomes.”
While all of this technology is meant to create efficiencies, improve outcomes, and ease the workload, Macauley says it all comes down to how medical professionals communicate with each other. The future of medical technology lies within professionals and students who will embrace it and create a system that lowers health care costs by reducing redundancy.
“Those people who leave the program in technology are thinking out of the box on using mobile devices and mobile technology and looking at ways of being innovative in using technology we’re all exposed to,” Macauley says.
Besides performing his regular duties as a public health nurse at Creek Nation Community Hospital in the town of Okemah, Okla., Jim Schmidlkofer, BSN, RN, might on any given day start an IV in the surgery and recovery unit, assist in the radiology lab or help treat patients in the emergency room. The hospital is part of a health care system that provides services to American Indians living within the boundaries of the Muscogee (Creek) Nation.
“All of the hospital’s different departments work together,” he says. “We’re like one big family. So many patients and people I work with [are people] I see in the community. We’ve become more like friends.”
This small-town camaraderie is just one of the rewards of working in rural health. The pace may be slower than in a big city, but the variety of the workday and the opportunities to make a significant difference in patients’ lives can’t be beat.
“When I worked in the city, there was a lot of focus on the technical aspects of health care,” Schmidlkofer says. “Here you have time to hold a patient’s hand.”
More minority nurses like Schmidlkofer, who is affiliated with the Potawatomi Nation, are urgently needed in rural areas, where they can play important roles in narrowing health care disparities and improving health outcomes in some of the nation’s most severely medically underserved communities of color.
Health disparities in rural America are so pervasive and troubling that it’s hard to know where to begin talking about them.
“Compared to the general population, rural residents are poorer and older, and these two factors make up the greatest predictors for health status,” says Brock Slabach, senior vice president of the National Rural Health Association in Kansas City, Mo., and a former rural hospital administrator in Mississippi.
People living in rural areas are less likely to have employer-sponsored health insurance or prescription drug coverage, and the rural poor are less likely to be covered by Medicaid benefits. Rural residents are also more likely to lack access to health care providers than urban residents. Many rural areas suffer from a shortage of primary care physicians, specialists, mental health services and nurses. It’s not surprising, therefore, that rural dwellers have higher rates of chronic diseases and poorer overall health than people in big cities.
Diabetes and hypertension, for instance, are rampant in east and central Oklahoma, where the Muscogee Nation Health System operates. Educating patients about disease prevention is a continual challenge for the system’s nurses.
“A lot of people have the [fatalistic] mindset that they’re just going to have diabetes,” says Sheryl Sharber, RN, director of nursing at the Creek Nation Community Hospital. “They figure, ‘Mom had diabetes, Grandma had diabetes–that’s just the way it is.’”
Disparities in health and socioeconomic status between rural and urban residents are especially pronounced among minorities. Although the term “rural poor” tends to invoke images of white Americans living in areas like Appalachia, the reality is that African Americans, Hispanics and Native Americans in rural areas are more likely to be poor than rural whites, according to Minorities in Rural America: An Overview of Population Characteristics, a 2002 report by the South Carolina Rural Health Research Center. And a greater percentage of rural minorities than rural whites live in federally designated Health Professional Shortage Areas.
Geographic isolation and lack of transportation are major barriers to health care for low-income rural residents, says Gloria N. Santos, RN, MS, vice president of patient care services at the 101-bed Feather River Hospital in Paradise, Calif., a small community in the Sierra Nevada foothills 85 miles north of Sacramento. Public transportation is sparse, and there are no sidewalks along main roads. Once a ride becomes available, patients show up at the hospital’s emergency room for treatment.
“Lack of transportation is sometimes the reason our emergency department patients give for not going to their regular doctors’ appointments,” Santos says.
To help improve access to care, the hospital plans to open a new outpatient clinic in Paradise which will be located right across the street from a bus stop.
Rural Cultural Competence
Although careers in rural health care might seem less “glamorous” than working in a large metropolitan area, this field offers tremendous opportunities for minority nurses to make a difference in communities where they are needed most. Demand is especially strong for nurse practitioners, health educators, emergency nurses and nurse managers.
The shortage of minority nurses is more acute in many rural settings because nurses of color are heavily recruited in urban areas, where pay and advancement opportunities are greater. Yet a racially and culturally diverse nursing workforce is just as important in rural areas as it is in urban locations. “It’s vital that the health care professionals mirror the community,” Slabach says.
