Raising Our Voice

The year was 2002. Gathered together in a small Asian diner in Hawaii, the board of the Asian American/Pacific Islander Nurses Association (AAPINA) was discussing whether or not their young organization had enough membership support to hold a national conference. Who would attend and why? What would be the criteria for determining whether the event was a success?

Back then, the board, consisting of 14 members, didn’t have answers to these questions. But today AAPINA has held four successful national conferences in different cities across the country and is preparing to hold its fifth annual conference, “Achieving Health Parity for Asians and Pacific Islanders through Practice, Research and Education,” on May 22-24 in Las Vegas.

The national conferences have given AAPINA members the opportunity to come together in one place to network, gain support and mentorship, and discuss issues facing Asian/Pacific Islander (API) nurses. This in-person camaraderie is important, because many members have little interaction with other API nurses in their day-to-day working lives.

“I didn’t feel like I had a political voice in any other nursing organization,” says SeonAe Yeo, PhD, RNC, FAAN, associate professor at University of North Carolina at Chapel Hill School of Nursing and immediate past president of AAPINA. “I felt that it was critical to bring our voice to the nursing profession.”

The idea of holding a national conference was implemented during Yeo’s presidency. “Prior to that, the association mainly communicated with its members through newsletters,” she explains. “Now that we have an annual conference, members get to see each other at least once a year. That’s one reason why membership grew during my tenure to about 200 members. When I began my presidency in 2001, we had less than 20. And it continues to grow.”

According to its mission statement, AAPINA has four main objectives:

• To identify and support the health care needs of API people in the United States and globally;

• To implement strategies to act on issues and public policies affecting the health of APIs;

• To collaborate with other interdisciplinary health and professional organizations; and

• To identify and support professional and nursing concerns of API nurses in the U.S. and globally through active networking and empowerment.

“We try to appeal to nurses working in different areas of the profession, including clinical, research and administration, and we’ll continue to do that,” says Yeo. “But what I’ve found is that this type of organization is particularly attractive to many international Asian graduate students [studying in America]. If you look at any major nursing school in the nation, about half of the graduate students are from various countries in Asia. These students are typically isolated. I’ve also found that many API nurse clinicians working in hospitals in staff or administrative roles are more isolated in their work environments and feel the glass ceiling effect more.”

Yeo notes that these nurses often have impressive titles and have earned graduate-level degrees and certifications, yet cannot advance to higher levels in hospital settings. “AAPINA provides them with a way to start thinking in terms of asking why they can’t get on a career path the way [majority nurses] are doing,” she says. “We’re [helping them address] the language barriers and cultural isolation that API nurses face. We also provide connections to other Asian and Pacific Islander nurses.”

Laying the Foundation

Compared to some other minority nursing associations, such as the National Black Nurses Association and the National Association of Hispanic Nurses, which have been in existence for more than 30 years, AAPINA is a relatively young organization. It was founded in 1991.

“That year, several of us [founding members] were attending a conference for ethnic minority nurses. This was the first time I had ever seen a group of Asian American nurses together in one place,” says Kem Louie, PhD, RN, CS, FAAN, associate professor at William Paterson University Department of Nursing in Wayne, N.J., and a past president of AAPINA. “We were all very concerned about [diversity in the nursing profession and creating more leadership opportunities for] minority nurses. So before we left the conference, I suggested that we stay connected, not realizing that this would be the impetus for forming AAPINA.”

AAPINA began with a group of 14 members who were committed to being advocates for Asian American and Pacific Islander nurses. These founding members represented a variety of geographic areas, from Hawaii to the East Coast. The fledgling association established bylaws and set out to bring the diverse voices of API nurses to the forefront of professional nursing issues.

Louie points out that one of the reasons why an association like AAPINA didn’t form earlier is because the API population is very diverse, encompassing many different ethnic subgroups. But even though, for example, the health care needs of Native Hawaiians are different from those of immigrants from Southeast Asia, “we are trying to [address the health concerns of the overall API population] and health disparities in particular,” she says.

Adds another AAPINA founding member, Mi Ja Kim, PhD, RN, FAAN, professor and dean emerita of the University of Illinois at Chicago College of Nursing, “Since we serve such a diverse population, language barriers can be a problem. English isn’t always [patients’] primary language.”

Over the years, AAPINA has been involved in several initiatives that have made a major difference in increasing national awareness of API health disparities and advancing health policy agendas that benefit the API population. In the late 1990s, under Louie’s leadership, the association worked with a coalition of other groups, such as the Asian and Pacific Islander American Health Forum, to get President Bill Clinton to establish a White House Initiative on improving the health status of API communities. Prior to this, the API population had been falsely stereotyped as a “model minority group” with few health problems. Therefore, they were rarely included in federal minority health programs or government-funded health disparities research studies.

