The Career and Education Resource for the Minority Nursing Professional • WINTER 2018
Friendships Between Nurses
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Culturally Competent LGBTQ Care
DOULAS IMPROVING BIRTH OUTCOMES NURSING WITH DIABETES
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Table of Contents
In This Issue
Cover Story
3
Editor’s Notebook
5
Vital Signs
9
Making Rounds
Friendships Between Nurses Can Reduce Stress
40
The Funny Bone
By Michele Wojciechowski
10 With a Little Help from Your Friends: How
Find out why sharing a laugh (or cry) with likeminded colleagues
Academic Forum 30 Continuous Glucose Monitoring Systems Reducing Hypoglycemia and Improving Patient Health Outcomes By Srinidhi Lakhanigam, BSN, RN, CCRN, CMSRN Discover how CGM systems can help improve quality of life for diabetic patients
can benefit your mental health
Features 16 Doulas Seeking to Impact Mortality and Morbidity Rates
By James Z. Daniels, MPA, MSc, and Janice Bonham West, MEd
Second Opinion
Learn more about the correlation between doula support and positive birth outcomes for minority women
32 Suboxone: The Wonder Drug? By Spencer Miller, RN
Can this drug help fight the opioid epidemic?
20 Nursing with Diabetes: Tips for Coping on the Unit
By Lynda Lampert, RN 34 Medical Cannabis Use in the Hospital Setting
Learn how to navigate the challenge of balancing diabetes and
By Nikki Denson, PhD(c), MSN, ACAG-NP
providing excellent patient care
A nurse argues that allowing cannabis in the hospital could cut down on overall opioid use
24 It Takes a Village: Nurses Work to Provide Culturally Competent LGBTQ Care
Health Policy 38 Ensuring Equitable Access to Safe and Clean Water Through Advocacy and Legislative Action
By Janice M. Phillips, PhD, FAAN, RN
A Q&A with the executive director of the Alliance of Nurses for Healthy Environments
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By Linda Childers Help spread awareness about LGBTQ health disparities to create a more inclusive health care environment
Editor’s Notebook:
CORPORATE HEADQUARTERS/ EDITORIAL OFFICE
We Are in This Together
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his year has been stressful for many of us for a variety of reasons, and it’s perfectly acceptable to need a little help every now and then. As the Beatles suggest, we all get by with a little help from our friends—whether they come in the form of a colleague helping you get through a rough day at work, a doula supporting your pregnancy, an educator sharing nutrition advice with you, or a medical professional giving you culturally competent care. As nurses, you may need just a little more help than others to get you through a rough patch—and who better to help you than your fellow nurses in the trenches who know exactly what it’s like to be in your shoes? In this issue’s cover story, Michele Wojciechowski investigates why friendships in the workplace can help you alleviate stress and provide better care (page 10). For those expecting, a doula may be the answer to a more positive birth outcome in the United States. James Daniels and Janice Bonham West examine the benefits of doulas for pregnant women who are low-income, socially disadvantaged, or who experience cultural language barriers (page 16). Are you struggling with diabetes? Consider connecting with a certified diabetes educator. Lynda Lampert offers tips from educators and diabetic nurses alike to help you navigate the challenge of balancing your health and providing quality care to your patients (page 20). Providing the best care possible for your patients starts with acknowledging—and respecting—their identities. Linda Childers interviews LGBTQ advocates to help you do your part in increasing awareness and providing culturally competent care to this community (page 24). Sometimes, help comes in the form of technology or science. Srinidhi Lakhanigam argues that continuous glucose monitoring systems can increase the quality of life for diabetics (page 30); Spencer Miller tells you why addicts should be using Suboxone (page 32); Nikki Denson makes the case for legalizing marijuana to allow continuity of care for patients (page 34); and Janice Phillips interviews the executive director of the Alliance of Nurses for Healthy Environments about the necessity of clean water (page 38). The next time you find yourself annoyed by a difficult patient or a family member being short with you, consider being that “little help” and respond with kindness. The world needs more of that in 2019. —Megan Larkin
Minority Nurse (ISSN: 1076-7223) is published four times per year by Springer Publishing Company, LLC, New York. Articles and columns published in Minority Nurse represent the viewpoints of the authors and not necessarily those of the editorial staff. The publisher is not responsible for unsolicited manuscripts or other materials. This publication is designed to provide accurate information in regard to its subject matter. It is distributed with the understanding that the publisher is not engaged in rendering legal or other professional services. If legal advice or other expert assistance is required, the services of a competent professional person should be sought. The publisher does not control and is not responsible for the content of advertising material in this publication, nor for the recruitment or employment practices of the employers placing advertisements herein. Throughout this issue we use trademarked names. Instead of using a trademark symbol with each occurrence, we state that we are using the names in an editorial fashion to the benefit of the trademark owner, with no intention of infringement of the trademark.