Minority nurses working in rural health can serve as role models and play a major part in increasing cultural awareness and delivering culturally sensitive care.
“[When you come from the same culture as your patients], you have a better understanding of what they go through and how they were raised,” says Arlene Isham, RN, who works in the family clinic of the Creek Nation’s Okmulgee Indian Health Center in Okmulgee, Oklahoma. “[Because I myself am a member of the Creek tribe], it makes a difference with patients. They’re more at ease. If a patient tells me he was playing stickball and fell and hurt his leg, I know what he’s talking about.”
Isham recalls one day when a patient brought her husband to the clinic because he was delirious. His blood sugar level turned out to be low as a reaction to taking medication on an empty stomach. The man had been on a one-day ceremonial fast, and Isham educated the patient about how to handle his medication when fasting. As a tribal member who also participates in ceremonial fasts, she knew the importance of the ritual from personal experience, which provided a deep understanding of the patient’s need for culturally appropriate care.
“I enjoy working with my own people and trying to raise awareness of their health issues,” she says. “I could go to Tulsa and make more money, but I really like working with my tribe.”
Isham also continues to deepen her knowledge of her cultural heritage. She is learning more of the Creek language, which she did not learn when growing up but is still exclusively spoken by some of the tribe’s elders.
Schmidlkofer says his affiliation with the Potawatomi Nation does not necessarily put him ahead of the learning curve when working with his Creek patients. “Each tribe is unique and a nation unto itself,” he explains. “The most important thing to learn is to be very patient and very respectful when giving information or receiving it.”
Rural Health Research
Rural patients tend to trust health care providers who look like them or whom they’ve known for a long time, says Randy Jones, PhD, MSN, APRN, an assistant professor of nursing at the University of Virginia in Charlottesville. Jones’ research focus is on health disparities in rural minority and vulnerable populations, and he is particularly interested in addressing prostate cancer disparities in African American men, who are 1.5 to two times more likely to develop the disease than white men.
Jones was principal investigator in a study by the university’s Rural Health Care Research Center that found that female family members–wives, sisters or daughters–influenced whether black men decided to get screened for prostate cancer. Trust of the health care system also played an important role. Study participants said they trusted doctors and nurse practitioners with whom they had long relationships.
Jones, who has also published research about diabetes among rural African Americans, says health care facilities need to create a welcoming, non-judgmental environment and educate people every time they come through the door about any health issues for which they are at risk.
Establishing trust is also critical for recruiting rural people of color to participate in health care research. Jones points out that many older African Americans remember the infamous Tuskegee syphilis experiment, in which the U.S. Public Health Service conducted research on 399 black men with syphilis from 1932 to 1972. The men were mostly sharecroppers with limited education and were told they were being treated for “bad blood.” In reality, they were given no treatment at all. The scientists planned to study data from the autopsies of the men and essentially left them to deteriorate from the disease. When the media exposed the story in 1972, the experiment finally ended and the men received treatment. By then, 128 of them had died of syphilis or related complications.
Jones, who is African American, says he thinks in some cases his race has helped him establish the trust needed to recruit African American participants into research studies. But most important was his openness and the time he took to explain the intentions of the research. He immersed himself in the community and became acquainted with “gatekeepers,” such as pastors, owners of barbershops and other small businesses, and members of city boards, town councils and the local NAACP.
Filling the Need for Nurses
Increasingly, rural communities are beginning to address the nursing shortage by growing their own RN workforce. Santos, for example, recruits recent nursing graduates from a nearby community college and from a BSN program at nearby California State University, Chico.
Recruiting seasoned nurses is more challenging, she says. Therefore, her hospital is looking at sending newly hired RN graduates to a hospital in Sacramento for a week or two to immerse them in a large-scale critical care setting. This would enable them to see a wider variety of patients and strengthen their skills and confidence in less time than it would take at the rural 12-bed critical care unit.
Santos also participates in a program at CSU Chico that matches minority nursing students with mentors to improve retention. She meets regularly with a Hispanic nursing student to offer encouragement, and she and her mentee have become friends.