There had already been many federal initiatives aimed at improving the quality of life for underserved African American, Hispanic and Native American communities, Louie explains. “It was quite exciting to be part of this movement that was saying, ‘Look, Asian Americans and Pacific Islanders would like some recognition that we, too, face great health disparities [and that we need more federal resources directed toward this problem’]. As president of AAPINA, I was invited to be a part of these important discussions.” President Clinton signed the executive order authorizing the API Initiative in June 1999.

Two years later Louie, representing AAPINA, published a landmark white paper on the health status of Asian Americans and Pacific Islanders in the journal Nursing Outlook. “The white paper was a review of API health disparities, what we need to do to remove them and recommendations for research,” she says.

Louie’s article noted, for example, that “Asian Americans and Pacific Islanders exceed other groups in health disparities in the areas of tuberculosis and hepatitis B, whereas cancer and cardiovascular diseases are leading causes of death within the Asian American and Pacific Islander populations.”

Sharing a Common Vision

In much the same way that AAPINA was established from a common bond among like-minded API nursing professionals, the National Coalition of Ethnic Minority Nurse Associations (NCEMNA) grew from discussions among leaders of several prominent minority nursing organizations. These dialogues revealed that the individual associations all shared a common goal—advocating for equal opportunity in nursing and better health care for communities of color.

“We decided to work together as a single unified force instead of each association separately competing for funding when we have such common missions and goals,” says Louie, who holds the position of secretary on NCEMNA’s board of directors.

NCEMNA, incorporated in 1998, serves as the umbrella organization for five associations: AAPINA, the National Alaska Native American Indian Nurses Association (NANAINA), the National Association of Hispanic Nurses (NAHN), the National Black Nurses Association (NBNA) and the Philippine Nurses Association of America (PNAA). Collectively, NCEMNA gives voice to 350,000 minority nurses and to the lived health experience of a constituency marginalized from mainstream health delivery systems.

Being part of the NCEMNA collaborative has enabled AAPINA to receive federal funding that an association of its size would have difficulty obtaining on its own. Each year, through a grant from the National Institute of General Medical Sciences (NIGMS), a different NCEMNA member association receives funding to support its annual conference. AAPINA is the 2008 recipient.

“The grant has helped in getting keynote speakers and panels for the conference,” says Jillian Inouye, PhD, APRN-BC, AAPINA’s newly elected president. “[On a broader level], it is stimulating research and development of minority nurse scientists.” NCEMNA is also using the $2.4 million NIGMS grant to fund the Nurse Scientist Stimulation Program, a five-year initiative to increase the number of minority nurse researchers who can investigate the causes of health disparities and develop culturally appropriate interventions.

“When we incorporated all the minority nurse associations through NCEMNA, it gave AAPINA a lot of energy and financial support to become more organized,” continues Inouye, who is a professor and graduate chair at the University of Hawaii at Manoa School of Nursing and Dental Hygiene. “Kem Louie was the association’s driving force throughout the early years. Now, [thanks to our involvement in the coalition], more people have become interested in AAPINA. We have more members, we’ve gotten our Web site up, we’ve started to hold conferences. And through NCEMNA’s Aetna Foundation grant, we’re able to offer scholarship opportunities to pre-doctoral or even master’s students. That has really helped draw more people to our organization.”

The annual Aetna/NCEMNA Scholars Program is another NCEMNA project designed to introduce nurses of color to careers as nurse scientists and socialize them into the research agenda to eliminate health disparities. Each year, the program provides financial and mentoring support to 10 nursing students—two from each of the coalition’s five member associations.

Mentoring is also an important part of AAPINA’s mission to support and empower Asian and Pacific Islander nurses and students.

“I’ve served as a mentor through AAPINA as well as through NCEMNA,” says AAPINA president-elect Oisaeng Hong, PhD, RN, associate professor, Department of Community Health Systems and director of the Occupational Health Program at the University of California San Francisco School of Nursing. “Our mentees are mostly doctoral students who are matched with a mentor based on areas of interest, research topic and target population. We spend one to two years together, but we don’t have to be in the same city. Communication happens through phone calls and email. We get face-to-face time during our annual conferences.”

Onward and Upward

With membership on the rise and the success of the national conferences firmly established, AAPINA’s leaders are setting goals to ensure the association’s future growth and sustainability while continuing to increase its value as a resource for Asian and Pacific Islander nursing professionals.