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1 IN 3 ADULTS HAS PREDIABETES. COULD BE YOU, YOUR BARBER, YOUR BARBER’S BARBER.
WITH EARLY DIAGNOSIS, PREDIABETES CAN BE REVERSED. TAKE THE RISK TEST. DoIHavePrediabetes.org
Vital Signs
New Nurses with Bachelor’s Degrees Feel Increasingly Better Prepared Than Nurses with Associate Degrees
Nurses with bachelor’s degrees report being very prepared in more quality and safety measures than do their peers with associate degrees, finds a new study by researchers at NYU Rory Meyers College of Nursing.
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he findings, published in the Joint Commission Journal on Quality and Patient Safety, demonstrate a growing gap in preparedness between new nurses with associate and bachelor’s degrees and support ongoing efforts to increase educational attainment among new nurses. In 2010, the Institute of Medicine (now the National Academies of Sciences, Engineering, and Medicine) published “The Future of Nursing: Leading Change, Advancing Health.” The milestone report provided recommendations for how nurses can best advance the nation’s health and meet the increased demand for care. The report calls for an increase in the proportion of nurses with bachelor’s degrees to 80% by 2020—a recommendation supported by studies showing that
nurses with bachelor’s degrees have better patient outcomes, including lower mortality rates. “The evidence linking better outcomes to a higher percentage of baccalaureate-prepared nurses has been growing. However, our data reveal a potential underlying mechanism—the quality and safety education gap—which might be influencing the relationship between more education and better care,” says Maja Djukic, PhD, RN, associate professor at NYU Meyers and the study’s lead author. “Understanding the mechanisms influencing the association between educational level of nurses and patient outcomes is important because it provides an opportunity to intervene through changes in accreditation, licensing, and curriculum.”
A nursing workforce that is well-prepared in quality and safety competencies is critical for delivering high-quality and safe patient care. However, a previous study led by NYU Meyers’ Christine Kovner, PhD, RN, FAAN, identified gaps in quality and safety education between associate- and baccalaureate-prepared nurses who graduated between 2004 and 2005. In their new study, the researchers—Djukic, Kovner, and NYU Meyers’ Amy Witkoski Stimpfel, PhD, RN—examined quality and safety preparedness in two additional cohorts of new nurses who graduated with either associate or bachelor’s degrees in 2007-2008 and 20142015. They surveyed more than a thousand new nurses (324 graduating 2007-2008 and 803 graduating 2014-2015) from 13 states and the District of Columbia, asking how prepared they felt about different quality improvement and safety topics. They then analyzed the differences in responses between nurses with associate and bachelor’s degrees. The researchers found significant improvements across key quality and safety competencies for new nurses from 2007 to 2015, but the number of preparedness gaps between bachelor’s and associate degree nurse graduates more than doubled during this timeframe. In the 2007-2008 cohort, nurses with bachelor’s degrees reported being significantly better prepared than nurses with associate degrees in five of 16 topics: evidence-based practice, data analysis, use of quality im-
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provement data analysis and project monitoring tools, measuring resulting changes from implemented improvements, and repeating four quality improvement steps until the desired outcome is achieved. For those graduating in 20142015, nurses with bachelor’s degrees reported being significantly better prepared than associate degree nurses in 12 of 16 topics: the same five topics as the earlier cohort as well as data collection, flowcharting, project implementation, measuring current performance, assessing gaps in current practice, applying tools and methods to improve performance, and monitoring sustainability of changes. The researchers note that laws and organizational policies encouraging or requiring bachelor’s degrees for all nurses could close quality and safety education gaps. For example, New York State recently passed a law—the first in the country— requiring future new nurses to obtain their bachelor’s degree within 10 years of initial licensure. Employers can also effect change by preferentially hiring nurses with bachelor’s degrees, requiring a percentage of the nurse workforce to have a bachelor’s degree, or requiring nurses with associate degrees to obtain a bachelor’s within a certain timeframe as a condition of keeping their employment. The study was funded in part by the Robert Wood Johnson Foundation and the National Council of State Boards of Nursing Center for Regulatory Excellence.
