Does the NCLEX-RN® Pass the Test for Cultural Sensitivity?

The last hurdle a new nursing school graduate must clear before he or she can practice as a nurse is often the most stressful one: taking the NCLEX-RN®. This licensing examination, developed by the National Council of State Boards of Nursing, Inc. (NCSBN), makes it official: Pass “the boards” (as the exam is familiarly called) and you become an RN.

This grueling, five-hour test of entry-level nursing knowledge and skills can be an intimidating experience for any new graduate. But some minority nursing leaders have voiced concerns that the NCLEX-RN playing field may not be level when it comes to students of color, especially if they were educated outside the U.S. Others dismiss these claims, arguing that the exam is indeed culturally sensitive and unbiased. Either way, strong feelings seem to arise when the subject of the NCLEX comes up.

Charlotte Richmond, RN, PhD, scientific director of anesthesia research at Mount Sinai Medical Center & Miami Heart Institute and an adjunct professor at the College of Health and Urban Affairs at Florida International University, believes that language barriers can sometimes hinder minority and international students taking the NCLEX.

“Here in Miami, the cultural diversity is very great,” says Richmond, who is part Cherokee Indian. “South Florida, particularly, has influences that come from the Caribbean Islands, Central and South America. The majority of international students who are attending the local nursing schools are having a difficult time passing the NCLEX, and it perhaps could be due to language problems.”

Americans use different terminology that international students might not know, Richmond explains. She likens it to the variations in word usage between America and England. “In that sense, the NCLEX questions are based on the American culture and not necessarily [other languages or cultures],” she adds.

Graciela Reyes, RN, BSN, CRRN, a member of the Dallas Chapter of the National Association of Hispanic Nurses (NAHN), agrees. “The [international] nurses’ difficulty is not with the content [of the test] but with the language,” says Reyes, a native of Mexico. “The medical terminology is not that much of a problem, because most of it is very similar in English and Spanish. What gave me the hardest time was the day-to-day English.”

Back in 2001, Jodi Gooden, RN, BC, PhD, an assistant professor in the College of Nursing at the University of Oklahoma, wrote an article for Minority Nurse about culturally biased classroom testing. She believes this same problem persists today. “I see it here where I teach,” says Gooden, who is part American Indian. “What I see today for some minority students is that there is a difference in their language.”

Gooden believes this issue could affect minority nursing students’ performance not just on classroom tests but also on the NCLEX–a situation that she finds particularly unfortunate. “I hate to see students put in a position where they are very knowledgeable in a clinical area, yet because of the NCLEX [and potential cultural barriers] they are limited in whether or not they can become a nurse.”

A Question of Culture

Language isn’t the only issue cited by those who feel minority and/or international nursing graduates may be at a disadvantage when taking the NCLEX-RN. “Some people don’t believe that cultural differences can be a problem,” says Richmond. “I have taught in three different states and the cultural diversity is different in each one. Language is part of [the potential difficulty for minority students], but the culture is another part of it.”

Jacqueline Crespo Perry, RN, BSN, president of NAHN’s Houston Chapter, agrees that culture can influence what minority nursing students learn. Perry has three nieces who are planning to go to nursing school. “One of them is really deep into her Hispanic roots and it is going to be a little hard for her to adjust to a lot of things she will encounter in her nursing courses,” she says. “The other two will swing right through.”

For example, Perry explains, traditional Hispanic families’ view of health care emphasizes treatment of illness rather than disease prevention. This cultural orientation can affect the way some Hispanic candidates may interpret and respond to questions on the NCLEX.

“When they read a question about children’s health, they are focusing on the illness. They look for the sick child and how you will treat that child,” Perry says. “But because the majority culture emphasizes preventing the child from getting sick, this would not be considered the ‘right’ answer.”

To cite another example, she continues, mental illness is considered a stigma in Hispanic culture. As a result, it is often not talked about, treated, or even taught in some international nursing programs. That knowledge deficiency, which can impair nurses’ performance on the psychiatric section of the NCLEX, needs to be addressed as well, Perry maintains.

In addition, the exam’s multiple-choice format can pose problems for international students, according to Cora Munoz, RN, PhD, an associate professor at Capital University in Columbus, Ohio. A native of the Philippines, Munoz is also a reviewer for the NCLEX-RN at the Kaplan Review Center in Columbus.