“One of our most important objectives at the moment is to expand our efforts in growing our membership and to reach more API nurses,” says Hong. “It’s hard work because we have no hired staff.”

Inouye says that implementing a strategic plan is one of her goals during her presidency. “I also plan to update our mission statement and Web site,” she adds. “Now that we have some funds, we’re able to hire an attorney for the first time to update our bylaws. I’d also like to expand our board of directors and [create more opportunities for our members to get involved as leaders in the association]. Currently, we only have an executive board, which includes the president, president-elect, secretary, treasurer, past president and the chairs of the membership and newsletter committees. So I’d like to create a board aside from that to help manage AAPINA. It’s a slow process, but it’s working.”

The strategic plan will also focus on establishing local AAPINA chapters in various parts of the country. “We currently have a student chapter in San Francisco and one that’s starting in Chicago. These are things that will be fleshed out as we develop the plan,” says Inouye.

Of course, AAPINA will continue to promote the expertise of Asian American and Pacific Islander nurses as culturally competent advocates who can play a crucial role in improving the health of API populations. “The health care issues that we [APIs] face are similar to those of other ethnic minority groups,” says Inouye. “These include diabetes and obesity. It may not seem that obesity is a problem for APIs, but their BMIs are increasing, which puts them at risk for cardiovascular disease and cancer. Our Native Hawaiian population is at risk for every kind of disease. They have very poor health outcomes.”

The association keeps its members abreast of key API health issues through its newsletter, Web site and workshops at the national conference. In 2005, AAPINA was one of several nursing associations that received grant funding from the national Nurse Competence in Aging (NCA) program to disseminate information to its members about the health care needs of minority elders. As a result, AAPINA was able to add a new section to its Web site focusing exclusively on gerontology/geriatrics issues and resources.

These successes are only the beginning of what AAPINA will continue to achieve through its dedicated and determined leadership. “In the future, I would like to have more [API] scholars and clinicians united in voice so that we can promote the AAPINA organization and our mission,” says Kim.

For more information about the Asian American/Pacific Islander Nurses Association, visit www.aapina.org.

Caring for Minority Veterans

According to the U.S. Department of Veterans Affairs (VA), approximately 20% of our nation’s 23.5 million veterans are people of color. Like other racial and ethnic minority populations, minority veterans face a variety of unique health care challenges, ranging from chronic disease disparities and high levels of post-traumatic stress disorder (PTSD) to difficulties in accessing medical treatment.

Testifying before the House Committee on Veterans Affairs in July 2007, Lucretia McClenney, MSN, RN, director of the VA’s Center for Minority Veterans (CMV), noted that “in many instances, any challenges that minority veterans encounter as they seek services from VA are magnified by the adverse conditions in their local communities. These challenges may include [lack of] access to VA medical facilities (especially for American Indians, Alaska Natives, Pacific Islanders and other veterans residing in rural, remote or urban areas), disparities in health care centered on diseases and illnesses that disproportionately affect minorities, homelessness, unemployment, lack of clear understanding of VA claims processing and benefit programs, limited medical research and limited statistical data relating to minority veterans.”

The CMV’s mission is to identify barriers to service and health care access, increase local awareness of minority veteran-related issues and improve minority participation in existing VA benefit programs. As a result, VA medical facilities throughout the country are implementing strategies to provide veterans of color with more accessible, culturally sensitive care. Each VA health care facility has a Minority Veterans Program Coordinator (MVPC) who serves as a liaison and advocate for minority patients. And VA health care professionals are taking the lead in developing innovative solutions for closing the gap of health disparities, from outreach programs designed to increase minority veterans’ use of services to diversity training programs aimed at increasing staff members’ understanding of patients’ cultural needs.

Not surprisingly, nurses are playing key roles in these efforts. Here’s a look at how individual nurses are working to improve health outcomes for minority veterans, one program at a time.

Native American Outreach

Bruce Kafer, MSN, RN, is a member of the Oglala Sioux (Lakota) Tribe that resides on the Pine Ridge Indian Reservation in South Dakota. Adopted as an infant by white parents, he grew up with virtually no knowledge of his tribal culture. After tracking down his birth mother in 2000, he began to learn about his lost Indian heritage from his Tiospaye (Lakota extended family) and tribal elders. Now, as American Indian/Latino Outreach Coordinator at the Louis Stokes Cleveland (Ohio) Department of Veterans Affairs Medical Center, Kafer is drawing on his rediscovered heritage to provide culturally sensitive healing to Indian vets.