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Vital Signs
Flu Vaccine Reduces Risk of Flu Hospitalization Among Pregnant Women Over the course of six flu seasons, getting a flu shot reduced a pregnant woman’s risk of being hospitalized from flu by an average of 40%.
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he findings come from a multi-country, CDCcoauthored study published in Clinical Infectious Diseases. This is the first study to show vaccination protected pregnant women against flu-associated hospitalization. Previous studies have shown that a flu shot can reduce a pregnant woman’s risk of flu illness. CDC recommends pregnant women get a flu shot because they are at high risk of developing serious flu illness, including illness resulting in hospitalization. “Expecting mothers face a number of threats to their health and the health of their baby during pregnancy, and
getting the flu is one of them,” explains Allison Naleway, PhD, a study coauthor from the Kaiser Permanente Center for Health Research. “This study’s findings underscore the fact that there is a simple, yet impactful way to reduce the possibility of complications from flu during pregnancy: get a flu shot.”
Flu Study Analyzed Data From Over 2 Million Pregnant Women For this study, CDC partnered with a number of other public health agencies and health care systems in Australia, Canada, Israel, and the United States through the Pregnancy Influenza Vaccine Effectiveness Network (PREVENT),
which consists of health care systems with integrated laboratory, medical, and vaccination records. Sites retrospectively examined medical records of more than two million women who were pregnant from 2010 through 2016 to identify those who were hospitalized with laboratory-confirmed flu. Key findings include: • More than 80% of pregnancies overlapped with flu season, underscoring the likelihood that pregnant women will be exposed to flu at some point during their pregnancy. • Flu vaccine was equally protective for pregnant women with underlying medical problems such as asthma and diabetes, which also increase the risk of serious medical complications including a worsening of those chronic conditions. • Flu vaccine was equally protective for women during all three trimesters.
mild to severe, but it presents a heightened risk for pregnant women who undergo changes to their immune system, heart, and lungs. These changes make them more prone to severe illness from flu throughout their pregnancy and for two weeks after pregnancy. These findings underscore the importance of ongoing efforts by CDC and other public health agencies and partners to promote influenza vaccination during pregnancy. During recent seasons in the United States, only about half of pregnant women report getting a flu shot (pregnant women should not get the nasal spray vaccine.) “Our study found that flu vaccination worked equally well for women in any trimester and even reduced the risk of being sick with influenza during delivery,” adds Mark Thompson, PhD, a study coauthor and epidemiologist with CDC’s Influenza Division.
Flu During Pregnancy
Benefits of Flu Vaccine for Pregnant Women and Their Babies
Flu illness can range from
Other studies have shown that in addition to helping to protect the pregnant woman, a flu vaccine given during pregnancy helps protect the baby from flu infection for several months after birth, before he or she is old enough to be vaccinated themselves. Flu shots have been given to millions of pregnant women over many years with a good safety record. CDC and ACIP recommend that pregnant women get vaccinated during any trimester of their pregnancy. Learn more about flu vaccination in pregnant women at www.cdc.gov/flu/protect/ vaccine/pregnant.htm.