“I will not go so far as to say the test is not culturally sensitive,” she comments. “But I think that foreign graduates do have a problem, not so much with content but with format. Multiple choice is not a common testing format in other countries. The format itself becomes problematic.”

In Mexico, nurses take their licensing exams orally in front of a panel of judges, Reyes points out. “Then you come here, and it’s multiple choice and done on computers.”

Narrowing the International Gap

On the other side of the argument, Barbara Nichols, RN, MS, DHL, FAAN, chief executive officer of the Commission on Graduates of Foreign Nursing Schools (CGFNS), believes the NCLEX-RN is culturally sensitive. The CGFNS has a certificate program that internationally educated nurses must complete before they can sit for their boards in some U.S. states. Currently, 36 states have this requirement.

Nichols, who is African American, says the National Council of State Boards of Nursing has put many safeguards in place to ensure the testing process is fair to everyone. “The NCLEX is testing minimal knowledge,” she asserts. “It is not a test of excellence. It is a test of basics.”

The CGFNS, a private, independent, non-profit organization, was created in 1977 at the height of a severe nursing shortage that had prompted many hospitals to import nurses from the Philippines and other countries to fill their staffing gaps. “At that time, only about 15% to 20% of these nurses educated outside the United States were passing the NCLEX-RN,” Nichols explains. “This was really a big dilemma. You had all of these foreign nurses coming in but not passing the licensing exam.”

Today, statistics from the NCSBN clearly show that CGFNS’ efforts have made a difference. In 2001, out of 8,613 foreign-educated candidates taking the NCLEX-RN for the first time, nearly half (49.4%) passed the exam. But a considerable gap still needs to be closed: The first-time pass rate for U.S.-educated candidates is 85.5%.

International nursing graduates earn their CGFNS Certificate through a three-step process: a credentials review of their foreign education, registration and licensure; the CGFNS Qualifying Exam, a one-day test of nursing knowledge; and the Test of English as a Foreign Language (TOEFL), an English proficiency exam.

Passing the Qualifying Exam, says Nichols, is a good predictor of who will pass the U.S. licensing exam. Fifty percent of the nurses who take the Qualifying Exam pass it, she reports; of that 50%, 90% pass the NCLEX. Those who fail the CGFNS exam receive a letter explaining their score and indicating the areas that need to be improved.

Despite this success rate, not all advocates for international nurses are enthusiastic about the CGFNS Certificate process being linked with the NCLEX. Perry believes it is another obstacle for international nurses. Test fees and translation costs are significant, she points out. If foreign credentials to be reviewed by CGFNS are not written in English, nurses must have them translated and pay for it themselves.

Reyes, too, feels the CGFNS Qualifying Exam is an extra step that international students shouldn’t have to face before taking the boards. “If CGFNS is saying foreign nurses and U.S. nurses are equally educated, why are they holding international nurses to a higher standard?” she argues.

The NCSBN Responds

What does the National Council of State Boards of Nursing have to say about all this?
“The [NCLEX-RN] includes effective checks to minimize the potential for bias due to culture, gender and other background factors,” NCSBN maintains. “It is important that each [question] development panel is composed of nurses representing each region, a variety of practice areas, and minority populations. . .

“Differential item functioning (DIF) is the statistical approach [we use] to determine potential bias. [Questions] flagged for high levels of DIF are reviewed by a group of trained sensitivity reviewers, consisting of at least five members: one male, one representative of three of the ethnic focal groups of NCLEX examination candidates, one member with prior experience on a DIF Review Panel [and] one member with a linguistic background. . .The panel’s recommendations are forwarded to the Examination Committee for final disposition of the items. Additionally, judgments of trained individuals are used to screen [questions] for potential bias.”

In addition to the numerous content reviews conducted by the NCSBN and its member boards of nursing, the National Council also does two formal reviews looking exclusively at issues of cultural sensitivity, adds Casey Marks, PhD, director of NCBSN Testing Services.

When asked if he believes minority nurses may have more trouble passing the NCLEX than their majority counterparts, Casey answers: “We have no reason to suspect that individuals of the same ability level have anything but equal opportunity to pass the examination at the same rate, regardless of their cultural, ethnic, linguistic or racial background.”

Strategies for Success

The current debate about whether or not the NCLEX-RN is a culturally sensitive, equal opportunity exam is unlikely to be resolved any time soon. But regardless of where they stand on the issue, many minority nursing leaders believe there are steps that nursing students of color and internationally educated nurses can take to maximize their chances of successfully passing the boards.

