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Editor’s Notebook Navigating the “New” Normal
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onducting a postpartum visit via telehealth with a patient in the back room of the restaurant where she’s currently working. FaceTiming with a patient’s loved one who cannot be present during their partner’s childbirth. Having prenatal visits in the clinic parking lot to avoid exposing patients. Pregnant women seeking alternative birthing options. These are just a few of the scenarios that have popped up in 2020 as a result of the coronavirus pandemic. In this special issue to honor National Midwifery Week, we highlight how practicing midwives and nursing students alike are navigating the “new” normal and how they are rising to the challenges and overcoming them. The coronavirus has effectively disrupted our lives and our health care system. Frontier Nursing University president Susan Stone kicks off this issue describing how certified midwives and certified nurse-midwives have been forced to adapt and figure out ways to still provide their patients with safe, quality care. Telehealth in particular has proved to be an effective method of care during these difficult times. Even whenever life returns to normal, it’s clear that telehealth will be here to stay and continue to improve our health outcomes and combat racial disparities.
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Providing culturally competent care is crucial to combating racial disparities. In today’s divisive climate, it is especially important for providers to take the time to learn—and respect—their patient’s world view. One nurse shares her out-of-the-box approach to getting a “macho” patient to improve his handwashing technique, and there are no doubt hundreds of untold stories of nurses and nurse-midwives using creative approaches to meet patients wherever they are at spiritually, emotionally, and physically. Right now, the United States is struggling to reopen schools safely for the fall season. Every week, the CDC guidelines appear to change. Nursing students and faculty alike are left scrambling to figure out how they can stay safe and still make sure they receive a proper education while maintaining social distancing recommendations and/or overcoming any technological hurdles to remote distance learning. If there are any lights at the end of this very long dark tunnel, it’s this: Vernell P. DeWitty, the AACN director of diversity and inclusion, forecasts that the public will have a new appreciation for the contributions of nurses and nurse-midwives after this pandemic, which will hopefully inspire a new generation to pursue this career path. And who doesn’t want a world with more nurses (and fewer politicians)? —Megan Larkin
For editorial inquiries and submissions: editor@minoritynurse.com For subscription inquiries and address changes: © Copyright 2020 Springer Publishing Company, LLC. All rights reserved. Reproduction, distribution, or translation without express written permission is strictly prohibited.
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Midwives on the Frontlines of a Pandemic BY SUSAN STONE, DNSc, CNM, FACNM, FAAN
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s we prepare to celebrate National Midwifery Week in the United States, it offers an opportunity to reflect on the last nine months and the effects of the international pandemic on childbearing women and on the practice of midwifery. Midwifery as practiced by certified nurse-midwives and certified midwives encompasses a full range of primary health care services from adolescence to beyond menopause including maternity care services. Midwives work in many settings including clinics, hospitals, birthing centers, and homes. Midwives pride themselves on working in partnership with women and their families to provide holistic care that includes health promotion, disease prevention, and individualized wellness and counseling.
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The term coronavirus or COVID-19 began to enter our consciousness in January of 2020, and by March 2020 we were deeply feeling the effects. Coronaviruses (CoV) are a large family of viruses that cause illness ranging from the common cold to more severe diseases such as acute respiratory syndrome. COVID-19 is a new strain that has not been previously identified in humans. In the beginning of the pandemic, we were very much at a loss not understanding completely all the ways it could be transmitted, who would be affected, and how severe those effects would be. As many hospitals quickly became overloaded with very sick COVID-19 patients, maternity care providers including midwives were struggling to understand the best ways to assist and care for women giving birth. Over
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Over time we learned that pregnant women and their babies were not at the highest risk of contracting the disease. And yet, we also knew that they and their family members could be carriers of the virus. time we learned that pregnant women and their babies were not at the highest risk of contracting the disease. And yet, we also knew that they and their family members could be carriers of the virus. Hospitals quickly instituted very strict visiting policies; some not allowing the pregnant woman to have any support persons
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accompany her to the hospital but more often allowing one person to support her. As social distancing became the norm, midwives quickly realized that they needed to put some procedures in place that would allow the family to have as safe and satisfying an experience as possible. In the prenatal period, midwives and obstetricians implemented telehealth visits for many of the low-risk women. Even though it seemed from the early data that pregnant women were not at increased risk of contracting or becoming ill with the COVID-19, we were unsure. We know for example that pregnant women are more susceptible to the flu and at higher risk for severe illness compared to women who are not pregnant. Therefore,
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telehealth prenatal visits soon became the new normal. Many, if not most, midwifery services adopted visit schedules that included both telehealth visits and office visits. Office visits were primarily done for times when the women needed an additional procedure such as ultrasound and/or glucose testing. Higher risk women and women closer to the expected birth date were more likely to have office visits. Ginny Bowers, CNM, a Frontier Nursing University midwife alumnus, reported doing prenatal visits in the clinic parking lot to keep her patients as far from exposure as possible. We soon learned women, especially low-risk women, were often very satisfied with telehealth visits. It provided
time to have a relaxed visit with the woman without the rushing around involved in traveling to an appointment. Midwives taught women how to weigh themselves, check their own blood pressure, and monitor the baby through kick counts. In terms of technology, the visits could be done either by computer, tablet, or by cell phone which most, but not all, women have access to. Midwives and nurses also quickly rose to the challenge of developing and implementing virtual childbirth preparation classes. Women could attend classes from their homes. People who were not skilled Zoom users quickly became skilled. In the intrapartum period, there was much distress. In many situations, women were
As social distancing became the norm, midwives quickly realized that they needed to put some procedures in place that would allow the family to have as safe and satisfying an experience as possible. being admitted to maternity units without being allowed to bring a support person including their partners or their doula. At the same time, nurses were stretched thin due to the acuity of care being provided in the rest of the hospital. Midwives were required to wear full Personal Protective Equipment while at the same time experiencing the inability to comply with the mandate due to shortages. Midwives stepped into the chaos and provided the needed health care and in many cases, became the woman’s primary support person as well. They committed to assuring women received the physical and emotional care
needed during this important life event. Most maternity units adopted a policy of testing for COVID-19 of every woman as she was admitted for labor. Many persons who are positive for COVID-19 are asymptomatic; therefore, some women were very surprised to learn the test was positive. This precipitated isolation and according to CDC Guidelines, separation of mothers and babies after the birth. Women could refuse to be separated from their baby, but were put in the unconscionable decision of trying to do the best for their baby under such difficult conditions. Midwives along with the rest of the health care team worked tirelessly to assure that women received not only excellent physical care but emotional care as well. This entire situation soon resulted in an increased demand for out of hospital birth. Midwives who were operating either home birth practices or free-standing birthing centers began to respond to the growing demand. Birthing
Centers operated by midwives reported hiring additional midwives and increasing the number of birthing rooms in an effort to meet women’s desire to remain out of the hospital. A group of midwives from the American Association of Birth Centers and the Commission for the Accreditation of Birth Centers developed Guidelines for Auxiliary Maternity Units. The goal was to provide guidance to health care systems and others seeking to move low-risk maternity care out of the hospital. A group of midwives from New York City used these guidelines to develop a brand new free-standing birthing center. As COVID-19 has continued to spread across our country, the disproportionate effect on racial and ethnic minorities has become glaringly apparent.