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Vital Signs
New Statistical Method Estimates Time to Metastasis of Breast Cancer in U.S. Women A statistical method could fill the gaps in the U.S. cancer registry data to estimate the short- and long-term risk of recurrence of hormone receptor (HR)-positive and HRnegative breast cancers, according to results published in Cancer Epidemiology, Biomarkers & Prevention, a journal of the American Association for Cancer Research.
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he study found that while women diagnosed with HR-positive breast cancer have lower risk of progression to metastatic disease soon after the diagnosis, their risk persists for several years. In contrast, for women diagnosed with HRnegative disease, the risk of progression to metastatic disease is high soon after the diagnosis, but the long-term risk is lower than that for HR-positive disease. “Progression to metastatic breast cancer is probably the most important concern women have when they are diagnosed with early-stage breast cancer,” says Angela Mariotto, PhD, chief of
Data Analytics Branch at the National Cancer Institute. “Knowing the risks of progressing to metastatic breast cancer is important for patients making decisions about their treatment as well as for cancer control experts identifying research priorities and health services planning.” Currently, there are no reliable data on the risk of metastatic breast cancer recurrence after a non-metastatic breast cancer diagnosis, because registries do not routinely collect information on cancer progression or recurrence, Mariotto explains. To estimate the risk of recurrence, Mariotto and colleagues
used data from a cohort of 381,430 women, ages 15-84, diagnosed with breast cancer from 1992-2013, from the Surveillance, Epidemiology, and End Results Program (SEER) database. The researchers applied a statistical technique called the “mixture-cure model” to the survival data to identify the “cure” fraction (fraction of women whose cancer did not progress). Then, they used two pieces of information that are available in the SEER database and published studies to estimate the time to metastasis for women in the “non-cured” fraction (fraction of women whose cancer progressed). “For the mathematically minded, if we know that A=B+C, and if we know C and A, then we can estimate B,” explains Mariotto. “A is the time from diagnosis to death, B is the time from diagnosis to metastasis, and C is the time from metastasis to death. We estimated B using published studies on cohorts of patients diagnosed with recurrent metastatic breast cancer (A and C).” “We were surprised by the insights the estimates provided into how the risk of recurrence for women diagnosed with early breast cancer in the United States varies with stage, HR status, age, year of diagnosis, and time since diagnosis,” Mariotto says. “We found that the risks of progressing to metastasis were lower for women diagnosed with breast cancer more recently, at younger ages, at early stage, and with HRpositive disease.” Mariotto added that for women who survived five or more years after diagnosis, their chances of progressing to metastatic breast cancer within the next five
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years were lower if they were diagnosed with HR-negative breast cancer compared with women diagnosed with similar stage but with HR-positive breast cancer. For example, among women diagnosed with stage 3 breast cancer at ages 60-74, the percent progressing to metastasis within five years from diagnosis is lower (34.5%) if their breast cancer is HR-positive and higher (48.5%) if their breast cancer is HR-negative. However, if they are still metastasis-free five years from diagnosis, the percent progressing to metastasis within the next five years is higher for HR-positive breast cancer (16.8%) versus HRnegative breast cancer (6.4%). “These are the first populationbased estimates on the probabilities of progressing to metastatic disease for women diagnosed with early-stage breast cancer in the United States,” Mariotto notes. “The approach is applicable to other cancers and can improve our understanding of the burden of cancer in the population.” A limitation of the study is that the recurrence risk measures the researchers developed were calculated by removing the chances of dying of other causes. “While these types of measures are useful for comparisons across groups of patients and for isolating the effect of a cancer diagnosis on survival, they may be less useful in predicting chances of recurrence at the individual level, especially for patients with comorbidities,” Mariotto says. Further, they did not have data on HER2 status at diagnosis for the entire duration of the study, so the estimates were not stratified by this factor.