Munoz advises international candidates to take NCLEX review courses, such as those offered by Kaplan, to gain experience in how to take multiple choice tests and to practice taking exams on a computer. Kaplan’s test-prep centers provide all candidates with test-taking strategies, she says, “but if you have international graduate nurses, probably my recommendation is to spend even more time in this area and maybe on how to handle anxiety when taking a test.”

Lilianne Cooper, RN, BSN, a member of the National Association of Hispanic Nurses, passed the NCLEX in August 2002. She agrees that preparation is crucial. “I started studying for the exam months in advance,” Cooper recalls. “The way they format the questions, you could be looking at four correct answers and your job is to pick the best one for that particular scenario. It’s the most frustrating kind of question I’ve ever had to work with.”

A recent graduate of Boston College’s William F. Connell School of Nursing who now works on med/surg floors at Brigham and Women’s Hospital in Boston, Cooper says nursing school helped prepare her for the NCLEX experience. “I received the tutoring and support I needed to help me tackle those questions,” she explains. “I basically had to learn how to answer these types of questions from scratch.”

Cooper also bought a NCLEX-RN review book with a computer CD included. “I encourage all nursing students to invest in some kind of computer review to get the feel for the computer format,” she says. “The one I purchased gave me the opportunity to take 100-question practice tests that were timed.”

Many international candidates must take English language courses before they can sit for the TOEFL. To address this need, Perry and Reyes, through the NAHN chapters in their respective cities, each run programs designed to help immigrant nurses from Spanish-speaking countries strengthen their English and other skills they need to obtain U.S. licenses.

Currently, some 42 nurses are taking English classes at the University of Houston through Perry’s program, which is called Nurses Helping Nurses. In Dallas, Reyes has set up a volunteer program in the Veterans Affairs North Texas Health Care System, where she works as a nurse educator. Internationally educated nurses who have not yet taken the NCLEX volunteer in the system’s hospitals, gaining the opportunity to work on their English with other nurses, doctors and patients. Reyes meets with the volunteers at lunch most days to discuss any language problems they may be facing.

The Dallas Chapter of NAHN also provides nursing review courses and helps candidates prepare for the NCLEX. The Houston program assists nurses who fail to pass the CGFNS Qualifying Exam by sending them to a local college to take a refresher class in the areas of nursing in which they scored poorly.

Licensing Has a Price

Many of the experts interviewed for this article believe there is still another area in which the NCLEX-RN playing field is not level: the costs associated with taking the exam. “For those in the minority community who may not be in the same socioeconomic bracket as majority candidates, there could be some disadvantages,” says Cooper. “First of all, [the cost of] taking the NCLEX alone is $300. Then on top of that, if you want to prepare for the test, you have to buy a review book and/or go to a review course. Either way, it’s more money out of pocket.”

Casquese Chaffin, RN, MSN, MA, a member of the Los Angeles chapter of the National Black Nurses Association, agrees that the cost of review courses could be a barrier blocking some minority students’ access to the licensing exam. She believes the foundations of large companies should be targeted to help foot the bill for such courses.

“These companies target their endowments [to causes] where they can ,” she contends. “It isn’t popular [to spend money] on review seminars for nurses. They won’t get a handshake for that. Until the minority community itself makes some noise–yells, screams and hollers–that won’t change.”

Money can be a big issue for international candidate as well. Munoz calls it the single biggest obstacle for nurses emigrating from the Philippines to the United States. Many Filipino nurses go to Faipan, a U.S. territory near Guam in the Pacific, to take the NCLEX exam before they come to America, and that travel represents an additional cost.

Perry’s Nurses Helping Nurses program is working to help immigrant nurses offset the costs of getting their credentials translated for CGFNS review, which can run as high as $70 per page. “We have found people who have been able to translate for us at a low cost,” she reports. “But you have to be careful. If CGFNS doesn’t think the translator is an acceptable source, they will send it back.”

Cooper thinks some minority students may not be aware of cost-cutting options available to help make the NCLEX process more affordable. “Every little bit helps,” she says. “I believe there are some [nursing employers] that offer reimbursements after new nurses take their boards and get their license. Whether it’s buying a used review book, spending an extra hour after seminar with your professor or even inquiring about a reimbursement at the hospital you applied to, it’s all more than worth it in the end when you get that license in the mail.”

