Researchers at the University of Michigan Health System, Ann Arbor, and the University of Pittsburgh found maternal opiate use had increased nearly five-fold between 2000–2009. Researchers call the increase an “epidemic,” and subsequent neonatal abstinence syndrome (NAS) and hospitalization costs saw substantial growth as well.
The study cites research from the Substance Abuse and Mental Health Administration showing just over 16% of pregnant teens and 7.4% of pregnant women aged 18–25 used illicit drugs. When those drugs were used during pregnancy, newborns experienced a higher risk of “adverse neonatal outcomes,” including low birth weights, as well as withdrawal symptoms such as respiratory and feeding problems, seizures and tremors, and increased irritability. Among those fetuses exposed to heroin or methadone, 60%–80% displayed these and other NAS characteristics.
The number of newborns experiencing NAS increased three-fold during this same period, from 1.2 to 3.39 per 1,000 hospital births annually—that’s roughly one birth every hour. Medicaid covered almost 80% of the infants and their mothers, and 36.3% lived in the lowest-income areas. Associated hospital costs for these newborns, who “experience longer, often medically complex and costly initial hospitalizations,” increased by 35%, from $39,400 to $53,400 per year. Total costs, as adjusted for inflation, grew from $190 million to $720 million.
The researchers called for increased public health measures, particularly regarding initial exposure to opiates, and considerably more research. Results of this study can be found in the Journal of the American Medical Association. It was presented at the Pediatric Academic Societies Annual Meeting in May. Visit http://jama.ama-assn.org for more information.
Two kinds of hospital-acquired infections—catheter-associated urinary tract infections and surgical site infections—have been on the rise, according to a new study. The research shows that the busy schedule and heavy workload of nurses were contributing factors to the rise in these infections.
According to an NBC news report, heavy patient loads and chronic burnout have long been among the top complaints of bedside nurses. The Maslach Burnout Inventory—a well-known scale that measures factors like emotional exhaustion, depersonalization, and sense of personal accomplishment—showed more than one-third of nurses reported levels of job-related burnout.
Researchers from the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing found that for every extra patient added to a nurse’s workload, there was about one additional hospital-acquired infection per 1,000 patients.
Also, according to a study in the American Journal of Infection Control, for each 10% jump in the proportion of nurses who reported higher levels of “burnout,” about one additional catheter-associated infection and two surgical site infections were found per 1,000 patients.
The nurses in the study, on average, cared for 5.7 patients each; a number that, if reduced, could help eliminate nurse burnout, and thus cut back the number of infections. The report states that reducing nurse burnout by 30% would cut urinary tract infections by more than 4,000 and surgical site infections by more than 2,200, which would save $28–$69 million per year in estimated costs to treat those infections in patients.
Previous research also supports the conclusions reached in this most recent study. Another University of Pennsylvania study found that adding a single patient to a nurse’s workload increased the risk of dying within a week by 7%. Additionally, a 2010 study found that patient deaths in New Jersey and Pennsylvania would drop 14% each if those states adopted California‘s mandated nurse-to-patient ratio of one to five in surgical units.
The NBC News report stated that some hospitals in the United States have worked hard to address these kinds of issues. Nearly 400 hospitals have achieved so-called “magnet” status, which recognizes health care organizations that achieve structural and clinical practices that empower nurses and lead to good patient results.
Neither the American Nurses Association nor the American Hospital Association tracks statistics on nationwide patient loads, which can vary from as low as one or two patients per nurse to more than five per nurse.
Hospitals For Humanity (HFH) is a registered nonprofit organization with 501(C) 3 status in the United States. The organization provides health care for people living in the least developed countries of the world. Their goals include providing health assessments and treatment for local citizens; updating existing medical facilities, assisting in the construction of modern hospitals, and providing training to local physicians; improving regional health and sustaining the quality of care through partnerships with local government; and responding to special cases of chronic illness and diseases through evaluation, diagnosis, and patient referral.