According to the CDC, as of June 12, 2020, age-adjusted hospitalization rates for COVID-19 are highest among non-Hispanic American Indian or Alaska Native and non-ÂHispanic black persons, followed by Hispanic or Latino persons. Black and Native Americans have a rate of five times that of non-Hispanic white persons. Why are people of color at higher risk? We see the same health disparities in many if not most health indicators. Midwives have been fighting a battle against maternal mortality which similarly shows much higher risk in people of color compared to white people. First, to be clear, there is no evidence that people of color have any biological factors that make them more susceptible to disease. Long-standing
We soon learned women, especially low-risk women, were often very satisfied with telehealth visits. It provided time to have a relaxed visit with the woman without the rushing around involved in traveling to an appointment.
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Midwives and nurses also quickly rose to the challenge of developing and implementing virtual childbirth preparation classes. systemic health and social inequities have put some members of racial and ethnic minority groups at increased risk of getting COVID-19 or experiencing severe illness, regardless of age, according to the CDC. Systemic racism affecting people of color in the United States results in these health disparities. Crowded living conditions, employment in an area of essential service (not allowing social distancing), lack of access to health care, lack of health insurance, financial challenges, and racism are some examples of obstacles to health. The stress
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of dealing with daily racial discrimination should not be underestimated; it has been linked to underlying conditions and can increase the risk of severe illness. Midwives have committed as a profession to eliminating health disparities. In 2018, the members of the American College of NurseMidwives adopted a Racism and Racial Bias position statement committing to a series of actions designed to eliminate race-based disparities. Examples of these include increasing the racial and ethnic diversity of the
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profession, addressing their own implicit bias through education and introspection, and increasing the education in midwifery programs about racism and race-based disparities. Ultimately, midwives committed to provide nonjudgmental, culturally sensitive care to all people while working simultaneously to identify and implement ways to reduce the effect of racism on the health outcomes for their patients of color. Midwives are fully engaged in the struggle of the COVID19 pandemic. We realize that a major goal of having any impact is to address the racial disparities. To do this, midwives are at the frontlines providing compassionate supportive care as well as doing simple but important education such as urging people to
wear masks in public to protect not only themselves but the people providing service every day. Midwives are also in the background lobbying for unfettered access to health care, and increased funding for education for midwives of color. COVID-19 has been a glaring reminder of not only the effects of a pandemic but once again brought to full exposure the weaknesses in our health care system. It will take the entire health system working together to make change. Midwives are an essential part of that team. Susan Stone, DNSc, CNM, FACNM, FAAN, is the president of Frontier Nursing University.
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Midwifery Adapt to COVID-19 BY LOUIS PILLA
From increased use of telehealth to alternative birth settings, nurse-midwives are creating optimal birth experiences for their patients during the COVID era.
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OVID’s reach knows no bounds, its tentacles encircling the old, the young, and even the unborn. For nurse-midwives, the pandemic presents unique challenges as they care for their pregnant patients. Because of COVID-19, nurse-midwives have had to make significant adaptations in caring for women. In this article, we’ll take a closer look at those changes, including the increased use of teleheath, limits to visitors during in-person visits, including labor and delivery, alternative birth settings, and more.
Tapping into Telehealth Like other providers challenged to provide care during COVID-19, nurse-midwives have dramatically increased the use of telehealth. “Most of our visits are face to face; telehealth was not a huge part of our practice,” says Mary R. Franklin, DNP, MSN, CNM, director of the Nurse Midwifery program and lead
lens shifts that it is going to be OK to continue with telehealth, and they feel safer and more protected,” than risking an exposure for themselves, says Jenna LoGiudice, PhD, CNM, RN, FACNM, an associate professor of nursing and program director of the DNP midwifery program at Marion Peckham Egan School of Nursing and Health Studies at Fairfield University in Fairfield, Connecticut. She is also secretary of the Connecticut affiliate of the American College of Nurse-Midwives (ACNM). The biggest change for the patient, says LoGiudice, is not hearing the fetal heartbeat during a telehealth visit. Recently, noted LoGiudice, the American Journal of Obstetrics & Gynecology MFM published guidelines for midwifery care in the time of
which are largely the visits associated with blood draws and ultrasounds, and in the last month of pregnancy. Midwives at Jefferson Hospital in Jefferson Hills, Pennsylvania, part of Pittsburgh’s Allegheny Health Network, also are making greater use of telehealth. “It’s actually been great,” says Amanda McPherson Shafton, DNP, MSN, CNM, lead midwife at Jefferson and Pennsylvania affiliate president of the ACNM. “Midwifery care is very much about empowering people to take charge of their own health care. And so for me a video visit fits straight in with that.” Getting to the office for a visit can pose a burden for some patients, Shafton notes. In one instance, she conducted a postpartum visit via
been difficult for the patient to fit a postpartum visit into her life. “With health care today we need to give people options, and this puts more power in the patient’s court,” Shafton says. It’s recognizing that health care should be where “the practitioner is in a partnership with the patients. It’s not that we hold all the knowledge, and they have to come to us to get it. It’s really trusting that a lot of times patients
COVID that detail how to safely deliver care through telehealth. It outlines, she says, which visits the patient should come in for an in-person visit,
telehealth for a woman who went into a back room while she was working at a fast food restaurant. Without this telehealth option, it may have
know exactly what’s going on with them, and I trust them to call me because nobody’s more invested in their pregnancy, in their baby, than they are.”