Spreading the Word

On a warm spring night in Miami, one of the nation’s foremost African-American oncology nursing scholars and researchers, Sandra Millon Underwood, RN, PhD, FAAN, is delivering an impassioned speech to a group of about 30 cancer nursing educators and clinicians about how it’s time to stop talking about minority health disparities and start doing something about them.

“I am appalled by the lack of information in nursing textbooks about health disparities that we know exist. [The Institute of Medicine report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care] shows there are disparities not just in occurrence [of cancer and other serious diseases] but in treatment. How many more reports do we need to write?” she demands.

“This is a time for commitment, for active involvement,” continues Underwood, who is the American Cancer Society Oncology Nursing Professor and Northwestern Mutual Life Research Scholar at the University of Wisconsin-Milwaukee School of Nursing. “If we are to be real nurses, we can’t sit here any longer and do nothing. Our efforts must be directed toward cancer prevention, early detection and cancer control throughout the community. We need to go out into our own communities and deliver information about cancer prevention where we live, where we shop, where we worship.”

Fortunately, the nurses in the audience, most of whom are African American, have no intention whatsoever of sitting and doing nothing. In fact, they’ve just spent much of the past year doing exactly what Underwood is talking about: creating and implementing successful education, prevention and screening programs designed specifically to close the gap of unequal cancer outcomes in America’s communities of color. And now they’ve come together at this Dissemination Colloquium to present their projects, share ideas and learn from one another.

The two-day colloquium, held last May, was part of an ongoing series of Cancer Prevention and Early Detection Programs for nurses involved with historically black colleges and universities (HBCUs) and minority-serving institutions (MSIs), sponsored by the Oncology Nursing Society and funded by a grant from the National Cancer Institute. Many of the participants had previously attended a prevention programs workshop taught by Underwood in August 2001, had found it incredibly motivating and had returned in 2002 eager to report on the activities they had developed as “homework assignments.”

Ending the Silence, Challenging the Myths

As the name implies, the purpose of the dissemination colloquium was to give the nurses an informal opportunity to network and exchange experiences about what strategies are working in the battle to bring effective, culturally appropriate cancer prevention programs to minority communities. There was even a presentation by a panel of nursing editors (including Minority Nurse) to encourage the attendees to share their success stories with the wider nursing community by writing and publishing articles about their projects.
But a more urgent undercurrent running beneath this focus on getting the word out was the need for nurses to not just share information with other health professionals but to bring the message directly to those who will benefit from it the most–at-risk minority individuals whose lives could be saved if they were better informed about cancer prevention and the importance of detecting the disease in its early stages when it is easier to treat.

During one networking session, the nurses spoke frankly about the problem of “silence barriers”–i.e., reluctance to talk about experiences with cancer–that have become a cultural legacy in many minority communities. This silence can result in a deadly lack of information that can prevent people from seeking screening or treatment until it’s too late. For example, some African Americans may never have been told by their parents that they have a family history of cancer. “Minority populations can’t afford to be silent about cancer,” one participant declared. “We need to start talking about it and get all the information out in the open. We have to end the secrecy.”

Added Underwood, “It’s more than just a question of getting the information out there. We also need to dispel the myths and challenge the incorrect information.” She cited the example of a widely circulated Internet hoax that scared many women into believing certain types of deodorants and underwire bras cause breast cancer. “If you receive one of these hoax emails, don’t just delete it,” she urged. “Respond to it and set the record straight. Send an email to each person whose name is on the list and give them the facts.”

Other participants–many of whom had lost friends and relatives to breast cancer or had suffered from the disease themselves–shared their own experiences with cultural beliefs and misperceptions that can create barriers to early detection and treatment in African-American communities. These included the reluctance of some black women to perform breast self-examinations because of cultural taboos against touching one’s own body, and the surprisingly common belief that cancer surgery does more harm than good because cancer spreads when it’s exposed to the air.

Yvonne Ford, RN, MSN, oncology patient resource manager at Duke University Medical Center in Durham, N.C., spoke eloquently about the nurse’s role in replacing cancer myths with facts as she presented her project, a colorectal cancer education and screening program targeted to African Americans in the Durham area. “Once the myths are dispelled, people want more information,” she said. “Information is power and it can save lives.”