Efforts are currently focused on communities in Haiti, Nigeria, and the Philippines. HFH’s total patient population is over 65,000 and includes general surgeries, ophthalmic surgeries, dentistry, emergency medical services, and more.
HFH is looking for compassionate volunteers who desire to enroll in the organization, including CRNAs, NPs, PAs, RNs, optometrists, pharmacists, MLTs, EMTs, surgical techs, and physicians of all specialties. Currently, two Medical Mission Initiatives (MMIs) remain for 2012: one in Okija, Anambra State, Nigeria, from October 12–19, and one in Ijumu Land, Kogi State, Nigeria, from December 1–12.
If you are interested in learning more or applying for a Medical Mission Initiative, visit www.hospitalsforhumanity.org. You can view an informational video, look at pictures from past MMIs, and submit an application. Questions not answered on the website can be directed to Adrian Johnson, Director of Recruitment, at [email protected] or 224-577-5479.
If there is one thing surgical nurse Rochelle Scott has learned from her patients, it is to assume nothing. No matter how well she might think she understands a culture or a tradition important to her patients, Scott learned through repeated interactions that each patient, no matter what his or her heritage, will interpret and use cultural norms in slightly different ways.
“Giving the culture respect, and honoring that when it is appropriate, shows the patient they can trust you,” says Scott, who is midway through her master’s degree in the nurse practitioner program at Mount Saint Mary College in Newburgh, New York.
When you care for patients of Southeast Asian descent, with cultures that may include but are not limited to Hmong, Vietnamese, Chinese, or Thai people, learning a bit about the cultural norms and traditions can positively impact health care outcomes. But the languages and traditions of this group are incredibly diverse and have many nuances that impact literacy, child-rearing practices, elder care, and self-healing. Thankfully, nurses are in a great position to do some research, interact frequently, and discover the individual subtleties of their patients’ heritages.
When Dr. Madeleine Leininger introduced the idea of transcultural nursing in the 1950s, the idea was outside the norm. As cultural diversity and the promotion of cultural competence in health care settings becomes more mainstream, the idea continues to take shape in nursing programs. Dr. Priscilla Sagar, R.N., A.C.N.S.-B.A., C.T.N.-A., professor of nursing at Mount Saint Mary College, says nurses are often called on to lead the journey, bringing cultural competence standards into practice in academic settings, health care practices, and research.
“One of the biggest barriers is the lack of research about the populations,” says Sagar, referring to Southeast Asian patients. “Usually [research] has lumped them in saying ‘Asian/Pacific Islanders’ instead of separating them.”
The distinctions are vitally important when trying to determine something like typical growth and development for instance, says Sagar. Growth and development in a Filipino child might look delayed to some when, in fact, it is normal for that group, she says.
On the job
When on the job, though, cultural competence may not be as well defined. For instance, Dr. Margaret Andrews, R.N., F.A.A.N., C.T.N., Director and professor of nursing at the University of Michigan-Flint, cites instances of health care practitioners suspecting child abuse when children have shown up at doctors’ offices with red marks from the Asian practice of coining. Coining—the custom of rubbing coins over the skin (especially ribs of children with a cold) to create friction and warmth to rid the body of what is assumed to be bad winds or to fight off a cold—also leaves red marks on the skin. If you are not aware of the practice, it might raise suspicions of maltreatment.
The idea of coining, says Andrews, is not so different from Western practices of trying to restore balance to the body. The outcome looks a little different, but it helps if the medical staff is aware of the practice and any other practices of the cultures they frequently treat. They can then respectfully and effectively treat the patient without seeming to dismiss their beliefs. For example, if a child’s cough really is pneumonia, more intervention is necessary. If any herbs have been used for self-treatment, there has to be enough trust so the patient will share what has been used without fear of rebuke. Andrews recommends nurses reference the National Center for Complementary and Alternative medicine’s website at nccam.nih.gov for more in-depth information.