Another major change due to COVID-19 is limiting the number of visitors that a woman can have, both during prenatal visits and during labor and delivery.
The biggest change for the patient, says LoGiudice, is not hearing the fetal heartbeat during a telehealth visit. instructor of the Women’s Health Nurse Practitioner program at the Frances Payne Bolton School of Nursing at Case Western Reserve University in Cleveland, Ohio. “Moving to telehealth was a huge change.” Although patients may have had some uncertainty about a telehealth visit, once they have that first visit, “their
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Limits on Visitors Another major change due to COVID-19 is limiting the number of visitors that a woman can have, both during prenatal visits and during labor and delivery. In New York City, notes Franklin, no visitors were allowed to be with women during labor and delivery, causing a great deal of stress. In other parts of the country, one visitor could be allowed. That too, however, was less than optimal, in that the woman might have to choose, for instance, between her doula and her partner. “Minimizing the number of support people was a big change and a real problem,” she says. The story at Allegheny Health Network is much the same. “We’ve had to limit the number of support people
that are able to accompany the birthing person, so we’re only able to have one support person in our network currently,” says Shafton. “A lot of times that ends up being the partner. So for a person who was planning on having a doula or their mom, or whoever it may be, as another support person or persons present during labor that can be a big change for them.”
The use of additional personal protective equipment (PPE), while not drastically changing the care midwives provide, makes for a different experience, notes Shafton.
One creative solution involved having a second person present during labor and delivery electronically, says LoGiudice. For instance, a doula could attend via a system like Apple’s FaceTime.
PPE Adds a Layer The use of additional personal protective equipment (PPE), while not drastically changing the care midwives provide, makes for a different experience, notes Shafton. “It definitely feels to me harder to emote with people when something really good or really terrible is happening,” she says. For many midwives, particularly those in out-of-hospital settings, additional PPE added another layer of separation, notes Franklin. The patient’s caregivers “were really
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removed by that personal protective equipment, so that was very stressful for the midwives and their patients.”
Alternatives to Hospital Concerned about exposure to the coronavirus while in the hospital, women inquired about alternatives such as outof-hospital settings and home births, says Vanessa Daou, DNP, WHNP, CNM, practicing nurse midwife at the Center for Women’s Health and Midwifery in New Haven, Connecticut. The practice is part of the Yale New Haven Health System. “There was a huge uptick in healthy women seeking out alternative birthing options,” notes LoGiudice. “They don’t want to walk into a hospital where COVID is so strong right
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now and risk exposing myself, my partner, my baby.” One big response was the opening of the Jazz Birth Center of Manhattan, said to be the first and only freestanding birth center in Manhattan. This occurred as the result of an emergency executive order from New York Governor Andrew
“There was a huge uptick in healthy women seeking out alternative birthing options,” notes LoGiudice.
providers who support lowintervention birth in a safe setting, she notes. “Whether that is a trained certified midwife at a home, or birth center or hospital, we definitely have had an uptick in interest in midwifery.” What’s more, in hospitals where both physicians and nurse midwives are delivering infants, there is a tendency for midwifery’s practice to become more of the norm, says LoGiudice. One example: Instead of a two-night stay for a patient who has had an uncomplicated vaginal delivery, there may be openness
may extend well beyond the end of the pandemic. “If we can do telehealth on an emergency basis pretty successfully for a lot of people, telehealth might become a bigger part of our practice going forward, because it works,” says Franklin. “I don’t think any of our health care encounters are going to ever be in the same way that they were before,” says LoGiudice. “COVID has permanently changed the landscape. We may now have more access for people in some ways because we all have had to become experts
Some of the changes nurse midwives and their patients are seeing in the era of COVID-19 may extend well beyond the end of the pandemic. Another plus, according to Franklin, may be encouraging the move toward full practice authority for advanced practitioners. Some states, she notes, have made emergency provisions for advanced practitioners to have full practice authority.
“Born for This”
Cuomo. In addition, there was in increase in the number of women inquiring about home births, says LoGiudice.
to discharge after one night. “Some things that were inherent to midwifery care, now our colleagues are looking to us for protocols.”
More Interest in Midwives COVID has also led to an uptick in interest in midwifer y, says LoGiudice. Many women are looking for
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Changed Landscape Some of the changes nurse midwives and their patients are seeing in the era of COVID-19
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in telehealth very quickly. I think we’re going to see improvements in telehealth as we go forward and if anything maybe it’s an opportunity for more access and for people to get access to specialty visits. So hopefully, there’s some positive coming out of all of this.”
“What we’re all doing and will continue to do is just meet women where they’re at,” says LoGiudice. “Midwives are really good at listening and supporting women. We’re going to really help people to have that birth experience that they’re looking for, even in the midst of all this. So, just because the landscape looks different, doesn’t mean that women are supported any less.” “I think midwives in particular are born for this, to be honest,” says Shafton. Midwives throughout history have “always been able to navigate through difficult circumstances by relying on our principles of providing really individualized patient-centered care. And that’s all we’re doing; we’re just adapting.” Louis Pilla is a seasoned publishing expert with over 20 years of experience in providing content and digital products to health care audiences.
Cultural Competence Seeing the World Through the Eyes of Others BY MICHELE WOJCIECHOWSKI
Experts explain why understanding and practicing cultural competence is crucial for nurses and midwives alike.
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ftentimes, the United States is described as a “melting pot”—meaning that people living here are made up of a variety of races, religions, and cultures. Because nurses and midwives will provide care to many different people in their careers— or depending on where they practice, every single day—it’s crucial for them to know as much about other cultures so that they can provide the very best care possible. This is where cultural competence comes into play.