Nurses who have found rewarding careers in rural health care say this field offers many advantages, from both professional and personal perspectives. “I think every nurse should work in a rural hospital in the early part of their career, because you have to do a little bit of everything,” says Sharber. “You get a broad exposure.” Although the Creek Nation Community Hospital doesn’t have specialty departments, such as obstetrics or pediatrics, it sees patients of all ages and all disease processes, she adds.
In a rural hospital, emergency nurses are often the first line in caring for patients. “Many times the physicians may not be in house or may be a few miles away,” Slabach says. He also notes that a rural hospital is a more personalized work environment. Nurses and administrators know each other well, and this can lead to greater understanding and flexibility.
Santos grew up in New York and worked in various Adventist Health System hospitals in large cities before moving to her current job at the system’s hospital in Paradise. Her position as vice president of patient care services is equivalent to a chief nursing officer at a larger hospital. But she also oversees other departments besides nursing, including respiratory and cardiology services.
“You’re never at a loss for learning,” she declares. “I just enjoy my work here. I like patient care and I enjoy being able to remove barriers to quality health care.”
Somewhere in rural North Carolina, an 85-year-old Cherokee Indian, who never attended school himself, can take credit for inspiring the career of his son—a nurse scientist whose groundbreaking research on Native American health issues has brought him to the pinnacle of the nursing profession.
In 2007, John Lowe, PhD, RN, FAAN, associate professor at Florida Atlantic University (FAU)’s Christine E. Lynn College of Nursing in Boca Raton, was inducted as a Fellow of the American Academy of Nursing—only the fourth-ever American Indian nurse to achieve that honor. That same year, Lowe was named Florida Nurse Educator of the Year, and the National Institute on Drug Abuse (NIDA) awarded him a $1.35 million grant to study substance abuse interventions for Cherokee adolescents.
Lowe, who is a founding member of the Native American Nursing Scholars Institute (NANSI) and one of only 14 doctorally prepared Native American nurses in the nation, grew up in a Cherokee farming community in the Southeast. He now splits his time between Florida and Oklahoma, where almost 270,000 members of the Cherokee Nation live in a 7,000-square-mile area in Northeastern Oklahoma. Lowe credits his father, a full-blood Cherokee, for being the impetus behind his more than 20-year career in researching solutions to Indian health disparities.
“My dad has really been my inspiration for the work that I do,” says Lowe, whose mother died when he was young.
“He did not have the problems that [so many other] Native people experienced [such as alcoholism and diabetes], so I wanted to know why he did so well when others didn’t.”
Like many other pioneering minority nurse leaders, Lowe initially had to overcome barriers of racial discrimination to become a nurse—a career he chose in high school after relatives, some of whom were nurses themselves, suggested it.
“I was interested in helping people and I was always the one who was kind of caring for others, and even the animals around us,” he says.
His high school had a licensed practical nurse program that Lowe enrolled in upon the advice of a school counselor, who leaned across her desk one day and said in a quiet voice that people like Lowe (Native Americans) usually become LPNs rather than RNs.
“So I said, ‘I guess that’s what I have to do,'” Lowe remembers. However, it didn’t take long for him to realize he was capable of moving beyond the LPN level, and by 1981 he had earned a bachelor’s degree in nursing from Eastern Mennonite College in Harrisonburg, Virginia.
One of Lowe’s first experiences providing nursing care to patients came immediately after earning his BSN, when as part of Mennonite Health Care Missions, he worked in Tanzania in a mobile clinic that offered maternal and child health care. After returning from Tanzania, he accepted his first job as a staff nurse, working in the orthopedic unit at Riverside Hospital in Newport News, Virginia. After a 15-month stint as a preceptor for nursing students and new employees at Riverside, Lowe moved to Oklahoma, where he worked at the City of Faith Hospital in Tulsa—first as a medical/surgical staff nurse, then in an administrative position. He later moved to a position in the hospital’s chemical dependency unit, working with adolescents who were struggling with alcohol and drug addiction—an experience that would ultimately shape the focus of his future research career.
Meanwhile, Lowe began working on a master’s degree in nursing from Oral Roberts University in Tulsa. He received his MSN in 1986 and began teaching at the Oral Roberts University Anna Vaughn School of Nursing. During the next few years he began developing an expertise in transcultural nursing. He worked with international students at Oral Roberts, served as a community health instructor for senior nursing students at the Cherokee Nation and traveled to China, Jamaica and Costa Rica, where he provided primary care and taught health promotion and disease prevention.