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Making Rounds
February/March
April/May
July
February 27–March 1
April 27–May 2
16–19
33rd Annual Convention Rosen Centre Hotel Orlando, Florida Info: 800-454-4362 E-mail: info@snrs.org Website: http://www.snrs.org
2019 Cruise Conference Carnival Cruise Line New Orleans, Louisiana to Cozumel, Mexico Info: 844-267-7665 Website: https://bnrcruise.com
44th Annual Conference Peppermill Resort Hotel Reno, Nevada Info: 919-573-5443 E-mail: info@thehispanicnurses.org Website: http://nahnnet.org
Southern Nursing Research Society
February 27–March 2
Dermatology Nurses’ Association 37th Annual Convention Marriott Wardman Park Washington, District of Columbia Info: 800-454-4362 E-mail: dna@dnanurse.org Website: www.dnanurse.org
March 6–9
National Association of Clinical Nurse Specialists 2019 Annual Conference Renaissance Orlando Orlando, Florida Info: 215-320-3881 E-mail: info@nacns.org Website: http://nacns.org
April 3–7
National Student Nurses’ Association 67th Annual Convention Salt Palace Convention Center Salt Lake City, Utah Info: 718-210-0705 E-mail: nsna@nsna.org Website: www.nsna.org
11–13
American Nursing Informatics Association
Black Nurses Rock
National Association of Hispanic Nurses
23–28
May/June
National Black Nurses Association
May 29–June 1
Academy of Neonatal Nursing 2019 Spring Advanced Practice Neonatal Nurses Conference Hyatt Regency Indian Wells Greater Palm Springs, California Info: 707-795-2168 E-mail: conferenceinfo@academyonline.org Website: www.academyonline.org
June 6–12
Association of Women’s Health, Obstetric and Neonatal Nurses 2019 Annual Convention Georgia World Congress Center Atlanta, Georgia Info: 800-673-8499 E-mail: customerservice@awhonn.org Website: www.awhonn.org
18–23
American Association of Nurse Practitioners
47th Annual Institute and Conference Hilton New Orleans Riverside New Orleans, Louisiana Info: 301-589-3200 E-mail: info@nbna.org Website: www.nbna.org
24–28
Philippine Nurses Association of America 2019 National Convention Atlanta Marriott Marquis Atlanta, Georgia E-mail: infomypnaa@gmail.com Website: www.mypnaa.org
August 7–9
Doctors of Nursing Practice 2019 National Conference Fairmont Washington, D.C., Georgetown Washington, District of Columbia Info: 888-651-9160 E-mail: info@doctorsofnursingpractice.org Website: www.doctorsofnursingpractice.org
2019 National Conference Indiana Convention Center Indianapolis, Indiana Info: 512-442-4262 E-mail: conference@aanp.org Website: www.aanp.org
2019 Annual Conference Rio All Suite Hotel Las Vegas, Nevada Info: 866-552-6404 E-mail: ania@ajj.com Website: www.ania.org www.minoritynurse.com
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With a Little Help from Your Friends How Friendships Between Nurses Can Reduce Stress BY MICHELE WOJCIECHOWSKI
Nurses have intense experiences that most other health care workers don’t. As a result, they tend to have a great deal of stress. Having friendships with other nurses tends to alleviate it and help in more ways than you might imagine.
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O
nly nurses understand what other nurses truly go through, says nurse practitioner, former attorney, author, and career/ lifestyle blogger Meika Mirabelli, JD, MSN, FNP-C, founder of BeautyinaWhiteCoat.com, which helps both health care students and professionals live balanced, successful lives
cohesion among friends had a positive impact on the level of job stress experienced by nurses.” The study concluded overall that the “strength and density of such friendship networks were related to job stress. Life information support from their friendship network was the primary positive contributor to control of job stress.”
The difficult work, both physical and mental, is why having friendships is necessary. It’s also great to have others who completely understand you. through sharing career and studying tips. Mirabelli knows firsthand how having friendships with other nurses can make a huge difference in the workplace—and how not having them can hurt. “I have experienced horrible treatment by nurses who were in the field of nursing longer than I have been. During those times, I would have to lock myself in the bathroom to hide and cry. I would count the days until I was done with that job and celebrated when I turned in my resignation,” Mirabelli recalls. But the good has outweighed the bad. “I have also worked with great nurses with whom I still have a bond today. My experience with those wonderful nurses definitely reduced stress and made me a better nurse and a better person. I have thoroughly enjoyed my shifts when I have coworkers that I could call my friends. I also was able to sleep better at night and looked forward to going to work.” Research has shown that friendships between nurses can reduce stressful situations. A 2016 study published in PLOS ONE found that the “degree of
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While it’s important to understand what research has discovered, it’s just as—if not more—crucial for nurses to know how this can help them in real-life situations.