Defining Cultural Competence According to the American Hospital Association (AHA), “Cultural competency in health care describes the ability of systems to provide care to patients with diverse values, beliefs, and behaviors, including the tailoring of health care delivery to meet patients’ social, cultural, and linguistic needs.” Laurie Cure, PhD, MBA, CEO for Innovative Connections, has consulted with health care organizations for more than 25 years, including in cultural
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competence. She takes the AHA’s definition of cultural competence one step further: “If we recognize cultural competency as a skill that supports the ability of care providers to achieve enhanced patient outcomes by not only respecting various differences in people but, perhaps more importantly, valuing those differences, then race, ethnicity, religion, sexual preference, and country of origin are all important to recognize and take into account when caring for patients,” Cure explains. “As a nurse, you are often the most trusted individual who is partnering with the patient. This requires you to value cultural differences. This valuing of others—knowing and appreciating what’s important to them— translates into everything you do in caring for the patient and their family.” “Cultural competence, at its core, is about embracing similarities as well as recognizing differences—whether they are based on race, gender, age, education, language, socioeconomics, sexual orientation, views on marriage, approaches to
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raising children, or anything else,” says certified nurse midwife Nola A. Holness, PhD, NP-C, CNM, a clinical assistant professor in undergraduate nursing at Florida International University Nicole Wertheim College of Nursing & Health Sciences. “Cultural competency means a willingness to respect and embrace such differences so we, as health professionals, can continue to deliver the highest quality of care to the patient while working within the cultural context of that individual, their family, and their community.” But cultural competence isn’t just about respect. It also can influence the care you provide. “Ultimately, cultural competency allows you to communicate more effectively, understand the decisionmaking process so you can create more effective medical treatments for your patients, and avoid medical errors that results from misunderstandings. In the end, you can create a better patient experience with improved safety and outcomes,” says Cure.
“Cultural competence, at its core, is about embracing similarities as well as recognizing differences—whether they are based on race, gender, age, education, language, socioeconomics, sexual orientation, views on marriage, approaches to raising children, or anything else,” says certified nurse midwife Nola A. Holness, PhD, NP-C, CNM, a clinical assistant professor in undergraduate nursing at Florida International University Nicole Wertheim College of Nursing & Health Sciences. Be Aware of Who You Are Before you can learn about your patients’ cultures, you must know who you are. This means understanding that everyone has their own culture, their own experiences, and even their own biases. “Cultural competency is also a two-way street. It’s a call to action for us as nurses to be self-aware and acknowledge how our own culture, our own beliefs, and even our stereotypes of others shape our outlook and the way we care for our patients,” says Latisha Barfield, ARNP, CNM, MSN, DNP, a certified nurse midwife and clinical assistant professor in undergraduate nursing at Florida International University. “This resonates now more than ever, given what is going on in our world today where everyone wants to be right and thinks their way of
doing things is right. Having a culturally competent mindset can help us transcend that.” Being culturally competent also means understanding that even if you’re a member of a minority group, that doesn’t mean that you automatically understand everyone in that group. “Cultural competency is rooted in the awareness of the differences among our patients, and between our patients and ourselves. As nurses, we need to examine ourselves and recognize our biases and other cultural characteristics that could possibly interfere with how we treat and develop therapeutic relationships with our patients, many of whom will not share our own background, experiences or customs,” says Holness. In addition, don’t generalize. For example, if an Asian patient acts in a certain way, don’t assume that all Asian people will. Besides being stereotyping and pigeonholing a patient, generalizing like this doesn’t take into consideration any patient’s personal upbringing and cultural experience. “There are dominant cultures, but there are sub-cultures within. We really need to understand that. Just because patients come from the same country, does not mean they share the same dominant culture, beliefs, or experiences,” Barfield points
Being culturally competent also means understanding that even if you’re a member of a minority group, that doesn’t mean that you automatically understand everyone in that group.
out. “Look at our own country and the differences from East Coast to Middle America to West Coast. The same holds true globally for other countries. We cannot generalize and should not generalize. We have ample opportunities to learn about other cultures and the variations within those cultures thanks to the internet and social media. It’s this desire to keep learning that can help us avoid the pitfalls of pigeonholing.”
Helping in Patients’ Care Having cultural competence can be crucial when caring for some patients. “Cultural sensitivity helps to break down barriers that may hinder patients from receiving the care they need. Nurses need to understand the impact cultural competence has on a patient’s health care outcomes,” stresses Jamil Norman, PhD, MSN, academic coordinator for Walden University’s RN-to-BSN program. She also makes sure to incorporate cultural competence into all of her teaching. “Interactions between nurses and patients can have either a positive or negative impact on the patient. Nurses should always strive to have a positive impact.” Barbara A. Anderson, DrPH, RN, CNM, FACNM, FAAN, professor emerita at Frontier Nursing University and editor of Best Practices in Midwifery: Using the Evidence to Implement Change, also works as a consultant for nursing education, public health, and nurse-midwifery. Having worked in 62 nations during her career, Anderson understands how difficult it can sometimes be to have a positive impact on a patient whose culture is quite different
from your own. This can even happen while you’re treating someone in your proverbial own backyard. For example, Anderson was treating a young Spanishspeaking patient in the United States for a severe, recurrent bladder infection. “As the teaching nurse, I was failing to convince him about the importance of handwashing to prevent infection—no matter how often I explained it in Spanish. He would take his pills, but he saw no need to wash his hands, saying the infections were caused by an evil spirit,” recalls Anderson. She explained to him that it wasn’t evil spirits causing the infection. But he wouldn’t listen. He then told Anderson that washing his hands wasn’t “macho.” “He would not budge—putting a protective, cultural barrier around his masculinity,” says Anderson. If she couldn’t get him to wash his hands, he wouldn’t get well and stay that way. Anderson realized that she hadn’t truly listened to her patient’s world view of what he believed caused his disease—evil spirits. “I was intrigued, trying to figure out how to convince him that these recurrent infections were connected to his poor handwashing techniques,” says Anderson. So she decided to approach the problem from his world view. Knowing that he was religious, she asked if he was baptized. He said he was and that baptism protected him against evil spirits. Since he was adamant that evil spirits caused his infection, she went along and said that they did, and she could show them to him on a machine.