Although colorectal cancer is very curable early on, it is usually not diagnosed until the disease is in an advanced stage. “Screening and early detection are critical–by the time you have symptoms, it’s too late,” Ford emphasized. “Our program was a targeted educational intervention, because I believed very strongly that the reason why people didn’t get screened was that they didn’t know about colon cancer, what the risks are and what the screening methodology was.”

To break down these barriers, Ford and her team of nurses held several community education events that featured quizzes to assess people’s knowledge of the disease, informative discussions about risk factors and symptoms, and–most importantly–free colorectal screenings. There were also demonstrations of colon-friendly, high-fiber cooking–“people will always come to a program if you feed them,” Ford pointed out–and distribution of informational materials Ford obtained from the American Cancer Society at little or no cost.

When you’re trying to arm people with empowering information about cancer, it’s important to allow plenty of time for questions, Ford advised. “These people have questions they probably wanted to discuss with their doctors, but they didn’t, for whatever reason. This is where you as a nurse have the opportunity to find out what their concerns are–whether you need to refer them on for further care, or if you need to calm their fears, or whatever. That was the piece of the project I actually liked the best.”

An Army of Educators

While nurses can play an extremely active role in bringing cancer prevention information and screening into underserved minority communities, they can’t do the whole job by themselves. That’s why many of the projects presented at the colloquium featured a strength-in-numbers strategy of nurses teaching people other than RNs to become community cancer educators. These “partners in prevention” included student nurses, high school teachers, community leaders and even minority medical students.

After attending Underwood’s 2001 workshop, a group of nine Chicago nurse educators, most of whom teach at the inner-city Dawson Technical Institute, teamed up to launch a project designed to increase their LPN students’ awareness of minority cancer disparities and encourage them to become involved in helping to address these issues. Calling themselves the Coalition of African-American Nurses (CAAN), the group’s members include Carol Alexander, RN, BSN, Alma Boykin, RN, BSN, Donna Calvin, RN, MSN, FNP, Rubie Elkins, RN, MSN, Rose Murray, RN, BSN, Muriel Reed, RN, BSN, Velita Sanders, RN, BSN and Alicia Theodore, RN, BSN.

Their project is particularly innovative because LPNs have been largely overlooked as a resource for fighting the war against unequal health outcomes. “Why shouldn’t we educate the LPN nursing student [about health disparities]?” argued Alexander, the coalition’s director. “LPNs are nurses who primarily function in direct patient care and they are also positioned to serve as positive role models for their patients and families. If they are equipped with the knowledge to appropriately counsel their patients, we will be able to increase the number of health care educators in the African-American community, where many LPNs currently serve.”

Other nurse educators showcased projects that enabled BSN students to gain hands-on experience in delivering cancer prevention education in minority communities. What was striking about these programs is that the outreach activities are incorporated directly into the school’s nursing curriculum.

For example, Linda Byrd, RN, MSN, CRNP, an instructor at Auburn University School of Nursing in Auburn, Ala., described her institution’s community-based curriculum, designed to serve an area where 23% of the residents are African Americans, many of them at poverty level. As part of the school’s community clinic program, students serve at two clinic sites to work on various health promotion projects–e.g., smoking cessation, healthy eating and drug abuse prevention.

Byrd asked the student nurses to introduce cancer prevention activities into this already established program. They eagerly accepted the assignment, going out into the community to distribute information and performing presentations and skits at the clinic sites. The new focus on cancer awareness was a huge success, Byrd said. The number of patients visiting the clinics increased and the students were well received by the community residents.

At the University of the U.S. Virgin Islands in St. Thomas, where student involvement in public service projects is an integral part of the BSN experience, students in two junior-level med/surg nursing courses taught by Edith Ramsay-Johnson are required to independently develop and implement health promotion projects for increasing awareness of cancer prevention in the local black community. “The students’ ingenuity and motivation has resulted in a number of dynamic, creative programs that reached a significant number of persons in our community,” Ramsay-Johnson reported proudly.

Working in teams, the students present preventive education and early detection programs at churches and senior citizen centers. In addition, said Ramsay-Johnson, “an optional aspect of the health promotion projects involves wider dissemination of the information.” Students have chosen a variety of avenues for getting the word out to a larger audience, including poster presentations at a shopping mall and appearances on local radio talk shows.