Why Friendships Help “There will always be bonds and friendships forged when you work with people in close proximity for long periods of time,” says James LaVelle Dickens, DNP, RN, FNP-BC, FAANP, who serves in the U.S. Department of Health and Human Services regional office in Dallas, Texas, as the senior program manager officer for the Office of Minority Health. “Having strong friendships at work is known to reduce stress. A study by Gallup found that people with a best friend at work are seven times more likely to be engaged with their job.” “I can think of many times when friendships with other Nurse Practitioners (NPs) have made a difference in my life,” says Dickens. “Sometimes, it’s having someone lift our own spirits after we’ve delivered a difficult diagnosis to a patient. Sometimes, it’s offering a younger colleague with coach-
ing to help them be the best professional they can be.” “Nobody really understands what a nurse does like a nurse, so those relationships provide support, and that support helps bring stress down,” says Benjamin Evans, DD, DNP, RN, APN, PHMCNS-BC, president of the New Jersey State Nurses Association. Evans explains that what makes nurses so different from other health care professions is that they are with patients more than anyone else. Other health care professionals may come and do a test, treatment, or procedure on a patient, but then they leave. The nurses are the ones who stay behind and help the patients cope with their stress, pain, or fear resulting from these processes or their conditions. But this is just one example of why nurses have so much stress. Dickens says that other reasons are heavy caseloads, interactions with patients and their family members who may not recognize the significant challenges of their complex health conditions, and dealing with death. “Oftentimes, the families are more demanding than the patients,” says Evans. “Every decision a nurse makes affects the health status of their patients,” says Judith Schmidt, RN, MSN, ONC,
mean a patient’s life. You have the life-and-death situations with the patients, their families, and the administration.” “Nurses have the type of job that requires a lot of mental clarity, physical demands, and empathy towards patients and their families,” says Flo Leighton, MS, RN, PMHNP-BC, a board-certified psychiatric nurse practitioner in private practice at Union Square Practice as well as an adjunct faculty member at New York University Rory Meyers College of Nursing. The difficult work, both physical and mental, is why having friendships is necessary. It’s also great to have others who completely understand you.
Friends “Get” You Erin Parisi, LMHC, CAP, owner of Erin C. Parisi Counseling & Consulting, LLC, learned about nursing friendships while working as a therapist in a residential treatment setting alongside nurses every day. “My biggest takeaway has been that having friends who are ‘in the trenches’ with you helps manage stress. In nursing, not only are you coping with the system you work in, with a boss/manager you may or may not like, and office politics, but you also have a really specialized knowledge that not everyone has,” says Parisi. “In a system where not
“Sharing a laugh in the midst of a stressful day lowers your blood pressure and helps put everything in perspective,” says Dickens. CCRN, CEO of the New Jersey States Nurses Association. “The public doesn’t realize how stressful these areas can be. If a nurse makes a mistake, it can
everyone you work with is in the same role, you might end up feeling a little more alone in your job. Non-nurses who don’t have the same or similar
training may not understand your jokes or fully wrap their heads around your stressors. “A lot of nurses have a dark sense of humor, which not everyone has an appreciation for. Not only is the friendship of a fellow nurse providing stress relief, but being able to make dark/weird/gross jokes to someone else who will understand and also think it’s funny can reduce stress in a big way,” explains Parisi. “Sharing a laugh in the midst of a stressful day lowers your blood pressure and helps put everything in perspective,” says Dickens. Having someone else who understands what makes nurses tick and what makes the profession unlike any other serves as the backbone of these types of relationships, he adds. “Having that support network and camaraderie does an NP’s mental health a ton of good.” Shanna Shafer, RN, BSN, nursing expert, managing edi-
tor, and strategic communications manager at BestNursingDegree.com has spent ten years in the nursing field working in everything from home health,