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Anderson called the lab and asked them to put a culture specimen on a slide under one of the microscopes. She took the patient to the lab and showed him a “swirling mass of bacteria.” He was horrified. “These are the evil spirits that are hurting you. They live on your hands. What do you think we should do about this? Should we baptize your hands to destroy those bad spirits?,” she asked. “He got it and became a fiery advocate of hand washing, explaining contagion and describing what evil spirits
“The best way to obtain cultural knowledge is to interact with and learn from people of different cultures,” says Norman. looked like to his macho friends and his pastor (who agreed with my approach),” says Anderson. “Some people criticized me for this approach, saying this wasn’t appropriate. But that day, the patient and I crossed a deep chasm of cultural difference. I learned that one aspect of cross-cultural competency is seeing the world through a different lens.” While Anderson’s approach may have been controversial, she succeeded in making her patient well—and helping him to stay that way. “Nurses should embrace being culturally competent and committed to learning as much as they can so that they are properly equipped to deliver care to people who have historically received less than optimal care due to cultural differences,” says Talonda Rogers, MSN, RN,
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a nurse educator for the practical nursing program at the Chester County Intermediate Unit in Downingtown, Pennsylvania and owner of RISCQ by TALONDA Healthcare Consultants & Educators, LLC. “Lives literally depend on it. Not being culturally competent could lead to adverse health outcomes for patients. Even worse, not being culturally competent can lead to death.”
Learning Cultural Competence In Anderson’s case, she learned how to treat her patient based directly on his personal beliefs. But it’s important to learn about cultural competency overall before learning the distinctions held by various patients. “The best way to obtain cultural knowledge is to interact with and learn from people of different cultures,” says Norman. “Reading books about different cultures can help nurses understand various perspectives. Continuing education that focuses on cultural competence in patient care should be required for all nurses.” “Nurses can join nursing organizations and take part in conferences, webinars, and trainings that will help them become culturally competent,” adds Rogers. If you want the organization you work for to begin offering classes or workshops in cultural competence, Cure suggests that you “determine which populations are most prevalent in your community or hospital. It’s difficult to understand all cultural dynamics, so prioritize those closest to you as a starting place.” She also says that “Reading books, watching movies, or seeking out information
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about various cultures can be an important step as well.” Most importantly, ask your patients. “Asking questions such as ‘Are there any special requests you have based on your identified culture? What culture do you identify with? How can we make sure your stay here honors your cultural needs, traditions, and values?’” recommends Denise L. Caleb, EdD, PHR, SHRM-CP, executive vice president of partnerships and chief transformation officer of Talent Plus, Inc. “There are so many questions that lead to understanding and allow for superior service to be delivered. If I do not ask, then I make assumptions, which could be misaligned and run the risk of not creating service excellence.” Rogers says that nurses “should ask if there are any religious or cultural beliefs or rituals the nurse should be aware of in order to make their stay better.” “I recommend keeping questions broad to avoid assumptions,” says Cure. “Showing respect is of utmost importance, but also remember that nurses
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must balance culture with patient needs as well as legal and policy considerations.” “Don’t be afraid to share cultural similarities and differences so your patient learns about you, and you learn about them,” says Holness. “As nurse midwives, we tend to do that.”
“Don’t be afraid to share cultural similarities and differences so your patient learns about you, and you learn about them,” says Holness. “As nurse midwives, we tend to do that.” Making Mistakes Cure says that if you’re being culturally competent, you will get something wrong sometimes. If you do make some kind of mistake, apologize. “In most situations, an authentic, specific apology is the best advice,” Cure says. “Since many cultures are hierarchical, don’t be surprised if feedback does not come directly
to you, but instead goes to your supervisor. Be open to your mistakes and work to adjust your behavior in a culturally competent way.” “Say ‘I’m sorry,’ then explain your intention, listen to how they were made to feel, provide concern, and show care for the offense. Then say, ‘My apologies,’ hit the clear button, and move forward,” says Caleb. Know too that you will never stop learning how to be culturally competent. “As our society continues to change, so does our cultural competency levels. Culture, diversity, and inclusion work is a journey and that journey does not have a destination,” explains Caleb. Remember just to try. “If we never try, we fail automatically out of the gate.” Michele Wojciechowski is a national award-winning freelance writer based in Baltimore, Maryland. She loves writing about the nursing field but comes close to fainting when she actually sees blood. She’s also author of the humor book, Next Time I Move, They’ll Carry Me Out in a Box.
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HOW NURSING AND MIDWIFERY SCHOOLS ACROSS THE UNITED STATES HAVE ADAPTED DURING COVID-19 BY SUSAN SINCLAIR, RN, MSN
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The years a student is in nursing school are challenging and exciting—a span of time that builds the foundation for a student’s nursing practice. It is no surprise that these challenges have increased during COVID-19. As everyone knows, the pandemic has introduced a myriad of uncertainties and has forced nursing schools to change and adapt their requirements. This article will address ways nursing and midwifery schools throughout the U.S. have adapted, a current student’s experience, tips for students, and long-term projections for nursing education.