Lowe moved to Florida in 1991 and worked at various hospitals on a per diem basis while pursuing a doctorate at the University of Miami, which at the time had a transcultural focus at the doctoral level. That same year, he began teaching at Florida International University as an adjunct faculty member, then as a visiting professor and, just before earning his PhD in 1996, an assistant professor. He joined the nursing faculty at FAU in 2003.
Lowe’s master’s thesis, “The Social Support That Contributed to the Abstinence from Substance Abuse After Treatment in the Native American Young Adult,” set the stage for a career in researching culturally competent interventions for reducing American Indian health disparities, with a particular emphasis on treating and preventing substance abuse in Native adolescents.
“It sort of evolved, since I was [already connected there through my work with teens in Oklahoma], and because I was familiar with the issues and with the substance abuse [problems in the Native community],” he says.
As Lowe began investigating why his father had managed to avoid substance abuse and other serious health problems common to Native Americans, he came to the realization that it was because his dad had been able to incorporate his Cherokee culture and traditions into his life. Unlike many other American Indians growing up in the early 20th century, Lowe’s father did not attend one of the infamous boarding schools that were designed to assimilate Native people into the white majority culture by separating them from their families and communities.
“He was able to maintain a traditional way of living,” Lowe explains.
Off-reservation boarding schools for American Indian children were first established in 1878, when Captain Richard H. Pratt opened the Carlisle Indian School at an abandoned military post in Pennsylvania. Pratt’s goal was to assimilate American Indian children into European culture by forcing them to abandon their Native culture—a concept he called “killing the Indian, not the man.”
The boarding schools were deliberately located far away from Indian reservations, and Native children and their families were discouraged from visiting one another. The students were forbidden to speak their language or practice their religion, and they were told that the Indian way of life was savage and inferior. Students wore military uniforms and were severely beaten for violating rules.
Those who returned to their Indian communities after leaving boarding school found they had a hard time fitting in. They had been stripped of their Native culture and identity by their experience in the boarding schools. Yet they didn’t fit into white culture either, because no matter how “non-Indian” they became, they would still never be viewed as an equal. So, if they weren’t Indians and they weren’t whites, then who were they?
This era became known as the “dispossession period” for American Indians. They had been “dispossessed” of their land and culture, yet they were not afforded the opportunities and services available to whites. This cultural destruction and other historical trauma, says Lowe, are the primary underlying causes of the severe health disparities that Native people face today.
Lowe realized that his father was able to stay physically and mentally healthy because he hadn’t been dispossessed of his culture and heritage. He knew who he was—he was Cherokee and proud of it. So it stood to reason that American Indian young people suffering from substance abuse problems might be helped by incorporating Native American cultural traditions into their lives.
Lowe’s doctoral thesis, “The Self-Reliance of the Cherokee,” which investigated the connection between traditional Cherokee values and the health of Cherokee people, became the theoretical framework for much of his subsequent research. Over the next several years, he conducted a number of studies that incorporated his Cherokee Self-Reliance Model—which consists of three components: being responsible, being disciplined and being confident—into interventions aimed at preventing substance abuse among Cherokee adolescents.
One such project, funded by the National Institute on Alcohol Abuse and Alcoholism, evolved from Lowe’s work at Florida International University with a program called Teen Intervention Project (TIP). He adapted the program for use in the Cherokee Nation school system and renamed it the Teen Intervention Project-Cherokee, or TIP-C.
“What TIP-C does is try to intervene early with teens who might be having some issues and have them go through this intervention, which is school- and culture-based,” Lowe says.
Some of his other recent intervention studies have focused on the use of Cherokee teen talking circles as a tool for preventing substance abuse and HIV/AIDS. The talking circle, a traditional Native American way of gathering and discussing issues, is characterized by mutual respect, equal say and no interruptions. “It helps turn the discussion into a much more powerful interaction,” says Lowe, who adds that everything discussed in the Cherokee teen talking circles is confidential. “It helps [the teens] open up, and they’re able to get in touch with all of the deeper issues that might be pushing them toward using [drugs or alcohol].”
Not all of Lowe’s research initiatives to improve health outcomes for Native Americans have been Cherokee-specific. He has also partnered with other doctorally prepared Native American nurse researchers on several landmark studies developed as part of the ongoing Nursing in Native American Culture project.