one else in a nurse’s group outside work—non-nurse friends, family, spouses, and significant others—can provide support, they simply can’t connect with
“Nobody really understands what a nurse does like a nurse, so those relationships provide support, and that support helps bring stress down,” says Benjamin Evans, DD, DNP, RN, APM, PHMCNS-BC, president of the New Jersey State Nurses Association. hospice, a community health center to vascular access, and in a burn intensive care unit. At the burn unit she says, “Friendships with other nurses blossomed and were essential to my own survival and mental health.” The bonds that nurses develop in various situations are amazing, she adds. Parisi adds that nurses witness and work on a daily basis with experiences that most people do not. While every-
nurses like other nurses or coworkers can. “Given the fact that nurses spend so much time at work—sometimes even more time than at home with loved ones—having friends at work can help make a shift more enjoyable. Nurses who work with you know what the day-to-day struggle looks like on any given shift,” explains Leighton. “The ability to get perspective from a work friend who understands
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how to handle on-the-job situations builds resilience and normalizes stressful situations. It makes us feel like we’re understood and not alone in the tasks that challenge us.” Having someone who “gets” you, can reduce stress and make you feel better in various workplace situations. “Research has shown that social health is an importance factor in stress management. Therefore, friendships among nurses could influence rewarding benefits in processing work-related stressors,” says Amy Moreira, LMHC, owner of More MH Counseling, LLC. “The nursing field is a challenging, demanding, and rewarding job with its own characteristics that are, at times, not fully understood by the general public…A nurse who finds friendship with other nurses can benefit from their shared direct experience, allowing themselves to feel better heard and understood—which
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to higher levels of job satisfaction, engagement in work and performance, as well as overall team cohesion,” says Dickens. “I wholeheartedly believe that a support system at work and in our personal lives is key.” Nurses who have friends in their workplace can also assist each other during stressful situations by giving each other someone to vent to. “It can put that nurse who is stressed in a better frame of mind. It almost permeates an entire unit if one nurse is stressed and could cause others to become stressed,” he says. Dickens adds that if a nurse is stressed, patients can sense it in the nurse’s voice and body language. But the opposite is is an important part of healing in stress management. Potential solutions can be offered from a different perspective with a more solution-focused outcome than advice from other friends and family. Workplace friendships among nurses allows for in-the-moment support and allows for open processing without the need to explain certain contextual aspects.”
Nurses Eat Their Young There’s the old adage that “Nurses eat their young.” Some more experienced nurses have
When nurses are friends, they aren’t just nice to each other, but they look out for each other. been known to let the young ones flounder. Nurse.org, though, has a new campaign to dispel this adage called “Nurses support their young.” The campaign is significant because
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when nurses are friends, the stress of the entire unit, floor, or facility can decrease. “It’s important for nurses to friend new nurses to allow for effective learning and adjustment on the team, including the patient,” explains Moreira. “Establishing friendships and aiding newer nurses can contribute to a more positive workplace environment and job satisfaction. Friendships between nurses can allow for a more experienced nurse to take on a ‘coaching’ role that enables stress-free learning with laughter, support, and understanding. Working past any frustrations associated with newer nurses lacking knowledge can often be processed when reflecting upon past mishaps in the experienced nurse’s own career.” “It makes for a healthy work environment when there are coworkers whom you work with whom you can be friends with and discuss difficult issues and challenges that you
“It’s important for nurses to friend new nurses to allow for effective learning and adjustment on the team, including the patient,” explains Moreira. couldn’t to someone outside the profession,” says Schmidt. And a healthy workplace will influence other people and environments as well.