For many nurses, the desire to understand other cultures is the first step toward effective change. “Without the desire, it would be difficult for health care providers to embark on this journey,” Sagar says.
For instance, many cultures in Southeast Asia are family focused and oriented, Sagar says. In the United States, where medical decisions are generally made independent of the extended family, a medical decision that weighs the opinions of many family members might seem different. “But in many of these cultures, the family is involved,” she says.
And while the health care providers have to recognize that, they also have to gain a sense of any underlying factors. Sometimes, especially for immigrants, there is a sense of being in two worlds, both of which might have conflicting values, Sagar says. “If they are second generation and if they were born here and have grown up here, their values may be more Western than Eastern,” while the family values remain decidedly Eastern. The opinions can create a real family conflict.
For nurses, it is a matter of figuring out how it all reflects on the patient’s care. “When you first get educated, it is all about retaining it and incorporating it into the health care with the patient,” Scott says. Even something as simple as being aware of major holidays for that culture can make a patient feel recognized and feel his or her culture is respected. No one wants to schedule a procedure around a major celebration if it is not necessary.
Perform cultural assessments and learn about the top three or four cultures you work with, even small details like how to address the patient, Andrews recommends. In some Asian cultures, the first and last names are in reverse order from Western usage. “Ask them, ‘By what name may I call you?’” Andrews says. “Generally, it is better to address more formally and wait to see if they give you permission later to call them something else.”
Andrews also recommends being aware of the tradition of wearing an amulet to bring good luck or a talisman to ward off bad luck that many Southeast Asian populations honor. “That may give a signal to the nurse that they have spiritual beliefs they are bringing to a health care setting,” Andrews says. “You need to respect those.”
When traditions or beliefs that are important to the patient are not recognized, it can set up a rocky start to a relationship between nurse and patient. “It is the little things that can be frustrating for the patient,” Scott says. “Then the patient feels neglected or disregarded.”
According to Guadalupe Pacheco, Senior Health Advisor at the Office of Minority Health, there is a disconnect that exists between the demographics of the nation and that of health care professionals. Pacheco says that while various ethnic groups compose nearly one-third of the population, the nursing population does not mirror that proportion.
When the patient and provider come from a similar cultural background, the common factor often inspires trust Pacheco, says, but even the most radically different backgrounds can still work well. “It is all about communication,” says Pacheco. “If you establish that rapport with a provider and patient, they will come back to you. They are going to trust the diagnosis you make and the treatment you are prescribing.” And while health care professionals work hard to overcome any language barriers, understanding the cultural barriers as well will ensure that a patient not only trusts a provider, but also understands what is being prescribed and why it is important to follow through.
Think like your patient
Imagine being in your patients’ shoes, says Pacheco, where the system may seem very foreign and difficult. Creating a calm environment is a big step toward putting a patient at ease, he says, despite the difficult time and pressure nurses are under.
Sometimes thinking like your patient, even briefly, gives clues as to how to proceed. Eunice Lee, Ph.D., G.N.P., a UCLA School of Nursing associate professor, had success in implementing change to get more Korean American women to have mammograms. Even the cultural differences between Korean and Korean American women can be vast. “I am struck by how cultural norms impact women’s behavior,” Lee says. “Korean American women do not tend to take care of themselves. Women prioritize family needs first with husbands and children. They are at the bottom of the list, especially if they have no symptoms.”
In the late 1990s, only 10%–20% of Korean American women were getting mammograms, says Lee. The number has since doubled but is still very influenced by the cultural context.
Lee implemented a program where she used a popular Korean vegetable dish as the program’s acronym, KIM-CHI (Korean Immigrants and Mammography: Culture-Specific Health Intervention). By presenting mammography as a normal, routine health screening and educating the husband and the woman together, screening rates jumped 15% in Lee’s intervention group.