Kafer, who works with Native veterans both in Cleveland and in Arizona, is also a PhD student at Case Western Reserve University in Cleveland, where he is conducting research with Indian vets to add to the limited body of knowledge available about this population. Through his research, he has discovered some compelling statistics about Native Americans who have fought for their country. During World War II, for example, 40% of the Cheyenne Nation volunteered service to the U.S. military. During the Vietnam War, 90% of eligible Cheyenne volunteered for duty, with the overwhelming majority serving in combat areas. Yet despite this long-standing history of service, Native Americans have historically underutilized VA services, Kafer says.

“Part of my role,” he adds, “is to help bridge that gap and make services more accessible.” To accomplish this, Kafer does outreach to the American Indian community, participating in powwows and other cultural events, visiting reservations in remote locations and working with Native veterans and elders from a variety of tribes to develop culturally appropriate programs.

There are about 562 federally recognized Indian tribes in this country and 365 state-recognized tribes, each with their own unique cultural traditions and, in many cases, their own indigenous languages. Therefore, VA nurses who work with Native veterans often find themselves treating a patient population that is not homogeneous but highly diverse—a concept Kafer calls “diversity within diversity.” Still, he says, while culture and language may differ from tribe to tribe, there are some basic beliefs about health, illness, healing and spirituality that are common to all Native people.

“In traditional Native American culture, health and healing begin first in the spirit, then the mind, then in the body,” he explains. “In the Western model of health care, it’s an opposite paradigm—health and disease begin first in the body, then in the mind, last in the spirit.”

Kafer won an award from the Society of American Indian Government Employees (SAIGE) for a VA diversity training video he helped produce, called “Native America: Diversity Within Diversity.” Created as part of the VA’s R.E.A.C.H. for Diversity program, the video has been distributed to all VA medical centers nationwide to increase employees’ understanding of the unique challenges Indian veterans face.

“Native America resonates with me and my history,” Kafer says. “I’m in a unique position to contribute to improving health care for Native American veterans because I understand about bureaucracy, government and the various phenomena that can impact tribal access to health care.”

Kafer is also involved in another innovative diversity training project, the Gathering of Healers program at the Southern Arizona VA Health Care System in Tucson. The program brings the facility’s staff together with Native veterans and elders to learn more about American Indian culture and how to provide culturally competent care.

“Staff come back from the Gathering of Healers and are more aware of the special needs of this [population],” says Yvonne Garcia, BSN, RN, the facility’s American Indian Nursing Case Manager. “They learn to treat people with cultural humility. They want to know more about them instead of making assumptions.”

Garcia, who is part Mandan Indian, also works with the Indian Health Service to complement services delivered to Native veterans.

Researching Health Disparities

Carol Baldwin, PhD, RN, CHTP, CT, AHN-BC, associate professor and director of the Office of International Health, Scientific and Educational Affairs at Arizona State University College of Nursing and Healthcare Innovation in Phoenix, is a nurse researcher who has focused some of her recent work on studying chronic disease disparities in Mexican American veterans, a population about whom very little health information is available. She led one study which found that, compared to non-Hispanic white veterans, Mexican American veterans were significantly more likely to have diagnosed type 2 diabetes and that having a high body mass index (BMI) put them at greater risk of developing the disease.

More recently, Baldwin published a study in the September 2007 issue of the Journal of Nursing Scholarship that compared homocysteine levels and other stroke risk factors between Mexican American and Caucasian male veterans. High homocysteine levels in the blood have been associated with increased risk of cardiovascular diseases, such as coronary heart disease and stroke.

Baldwin conducted her research in Tucson at the Southern Arizona VA Health Care System’s Minority Vascular Center. She found that Mexican Americans have higher homocysteine levels regardless of whether they scored a high or low risk for stroke. She also determined that the Framingham Stroke Profile, a commonly used stroke risk assessment tool, was derived for a predominantly Caucasian population and does not necessarily provide relevant stroke risk factors for people of other races and ethnicities.

Baldwin says her findings suggest that Mexican American veterans, like other minority populations, face barriers to stroke prevention and therapy, including lower income and education, as well as dietary, genetic and environmental factors.

There has also been very little research conducted on the health care needs of Puerto Rican veterans, says Constance Uphold, PhD, ARNP-BC, FAAN, a research health scientist with the Rehabilitation Outcomes Research Center at the North Florida/South Georgia Veterans Health System in Gainesville. Her current work focuses primarily on the health challenges experienced by Puerto Rico veterans returning from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF).