For example, he collaborated with the late Dr. Roxanne Struthers to develop a nursing model designed to guide American Indian and Alaska Native nurses in providing culturally competent care to Native patients. The model, “A Conceptual Framework of Nursing in Native American Culture,” was published in the Journal of Nursing Scholarship in 2001. Today, says Lowe, the framework is used by some nursing schools and tribal colleges to guide their curricula, helping both Native and non-Native nursing students learn to provide culturally competent care to the Native American population.
John Lowe, PhD, RN, FAAN (center, holding stick) regularly brings his nursing students to Oklahoma to volunteer in the Cherokee Nation community.
Collaboration is also the focus of Lowe’s current NIDA-funded project, entitled “Community Partnership to Affect Cherokee Adolescent Substance Abuse.” Drawing on both the success of TIP-C and on the experience and involvement of the Cherokee Nation community, the project uses a community-based participatory research (CBPR) approach to develop and evaluate different school-based interventions—some using the Cherokee Self-Reliance Model and some not.
One of the project’s key components is a steering committee made up of representatives from the Cherokee community. Formed in the study’s first year, the steering committee played a major role in assessing the community’s needs regarding substance abuse. Lowe then partnered with the steering committee to develop culturally appropriate intervention materials and outcome measurements. By involving the community directly in the research process, the CBPR approach is a culturally appropriate alternative to the so-called “helicopter research” conducted all too frequently in Native American and other minority communities. “So many times what researchers will do is [go into a research] site, collect data and leave,” Lowe explains, “whereas here I have a community steering committee that is helping to guide the entire research project.”
Now, in year two of the study, Lowe is comparing the effectiveness of the intervention methods he and the steering committee developed against standard school-based anti-drug interventions, such as the national Drug Abuse Resistance Education (D.A.R.E.) program. Another goal for years two and three of the project is to evaluate the impact of talking circles on helping Cherokee youth resist the pressure to become involved in substance abuse.
“Hopefully Cherokee communities will eventually adopt [this intervention program] as a service they want to provide in their schools,” Lowe says, “because there will be evidence that this is a better way of dealing with this issue.”
Getting His Students Involved
For the past three summers, Lowe has been bringing his class of Florida Atlantic University senior nursing students to Oklahoma to volunteer at the Cherokee Nation’s Healthy Nations Summer Camp for children ages nine to 12. The camp is dedicated to promoting physical fitness, health and wellness, and teaching children to make healthy choices.
“I wanted to create an intervention that would get to the heart of critical issues our Cherokee youth are facing, such as diabetes, obesity and substance abuse, and also allow the students to practice the Nursing as Caring theory that I teach at FAU,” says Lowe.
During the week-long camp, the nursing students—many of whom are of international origin and hail from countries such as Cuba, Jamaica and Haiti—live with the children, teach classes on nutrition and diabetes, and supervise them in a variety of physical activities. To strengthen Cherokee identity, the nursing students and children are organized into “clans.” The campers attend Cherokee language classes that emphasize the importance of family and caring; the nursing students enjoy a rare opportunity to observe and participate in Cherokee culture, such as powwows and traditional dances.
And during the spring and fall semesters, Lowe brings FAU nursing students to community schools within the Cherokee Nation to conduct health screenings and give presentations on disease prevention, health promotion and career opportunities in health care, while interacting with the Cherokee students about their own diverse cultures.
Lowe believes nurses who want to provide culturally competent care to Native American patients—as well as patients from other minority cultures—must “learn to become the learner.” Many times nurses and other health care professionals spend so much time becoming the “expert” that they forget they can learn a lot from their patients.
“So what happens is, you learn to assess people and then tell them what’s wrong with them and what you’re going to do about it,” he says. “You have to back up and learn from the patient or person in the community, and say: ‘You teach me.'”
Future projects Lowe wants to pursue include using Native American doctoral students to replicate and pilot the Cherokee community partnership study with other Indian tribes in other parts of the country.
Lowe is humble when asked to describe the legacy he hopes his work will leave, describing it simply as “giving something back” to his Cherokee family and community. Speaking at the 2007 National Alaska Native American Indian Nurses Association (NANAINA) annual conference, he summed up his remarkable career this way: “The bottom line is, I want to do research that makes a difference in improving the health of Indian people, beyond just having academic value.”