“When you educate the woman, you need to consider and evaluate her support system and how they can help her, rather than have it purely focused on the individual,” Lee says. Health care providers might want to encourage the husband to support the woman in taking time off from work or family obligations to get screened. Lee also expressed the strong cultural resistance to getting treated, even in a screening manner, for illness in the absence of any symptoms. “When you don’t have symptoms, you are not ‘sick,’” she says of some patients’ beliefs.
Use your resources
At Lowell General Hospital in Massachusetts, Brenda Murphy, R.N., a med/surg float, works closely with the hospital’s cultural interpreters to give her patients the best care. In addition to taking advantage of work-sponsored cultural education and training, she picks up appropriate behaviors within each culture from observing and asking questions.
Murphy, who works with Lowell’s extensive Cambodian population, says she always put her hands together to give an elderly patient a small bow as a sign of respect when leaving. At the advice of a cultural interpreter, she adjusted the height of her hands, as hands that are placed too low can be seen as insulting, rather than respectful. Murphy also says she is careful when touching the head of a Khmer patient as the cultural traditions of some Khmer say the soul resides there. If it is possible to ask permission, she always does. Eye contact might be unnerving to Khmer patients as well, who sometimes avoid it as a sign of respect. They may prefer also very limited physical contact.
Many hospitals prefer to use medical interpreters to ensure accuracy in translation of complex medical terms and to protect a patient’s privacy. In their absence, nurses might have to rely on more rudimentary methods like flash cards or pictures to help both patient and nurse. Pacheco discourages the use of family members as interpreters, especially children. “Sometimes you have no choice, but it is best to introduce a bilingual neutral party who also understands medical terms,” he says. Family members can help fill in the missing information about symptoms the patient is experiencing or treatments used.
“It is encouraging,” Sagar says of the progress being made. In the next couple of decades, as minority populations grow, cultural competence in nursing will become much more crucial to quality patient care. “I am passionate about cultural diversity and the promotion of cultural competence,” she says. As an immigrant herself, Sagar says she knows the experience of “being different from the rest.”
When Lowell General Hospital was forming plans for diversity training, staff recognized that diversity was as much of an essential component of patient care as medicines and procedures, says Deborah Bergholm-Petka, Manager of Training and Development. Nurses have the opportunity to learn about cultures through monthly celebrations in the hospital. The staff is also encouraged to reference the book Culture & Clinical Care,which gives general summaries of many cultural beliefs and attitudes.
Use what your work environment offers and know a little bit about the cultures served. “Know who your resources are and how to access them,” Murphy suggests. “Now we are more proactive and aware of who makes up our communities.”
Be ready for all situations when you work with many different cultures. Continually ask yourself reflective questions, suggests Venus Watson, chair of Lowell General’s Diversity Council. For instance, how will you navigate various cultural wishes and accommodate a patient while ensuring the best care and follow up? If family members want to speak for a patient, how can you best introduce an interpreter?
“It is not about the nurse,” Scott says. “It is about the patient. You can offend people when it comes to culture.” Never assume you know what a patient wants, she says. Rather, gain knowledge, be aware, and ask the patient—the solution is often that simple. “People do pass judgment on beliefs,” Scott says, “but it is education that will change the system.”
When her third child, Ian, was a baby, Zenora Thompson knew something was different. At first, Ian mirrored his talkative family and verbalized normally. But, suddenly, he stopped talking completely and became fretful.
“Nothing would satisfy him,” says Thompson, who works as a nurse in Ohio.
“He would cry at everything, and wouldn’t ever rest. He would just collapse when he went to bed.”
When Thompson took Ian to the pediatrician’s office, her doctor said she was worrying too much and comparing Ian to her other children. The doctor recommended Thompson give her son more time to develop. But nothing changed, so Thompson brought Ian back to the pediatrician. “Just to appease me, she finally ran some structural tests done for issues with his ears and things, and it came back no problems,” says Thompson. For over a year her doctor told her she was overreacting.