Most of the colloquium participants who were actively enlisting their nursing students into the fight to eliminate unequal cancer outcomes came from HBCUs or schools with large minority student populations. But the information exchange also included the perspectives of educators at predominantly white schools, whose projects focused on building their students’ awareness of minority cancer disparities and preparing them to provide culturally sensitive care to patients from a diversity of backgrounds.

For instance, Sheila Fredette, RN, EdD, who teaches the clinical component of a community health nursing course at Fitchburg State College in Fitchburg, Mass.–a public college where the student population is 82% Caucasian, 15% Hispanic and 3.6% African American–is developing a program that would require students to create a series of poster sessions on five major cancer types that disproportionately strike African Americans. The students will then present this information to audiences such as the school’s black student union, community service agencies and members of local African-American churches.

Turning Awareness Into Action

Knowledge may be power, but when it comes to fighting cancer in minority communities, spreading the word about the importance of prevention and early detection is only half the battle. Another recurring theme uniting many of the presentations was the challenges nurses face in getting people to translate cancer prevention knowledge into action–such as going in for screening or making lifestyle changes that can help decrease their risk.

Early on in the colloquium, Barbara Buchanan, RN, EdD, FNP, and Quentin Newhouse, Jr., PhD, from Tennessee State University presented their study, “Cancer Knowledge and Health Beliefs Among Select Groups of African-American Women.” The researchers surveyed a sample of 126 black women between the ages of 23 and 79 with no prior experience with cancer, asking them to respond to true-or-false statements such as “cancer is curable,” “all cancer drugs have the same effect” and “keeping cancer secret will make everyone less afraid.”

The results, Buchanan reported, showed that the women’s knowledge base was high and their beliefs about cancer were sound and realistic. “The respondents strongly believed that taking charge of one’s health is important and necessary,” she concluded. “But do they really do that? We’ll have to go back and see.”

This concern was echoed by other attendees, who related their experiences with patients who know preventive screening can save lives but don’t take the next step and follow up on that knowledge. Why, the nurses asked with obvious frustration, do so many African-American women make appointments to get mammograms and then not show up? Why is it, as research studies have revealed, that more than 95% of all women report knowledge of breast self-exams (BSEs), yet less than 50% actually perform them on a monthly basis? Clearly, in cases like these, lack of information is not the problem.

One presenter who directly addressed this situation was Linda Forté, RN, DSN, of the Mississippi University for Women in Columbus, Mississippi. “The discrepancy between knowledge of BSE and practice of BSE is still an unsolved clinical problem,” she emphasized. “[Nurses], as health educators, could play a big part in being able to resolve that issue.”

Forté’s project, “Circling the Issues,” involved teaching African-American 11th and 12th grade students how to perform BSEs on themselves and then share what they’ve learned with other important people in their lives, such as mothers, sisters, peers, and even fathers and brothers. “These people would be receiving the information from someone in their own group, someone they trust, and therefore they would be more willing to learn it and to do it,” she explained.

Eight of Forté’s BSN students worked with teachers at a local high school to conduct a one-day education session that included a BSE video and a 30-minute presentation on breast cancer facts. Next, the teens practiced performing BSEs on a model before examining themselves.

“For Sisters Only,” a project developed by Glenda Sims, RN, PhD, to increase the use of mammography by African-American women in medically underserved communities, took a different but equally innovative approach to the problem: making mammograms impossible to avoid. “We bring the mobile mammography unit directly into their communities for free screenings,” explained Sims, who teaches at the University of South Carolina at Spartanburg. “We will even go pick them up and bring them in for their mammogram, and provide a ‘buddy’ for them if that’s what they need in order to feel comfortable about coming in to get the test. And we don’t ask them any questions about their financial status, because that is also a barrier.”

What it all boils down to, everyone agreed, is empowering people of color to take control of their own health. Nurse educators, clinicians and students can do this by giving minority patients the facts about cancer, by providing accessible and affordable screening options and by encouraging them to become active participants in the health care process.

For example, the nurses stressed the importance of teaching minority patients how to communicate more effectively with their physicians, and letting them know they have the power to “fire” their doctor if necessary. In the words of Ritha Bookert, RN, MSN, FNP, of Brandon, Miss., who was so inspired by Underwood’s previous workshop that she went back and started her own 501(c)3 health education corporation: “If you are going to a doctor who is not talking to you about doing breast self-exams, you need to change doctors.”