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linicals have always been a cornerstone to nursing education whether formally or informally. In the 1870s, nursing “clinicals” entailed direct patient care and learning on the job while being part of hospital staff. The student was primarily an employee and secondly a student. Nursing education has come a long way. However, at the height of COVID-19, hands-on direct patient care was not permissible. Therefore, creativity and more in-depth utilization of online learning and simulation occurred in nursing and midwifery schools alike. Perhaps never before in history did nursing simulation labs receive more attention and use. Deborah Zbegner, PhD, CRNP, is dean of the Passan School of Nursing at Wilkes University. In an interview she stated, “each clinical course at Wilkes has hands-on simulations that students must
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complete. All simulations are tested using Lasater’s clinical judgment rubric to measure program outcomes related to clinical judgment. In addition, the Creighton Instrument is used to evaluate the graded simulations and measures clinical competence.” In a March 2020 memo to the midwifery program directors, chair of the Accreditation Commission for Midwifery Education board for review, Gretchen Mettler, PhD, CNM, advised, “…the issue is clinical competence. Students need to demonstrate competence.” Like undergraduate and graduate nursing programs, midwifery programs are required to document how they meet their curriculum and program goals and objectives. During the COVID-19 pandemic, educators have had their work cut out for them. Fortunately, there are resources to aid educators in adapting to a simulation and
Midwifery Week Special Issue | OCTOBER 2020
online-focused education. One resource that assists in keeping track of various states’ changes to nursing curriculum requirements is the National Council of State Boards of Nursing. They have devoted a website that provides links to changes in each state. Another resource for educators is Wolters Kluwer’s “Transitioning to Online Learning in the Age of Social Distancing,” which provides many links, podcasts, blogs, and webinars such as transitioning to online learning, bulking up an educator’s simulation curricula, and tips for teaching. Springer Publishing Company also offers nursing educators a variety of resources for those making the switch to online teaching. There are several tips for students to help them succeed in learning online. Students must try to stay organized and acknowledge that this is a different learning landscape. Schools
However, at the height of COVID-19, handson direct patient care was not permissible. Therefore, creativity and more in-depth utilization of online learning and simulation occurred in nursing and midwifery schools alike. are utilizing web-based video conferencing to connect with peers and teachers; become familiar with the programs. According to Tonya Nicholson, DNP, CNM, WHNP-BC, CNE, associate dean of Midwifery and Women’s Health at Frontier Nursing University, “the most important thing: don’t go MIA. Reach out to faculty…and be forthright if something is going on.” Other adaptations nursing schools are undertaking are loosening assignment and project deadlines. “We have allowed two academic hiatuses [if needed] to allow students who have to work,” says Nicholson. “There is a fine line between leniency and asking for trouble, so in the end, all students must be safe to practice.” This has been a good strategy to enable working nurses to continue their education while working during the pandemic. What do these adaptations mean for nursing schools in the long term? It is difficult to say, but online learning may be here to stay, especially if the pandemic returns. It is possible entire cohorts may be suspended for a specific time period. The health care structure as a whole may be shifting, which may impact
nursing schools and the nursing workforce. Karen Cotter, PhD, RN, CNE, is associate dean for prelicensure programs at Louise Herrington School of Nursing at Baylor University. “As we look forward to Fall 2020, with so much uncertainty about the extent and impact of the pandemic, we have a lot of these tools [intensive virtual simulation] now in our arsenal, and will more easily launch them to meet the needs of our students,” she says. Cotter does not anticipate much difference in how students will prepare for NCLEX. According to Nicholson, Frontier University will keep providing its first midwifery clinical course online. She has noted that students have responded positively. “We cover history-taking and establishing rapport, then demonstrate the skills. Our students
have provided feedback that by the end of the clinical their confidence is improved.” As mentioned above, some changes in curricula made during COVID-19 may stick in the long term.
Other adaptations nursing schools are undertaking are loosening assignment and project deadlines. “We have allowed two academic hiatuses [if needed] to allow students who have to work,” says Nicholson.
How are Students Adapting to These Abrupt Changes in their Education? We interviewed Rachel (R.), a student who just completed her freshman year at Gwynedd Mercy University, a four-year university located in Gwynedd Valley, Pennsylvania. The interviewee’s name has been changed to protect her privacy. Like all colleges in the United States, your college campus closed for spring semester 2020 and summer courses are all online. What was it like for you when this closure was first announced in March? “In a way, I was watching other colleges shut down and myself and other students were confused. We didn’t know if school was going to continue. It was confusing and frustrating. Some teachers were prepared [with providing work to do], others were not.” Should nursing students care about not having clinicals? “Students should definitely be worried…now we will be relying more on textbooks.” How can students study differently now that there are no hands-on labs? “We can practice blood pressures on friends or family. There are simulation websites. It’s difficult because to be a nurse we need the hands-on.”
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Only time will tell if online learning and simulationintensive learning will be the permanent “normal.” Students have also adapted and changed their framework for education. Only time will tell if online learning and simulation-intensive learning will be the permanent “normal.” Students need more support than ever to overcome these challenges to graduate and be safe practitioners. Susan Sinclair, RN, MSN is a home health nurse. She is also a writer and has written for TheStayAtHomeNurse.com
It is indisputable that COVID-19 has changed the entire learning environment.
Nursing and midwifery schools have rose to the challenge and have adapted
to ensure students are gaining experiences as well as progressing through classes.
and DailyNurse.com.
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Act Two: How to Fast-Track Your Career Change BY JEBRA TURNER
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M
any people want to make a difference as a nurse but put off that dream; it’s never too late to enter nursing, especially for individuals who are able to accelerate their education. In an attempt to fill a shortage of minority nurses, many organizations are specifically targeting second-degree or second-career candidates, versus recent high school-entry baccalaureate students. Who might excel as a second-act nurse? Sometimes it’s a young veteran who served as a medic but now doesn’t qualify for civilian work without transitional assistance. Or it could be an IT executive who retired early and wants to make use of his technological savvy as an informatics nurse. Perhaps it’s a warehouse shipping clerk whose job has been shipped overseas and who wants to totally switch-up her career rather than going through another layoff. “As someone who has been in the profession for almost 40 years, I know it takes a special person with certain qualities to be a successful nurse,” says ANA President Ernest Grant, PHD, RN, FAAN. “One must possess the innate qualities of compassion, dedication, and human dignity; an interest in the arts, science, research, and technology; and one must be willing to be a life-long learner.”
When is Nursing Attractive as a Second-Act Career? As demographic analysts have been saying for decades: nursing is a guaranteed highgrowth field. It is one of the most popular professions for career changers, too, with high percentages of students over
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the age of 30 or male. The predominantly female profession is known to be more accepting to newcomers than other well-paying and high prestige occupations. The federal Bureau of Labor Statistics projects that nursing employment opportunities will grow at a 15% rate through 2026, which is faster than most other occupations. In addition, there are many options as to specialty, geographic location, and type of work environment. Opportunity abounds for patient care, entrepreneurship, management, and research. Add to that the potential for growth in salary, benefits, and advancement, and you have a clear winner.
Ernest Grant
As the profession grows more complex and raises its profile within the health care system, nursing schools aim to keep up. Students with prior education and skills can proceed at an accelerated pace to higher levels; post-graduation, they’re greatly sought after by employers. Why are they prized in the workplace? Often they are more mature and distinguish themselves with their academic coursework and strong
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Students with prior education and skills can proceed at an accelerated pace to higher levels; post-graduation, they’re greatly sought after by employers.
clinical skills. Excellent students quickly become highly qualified nurses, shining as analytical thinkers and strong patient advocates. Some health care employers seek to recruit these impressive graduates by partnering with nursing schools and offering tuition reimbursement as an incentive.