When Ian was two years old, Thompson knew her son had a serious behavioral problem. She took him to a psychologist, who told her Ian had symptoms related to autism, but wouldn’t diagnose him yet. Most children are not diagnosed with autism until two years old.
Thompson took her son to a special needs program at his preschool. After sharing the psychologist’s findings with her pediatrician, they made an evaluation that would eventually develop into a diagnosis for autism. “From day one I learned to pick my battles,” Thompson says.
The Thompson story unfolded during the 1980s, when the autism ratio was much lower. According to studies conducted at the time, 0.3–0.4 per 1,000 American children were diagnosed, according to the Journal of the American Medical Association. There weren’t many medical resources, and Thompson was handed a book that dated back to the 1930s to consult for advice and research. This book associated autism with “cold mothers,” blaming them for the disorder in their children.
“At that time I just cried,” Thompson says. “I thought there wasn’t a lot of hope for my child.” People told her she might have to institutionalize her son. “Thank God now it’s different.”
Yet, even in the 1990s when Ian was enrolled in a Cleveland school for special needs children, his medical care was lacking. “I changed my son’s pediatrician, and she said when she met him for the first time, ‘Can’t you control this child?'” Right then, Thompson told her, “If you’re going to treat my son and this population, you have to be aware of what’s going on with him.”
Despite more prevalent resources and an ongoing national dialogue concerning children with autism, research indicates that many of these resources may still be missing from minority communities, particularly among African Americans.
According to a study conducted in Atlanta between 2000 and 2006 by the National Center on Birth Defects and Development Disabilities at the Centers for Disease Control and Prevention, non-Hispanic black (NHB) children were less likely than non-Hispanic white (NHW) children to be identified with less severe autism spectrum disorders (ASDs).
“While the overall prevalence of ASD was indeed lower for NHB children in all years that we examined, among those children who had been identified, diagnoses in NHB children were more likely to be those generally associated with a higher level of severity,” said Laura A. Schieve, Ph.D., an epidemiologist and one of the principal investigators of the study. “In comparison, NHW children had a wider range of all ASD subtypes identified.”
The conclusion of the research found an “under-identification” of ASDs in non-Hispanic black children. “If the ASD prevalence was truly lower in NHB children, we would expect to see that they had a similar distribution of types of ASD as NHW children,” Schieve says. She is also one of the principal investigators with the Study to Explore Early Development (SEED), a multisite case control study of autism spectrum disorders in U.S. children.
“We can’t give [this population] enough information, and before you know it, a child where they needed minimal intervention now needs maximum intervention because they are misdiagnosed,” says Thompson.
In 2002 white children were diagnosed, on average, at 6.3 years old, versus black children, who were diagnosed at an average 7.9 years old, according to a study conducted in Philadelphia by the University of Pennsylvania. David Mandell, Associate Director for the Center for Autism Research at the Children’s Hospital of Philadelphia and one of the authors of the study, concluded that these disparities might exist as a result of a parent’s interpretations of symptoms. “There may be cultural differences in how the behavior of children with autism is viewed or awareness of what these symptoms mean. More likely, there may be challenges to communication between parents and the clinicians who are doing the diagnosing.”
In the UPenn study, black children also spent more time in treatment with a physician before receiving an official diagnosis. When children were diagnosed, NHB children were also more likely than NHWs to be misdiagnosed with conduct disorder and adjustment disorder, while they were 2.6 times less likely to receive an autism diagnosis than non-Hispanic white children.1 Mandell said the most important areas where a misdiagnosis might affect a child with ASD is “mistreatment, especially with medications, and lack of appropriate intervention.”
According to a 2007 National Early Intervention Longitudinal Study, children with ASD have shown better prognosis with early diagnosis and intervention. Unfortunately, minority families at lower income or education levels were less likely to enter early intervention therapy.2 Under-identification of ASDs in non-Hispanic black children could affect the child’s developmental progress by limiting their access to care. If a child is diagnosed under three years old, they may qualify under the Individuals with Disabilities Education Act for early intervention services and evaluations.