In one study, Uphold—who has a master’s degree in transcultural nursing and a doctoral degree in family health nursing—examined mental health issues affecting Hispanic veterans and their caregivers and families. She documented stressors from each group’s perspective, as well as successful coping models. Based on her findings, Uphold and her colleagues developed 12 culturally competent fact sheets for veterans, family members and clinicians. These educational materials are tailored to Puerto Rican veterans, complete with colors and symbols from the Puerto Rican flag. She’s now working to secure funding to reproduce and disseminate the fact sheets.

This past February, Uphold became a co-investigator of a grant that will research stroke interventions and family caregiving for Hispanic veterans, as well as how to disseminate stroke prevention information to this population. The Spanish-language information will be posted on MyHealtheVet.com, an interactive Web site that encourages veterans to take charge of their own health.

Promoting Health Literacy

Teaching minority veterans with chronic diseases how to self-manage their conditions is also a priority for Jawel Lemons, RN, MS, FNP-C, associate director of Patient Nursing Services at the Charlie Norwood VA Medical Center in Augusta, Georgia. Lemons remembers watching her own father struggle with his health. The man who raised her had a third-grade education and couldn’t read the directions printed on his medicine bottles.

“I thought, ‘If he wasn’t living with me, what would he do?’” she says. “That’s when I came up with the idea for the labels.”

The “labels” in question were part of a highly successful health literacy program Lemons created and implemented at the Dallas VA Medical Center in Texas before transferring to her current position in Augusta last year. As a cardiology nurse practitioner in the medical center’s congestive heart failure clinic, she often received referrals from primary care providers for patients who appeared to be noncompliant with their medications. Assessing the situation, Lemons discovered that the real reason why the veterans weren’t taking their medicine was that they had low literacy levels and couldn’t understand the instructions printed on their prescription labels.

So she designed a protocol for teaching her low-literacy patients how to take their medications correctly, using pictures instead of words. She found colorful, easy-to-understand computer clip art symbols, copied them onto adhesive labels and stuck them on the patients’ medicine bottles. For example, a rooster pictured with a sunrise symbolized a morning medication, while a bed indicated a nighttime medication. Lemons also transferred the same symbols to the patients’ pill boxes. As a result, the patients’ health improved dramatically.

VA Travel Nurse Corps

Her current goal is to establish special needs clinics across the VA system, with physician consults on site and nurses who are trained to make sure medications are properly labeled. She also hopes the concept of using picture labels will catch on with pharmacies.

Another way Lemons is empowering minority veterans to take control of their health is by providing them with culturally relevant dietary guidelines. “A lot of our [patient education] information is geared toward the average [majority] American, but there’s not much on the different cultures,” she notes.

Suggested menus for a low-salt diet, for example, are usually designed with Caucasian patients in mind and don’t always address the foods that African American or Hispanic patients may include in their regular diets. Lemons provides her patients with the general list of approved foods, but she also offers additional food lists that take into account a patient’s particular culture.

This is another example of how minority patients can be labeled as “noncompliant” when the real problem is that they simply could not overcome cultural barriers to their care, Lemons emphasizes. “If they don’t understand how to eat and take their medicine, they’re not in control of their ailment,” she says. “It really impacts the cost of health care when you have people who end up in the hospital over and over because they just don’t understand what they’re supposed to do.”

One of the Department of Veterans Affairs’ newest initiatives for increasing minority veterans’ access to culturally sensitive nursing care is the VA Travel Nurse Corps (TNC). Designed for RNs who prefer the flexibility and adventure of travel nursing, this program will establish an internal pool of nurses who can be available for temporary, short-term assignments at VA medical centers throughout the country. The TNC deployed its first nurse in December 2007.

Jacqueline E. Jackson, RN, MS, MBA, director of the TNC, says the new program is actively recruiting nurses from culturally diverse backgrounds. “[Minority] VA nurses bring not only cultural competence but respect and acceptance to the many culturally diverse patients under VA care,” she explains. “Nurses in the VA Travel Nurse Corps have an opportunity to travel the country working with a diverse VA patient population and a diverse VA workforce.”

For more information about the VA Travel Nurse Corps, visit www.travelnurse.va.gov.

 Who Are Today’s Veterans?

Estimated U.S. Veterans Population: 23,532,000

Number of Total Enrollees in VA Health Care System (FY 2006): 7,900,000

Veteran Population by Race:

  • White Non-Hispanic 80%
  • Black Non-Hispanic 11%
  • Hispanic 6%
  • Other 3%

Veteran Population by Gender:

  • Male 93%
  • Female 7%

Percentage of Veteran Population Age 65 or Older: 39%

Source: Department of Veterans Affairs, October 25, 2007