Accelerated Programs FastTrack Nursing Careers One of the most innovative segments of nursing education are accelerated degree
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programs for non-nursing graduates offered at both the baccalaureate and master’s degree levels, according to Vernell P. DeWitty, PhD, RN, director of diversity and inclusion for the American Association of Colleges of Nursing (AACN). These programs have also been gaining momentum in recent years. In 2019, there were 295 nursing schools with accelerated nursing programs at the bachelor’s level, enrolling 27,331 students, and graduating 14,977. In addition, they offered 65 accelerated masters programs, with 7,901 enrolled students and 3,254 graduates. These accelerated programs offer a quicker and less costly way for individuals from other disciplines to transition into nursing. Generally, an accelerated BSN can be completed in about a year, though many students continue on for another two years of graduate
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Vernell DeWitty
study to earn an MSN. An advanced degree makes sense for someone who already has a bachelor’s degree in another area and wants to ensure a higher return on their tuition investment. Some accelerated nursing programs have had a focus on increasing diversity within the profession by recruiting males and other minorities,
says DeWitty, such as the lapsed Robert Wood Johnson Foundation New Careers in Nursing Scholarship program offered in collaboration with AACN. “It was a strategic program using scholarships as the mechanism to recruit underrepresented students. The Robert Wood Johnson Foundation invested $35 million, schools would apply to AACN for grants, and each student could receive a scholarship for $10,000,” she explains. “Consequently, we were able to add 3,264 new nurses who came from diverse backgrounds over that seven and one-half year period.” Health care is a sector that continues to grow. After the COVID-19 pandemic, DeWitty forecasts that the public “will have a new appreciation for the contributions of nurses to the health
of this nation,” which may lead more workers in other fields to want to enter the profession. Ensuring diversity within the ranks of new nursing students will help fill the pipeline with nurses who are more in alignment with the population, improving communication and increasing trust between provider and patient. “Having a health care provider who looks like you is critical,” says DeWitty. “Reducing health disparities and health inequities, that’s critical. As we’ve seen during this pandemic, African Americans account for higher levels of COVID infection cases and deaths.” Additionally, underrepresented health care providers are more likely to return to their communities and address unique health care issues there. “One scholar attended University of Hawaii and then went back to the small island where she grew up and became a correctional nurse. That’s an example of a student who gives back to the community in a very tangible way,” she adds. Individual universities may offer their own accelerated nursing degree programs and those programs may serve to recruit underrepresented students. For instance, some nursing schools may tailor programs to help incoming
An advanced degree makes sense for someone who already has a bachelor’s degree in another area and wants to ensure a higher return on their tuition investment.
armed forces veterans who served as medics. They often have a lot of medical fieldwork under their belts, but not much formal coursework or familiarity with continuity of care for common civilian diseases. ANA’s Grant points to his alma mater, the University of North Carolina at Greensboro, which “offers an accelerated program for veterans who meet the qualifications … and they quickly transfer to the acceler-
profession, where the average age of working RNs currently is 50 and older, applicants are welcome. Americans whose jobs have been shifted offshore may be eligible for Trade Adjustment Assistance, a little-known government career retraining program. Workers may suspect they’ll require further training to recoup the salary that they once enjoyed, and so look to nursing as a good option.
ated BSN program.” At North Carolina Central University, though, there is a less formal program that waives some general education courses on an evaluation of their military transcript, he says. Another class of second-act nursing students that may take advantage of accelerated programs are retirees or mid-life career changers. The AARP says that there is a revolution in Americans changing careers after age 50—longer lifespans mean it’s never too late to start fresh. Within the nursing
Some colleges will give returning students credit for life and work experience, as well as previous college courses, which makes it easier for mid-life career-changers to earn a nursing degree, even if it isn’t part of an accelerated program. Many state university systems even allow retirement age residents to audit college classes on a space available basis at no charge. That’s a good way to brush up on prerequisites before applying to a nursing program. Some
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Americans whose jobs have been shifted offshore may be eligible for Trade Adjustment Assistance, a little-known gover nment career retraining program. states even extend that privilege to for-credit courses. For instance, Georgia allows resi-
dents aged 62 and over to take classes free, so an entire nursing education can be earned cost-effectively.
Second-Act Nurses Share Their Journey and Tips for Success Here are spotlight profiles of three resilient former Robert Wood Johnson Foundation New Careers in Nursing scholarship recipients who continue to progress and distinguish themselves in the profession. Gaea A. Daniel, PhD, RN, postdoctoral fellow at Emory
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University, is an example of a nurse who slowly made her move from a career in childcare and education to health care. She earned a bachelor’s degree in liberal studies and ran camps and afterschool programs for a decade during and after college. Then Daniel dipped a toe into wellness, training full-time as a massage therapist for a year, then practicing for three years in a chiropractic clinic. At that point, she was ready to take the next big step toward a career in a
entered nursing school in an entry-level accelerated master’s program, a 16-month program.” At the conclusion, Daniel received a Robert Wood Johnson Foundation Future of Nursing scholarship for an accelerated PhD program. She is now a postdoctoral fellow, transitioning to a tenure-track faculty position. Her scientific research supports minority communities in improving health outcomes. Daniel doesn’t regret the
She encourages prospective minority nurses to value their own life experience, even if it seems far afield of nursing. “From a waitress who has to anticipate the needs of their customer or an infant daycare worker who has to care for babies who cannot verbalize their needs...there is an abundance of diverse skills that translate to favorable outcomes as a second-career nurse,” she says. “I’ve realized that it’s the best career decision I could have ever made.
health care profession—but which one? “I thought I was interested in physical therapy but at a house party someone suggested nursing,” she says. “I started exploring it and it hit me like a ton of bricks. I
long, circuitous path she took to get to her career destination. She believes previous formal education work and work experience is a plus, and helped her to get accepted to nursing school and to win academic scholarships.
After the COVID-19 pandemic, DeWitty forecasts that the public “will have a new appreciation for the contributions of nurses to the health of this nation,” which may lead more workers in other fields to want to enter the profession.