“While early intervention is extremely important, intervention at any age can be helpful.” Schieve says. Developmental screenings are short tests used to determine if children are learning basic skills when they should be, or if they might have delays. Schieve says all children should be screened for developmental delays and disabilities during regular well-child doctor visits at nine, 18, and 24–30 months. Additional screenings might be needed if a child has high risk for developmental problems due to preterm birth, low birth weight, or other reasons. In addition, all children should be screened specifically for ASDs during regular well-child doctor visits at 18 and 24 months. Yet another screening might be needed if a child is at high risk for ASDs (e.g., they have a sister, brother, or other family member with an ASD) or if behaviors sometimes associated with ASDs are present.
For the Thompson family, who had few resources to turn to when Ian, now 22 years old, was growing up, intervention took some creativity. Their first area of focus was building a support system within their own family.
“Right away when I came home and told [his siblings] he was different, and asked them how they were going to help their little brother, they were my biggest supporters,” Thompson says. Ian’s brother offered to teach him sports, while his sister helped him with getting dressed and hygiene. Ian’s father focused on verbal and social interactions; consequently, Ian is the most verbal with his father.
The Thompson family also found their church to be more supportive than expected. In their religious community, autistic people were not always allowed to attend services because their condition was “often looked on as possession,” says Thompson. Today, close friends of the family are as supportive as they can be, but socializing is still challenging for Ian because he is so unwilling to break from routine and doesn’t trust many people.
The most difficult moments with Ian happen in public. “Going to the mall I want to put a T-shirt on my son that says ‘I’m not bad, I’m just autistic,'” said Thompson. “Some days you’re up to fight those battles and other days you just aren’t up to it. I learned to pick my battles and chose the ones that would impact change.”
Ian was fortunate to enroll in a special needs preschool as soon as he was diagnosed. According to a 2002 study on Racial Inequality in Special Education, there is a lack of early intervention for minority children, including “inadequate services, low-quality curriculum and instruction, unnecessary isolation from their nondisabled peers, and hardship.”3 The study concluded that these factors might exacerbate learning and behavioral problems in minority children with special needs.
As a minority nurse, Thompson wants to research the issues her son faces now as a young man with ASD. Some of Ian’s friends with ASD are currently going through difficult phases, especially those who were diagnosed later in life, she says.
One particular challenge is diet. Young adults with autism typically don’t monitor their own dietary intake. As a result, many of those who are not regularly monitored by their families suffer from hypertension and diabetes—medical issues minority communities already experience in disproportionate numbers—in addition to their ASD symptoms.
“Special needs populations are living longer,” Thompson says. “To provide them with quality and competent cultural care we have to become informed about it.”
According to a study regarding young adults with special needs, 75% of African Americans in this population are unemployed after being out of school for two years. Fortunately, Ian’s mother enrolled him in an adult activity center where small businesses send in projects for members of his team to work on. Ian works half the day, and the other half he has activities and socializes. Ian’s opportunities are in many ways due to his mother’s research and advocacy for her son. It’s another battle she does not consider over.
“There is not a lot of research on adult autism and not a lot of facts on treatments and modifications for them in adulthood,” says Thompson. “Consequently I’m back in a box again a little bit.”
1. Mandell, D. S., Listerud, J., Levy, S. E., and Pinto-Martin, J. A. (2002). “Race Differences in the Age at Diagnosis Among Medicaid-eligible Children with Autism.” Journal of the American Academy of Child and Adolescent Psychiatry, 41:12, 1447-53.
2. Hebbeler, K., et. al. (2007). “Early Intervention for Infants and Toddlers with Disabilities and Their Families: Participants, Services, and Outcomes.”
3. Losen, D. J., and Orfield, G. Racial Inequity in Special Education, (Cambridge, MA: Harvard Education Press, 2002).