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You can literally do anything in nursing, no matter your interest!” Another piece of advice that Daniel would like to pass on is for students to proactively pursue funding. “Opportunities exist specifically for minority nursing students through national nursing organizations like the National Black Nurses Association,” she says. “The local chapters of these national organizations like the one I’m a member of, the Atlanta Black Nurses
Gaea A. Daniel
Association, also provide mentorship and scholarship opportunities, community engagement, and a strong support system.” Other sources of financial support include nursing scholarships for minorities through Health Resources & Services Administration (HRSA) and for graduates, the Nurse Corps Loan Repayment Program, also funded through HRSA. Onome Henry Osokpo, MSc, MSN, RN, a PhD candidate at the University of Pennsylvania School of Nursing, is someone who followed his heart into nursing from a head-centered career as a chemist. Osokpo earned a bachelor’s in chemistry education, a master’s in analytical chemistry, and worked as a chemist for three years before embarking on a PhD in the field. To defray educational costs, he worked part time at the United Cerebral Palsy of Greater Suffolk helping clients develop independent living skills. “It was like my world changed,” he says. “I was there for a year when one the directors called me in and asked ‘Have you ever thought about a career in health care?’ Then
someone else said, ‘You should be a nurse—you’re wired to be a nurse.’” He started to think that maybe chemistry and scientific research wasn’t the right path for him after all. “I’m an extrovert, playful, and I like to laugh at work. In the lab my manager always said, ‘We have to be serious,’” he explains. “On my other job, they [clients] were non-verbal but it gave me joy, fulfillment, and excitement.” He took his solid background in the sciences—biology, chemistry, and math—and applied it to a nursing career. “I chose Stonybrook School of Nursing because of the program and name. Choosing an expensive school may be a good investment in certain instances. I would not encourage someone to pay that too much for just any school, though,” he says. Three semesters totaled about $15,000 in state tuition for a 12-month accelerated BSN. “The $10,000 scholarship was huge,” he says. “During the semester I studied fulltime and during the breaks I worked a lot of hours” at United Cerebral Palsy. Osokpo says that in addition to the scholarship, work, and loans, he received support from his family and community. “After school I was making over $70,000 a year [as a bedside nurse] so it was a good investment,” he says. The next leg of his journey is the PhD program at University of Pennsylvania School of Nursing in 2017. “I’m a presenter for the PCA—I deliver evidence-based programs for senior centers. I’m an adjunct clinical instructor at Penn, and also work PRN as a nurse during breaks,” he says. “My
research goal is to develop selfcare interventions that would help foreign-born blacks with chronic illness.”
Zegers cautions that minority nursing students may “experience isolation or limited diversity in their classes,” but they should stay the course regardless. Osokpo has these two major pieces of advice for second-act nursing students: • “Keep your eye on the goal. Most accelerated programs have highly motivated students, which creates an environment for drama. I refused to get drawn into those situations. Someone overly sensitive won’t do well in school there. You have to be thick-skinned and stay focused,” he says. • Reach out to your community. “After I graduated, someone from Ghana reached out to me through the school,” he remembers. “I met with that individual and all I did was share strategy. ‘How do you study?,’ I asked. He was almost failing but the issue wasn’t his cognitive ability—he just needed help to strategize differently.” Carli Zegers, PhD, APRN-NP, FNP-BC, is a second-degree (but not second-career) nurse who decided to pivot into nursing before her first choice of profession was even launched. “I have an exercise science [bachelor’s] degree,” she says, “Not a lot of options so went back to school.” She
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sped through an accelerated program with flying colors, which culminated in both a PhD in nursing and Family Nurse Practitioner degrees at the University of Nebraska Medical Center. Now Zegers is an assistant professor at the University of Missouri-Kansas City School of Nursing and Health Studies and a nurse practitioner in the Emergency Department at Truman Medical Center. “I used my first degree and work experience to obtain my first job and quickly transition into a supportive team member,” she explains. “One of the hardest parts of nursing is ‘making it real’ when studying and I believe second-degree nurses are well equipped to make that transition.” Her previous degree also gave her the study skills and work ethic to put in 40-hour weeks, including early mornings and late nights. “It is important to know that nursing is a tough profession at times and interpersonal skills are incredibly important,” she explains. “Nursing is also a very thankless profession meaning that nursing requires a lot of both physical, mental, and psychosocial work.”
Onome Henry Osokpo
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Carli Zegers
One of the issues that Zegers has focused on is developing a pipeline program for high school students from underrepresented and underserved backgrounds who seek a career in health care. Zegers cautions that minority nursing students may “experience isolation or limited diversity in their classes,” but they should stay the course regardless. “Minority nurses are in an exceptional position to also bring their bicultural and possibly bilingual experience to nursing. I was able to connect with my patients more closely than many of my other nursing school peers,” she says. Nurses can take a proactive stance for diversity by joining professional associations and networks. “I really have enjoyed participating with the National Association of Hispanic Nurses; I have a true sense of familia. I often feel alone and tapping into the resources built by amazing nurse leaders is incredibly important, starting as early as nursing school.” As a professor, Zegers serves as an inspirational role model—signaling that the profession values ethnic diversity
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and offers a career ladder for nurse leaders. Statistics indicate that only 15% of full-time faculty are from underrepresented groups, according to the AACN. “Nursing needs seconddegree nurses who are diverse,” she says. Nurses who have studied other disciplines and worked in far-flung fields are prime candidates for the next generation of nurse leadership. These second act nurses show how it’s possible to fasttrack a nursing education and still perform spectacularly. States, hospitals, and universities are offering scholarships, reimbursement, accelerated courses, or otherwise making it easier to enter the profession. Truly, it’s never too late to become a nurse. Jebra Turner is a freelance writer located in Portland, Oregon. Visit her at www.jebra.com.
Midwifery Week Special Issue | OCTOBER 2020
Full-Time, Non-Tenure Track, Faculty Position in Nurse-Midwifery Program at Vanderbilt University School of Nursing. Rank and salary commensurate with experience. Vanderbilt University has a strong institutional commitment to recruiting and retaining an academically and culturally diverse community of faculty. Minorities, women, individuals with disabilities, and members of other underrepresented groups, in particular, are encouraged to apply. Vanderbilt is an Equal Opportunity/ Affirmative Action employer. Qualifications: Doctorate in nursing or related field Three years high-quality formal teaching experience in an advanced practice program Substantive advanced practice clinical experience with five years preferred CNM national board certification Unencumbered license as a registered nurse and advanced practice nurse in Tennessee or eligibility to obtain licensure in Tennessee Stated commitment to working with diverse populations
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