The Ripple Effect When nurses are friends, they aren’t just nice to each other, but they look out for each other. While working as a staff nurse, Leighton developed a core group of nursing friends. “We collectively pitched in to make sure that if someone needed a day off or a last-minute shift coverage, we helped one another. It was an unspoken understanding that we took care of one another,” she recalls. “While I think that friendship is important in all aspects of our lives, we do know that workplace friendships are tied
true as well: a happy nurse can make a happy patient. And sometimes a happy nurse, can just make a happy nurse. That can be essential enough. Nurses who are less stressed because of friendships can have improved mental, emotional, and physical wellness, says Moreira. “Nurses with reduced stress often prioritize self-care, which allows them to give their best selves to others.” 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 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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Doulas Seeking to Impact Mortality and Morbidity Rates BY JAMES Z. DANIELS, MPA, MSc, AND JANICE BONHAM WEST, MEd
W
hen North Carolina native Kelly Drose was pregnant with her first child, things did not go as she planned. Her already-small baby stopped growing at 35 weeks gestation and had to be delivered by emergency C-section. After her first traumatic childbirth experience, Drose wanted to try to have a VBAC (Vaginal Birth After C-Section) for her second delivery. Her best friend—a doula—explained in detail what Drose could expect during her VBAC, how a doula could be helpful, and offered her continuous perinatal (before-, during- and after-labor) support. Drose believes her decision to engage a doula was the most important thing she did to ensure a successful VBAC delivery. Doulas provide continuous, one-on-one emotional and informational perinatal support. Although they are not medical professionals and do not provide medical services, doulas advocate for patients while working alongside midwives, nurses, obstetricians, and
other health care providers. The rate of doula use in the United States is rising, and mothers and their babies are benefitting in many ways: • The presence of a companion of a woman’s choice during childbirth is proven to have a positive effect on her satisfaction with the birth process. • Doulas offer continuous support and client-advocacy in the health care system before, during, and after one of the most critical events in a mother’s life. • Doula services can moderate increasing medicalization and cost of health care. • Patient morbidity (mother and child) declines with doula services, particularly in low-income and minority pregnancies. As Drose continued recounting her experiences during her three pregnancies, more differences became apparent. “After my first birth, I was diagnosed with PTSD brought on by trauma, including the prenatal distress and condition of the baby, the emergency C-
section, and my disappointment at not having a vaginal birth. Perhaps a doula would have been helpful,” she explains. “After the second birth, I experienced what I believed to be postpartum depression— anxiety, moodiness, feelings of inadequacy, and being overwhelmed by the arrival of the second child. My doula was very helpful because she stayed
the doula focused on Drose. “I was struggling during that period, so her checking on me, staying in contact, and being supportive and engaging was key to helping with my recovery,” she says. Drose chose the services of a doula for the second birth because she wanted continuous perinatal support from “someone who would be on
A 2014 study by the American Journal of Managed Care analyzed 2,400 births and found that continuous labor support confers measurable clinical benefits to both mother and baby.
engaged with me about my health, asked how I was feeling, and got me to express myself. She sensitively examined what I was experiencing and let me know she was there for me completely.” For the first two days after Drose’s second baby was born, the doula focused on the baby’s needs, but for the remainder of the two weeks after the birth,
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my team and advocate for us right up until the time I was to go to the hospital.” Continuous labor support is the care, guidance, and encouragement provided by those who are with a pregnant woman in labor, supporting labor physiology, control, and participation in childbirth decision-making. In essence, continuous perinatal support is what a doula offers.
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Drose’s doula presented options and choices and asked her what she wanted to do, rather than just telling her what to do. “My doula assisted me during times of great discomfort. She showed my husband how to hold me, how to position me in the bed, and how to massage my back,” Drose explains. She did not tell her obstetrics practice in advance that she was hiring a doula. “I just took her with me to appointments with my doctor and allowed them to meet and interact. On the day of my delivery, my doula came with me to the hospital and I introduced her to the hospital staff. I detected no [negative] attitude, probably because they
Venus Standard, MSN, CNM, LCCE
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were familiar with doula services from prior patients. I sensed no tension.” A 2014 study by the American Journal of Managed Care analyzed 2,400 births and found that continuous labor support confers measurable clinical benefits to both mother and baby. The study concluded that, “While many different individuals can and commonly do provide continuous labor support (including obstetric nurses, husbands and partners, close friends, and family members), the strongest results were achieved when continuous labor support was provided by someone who was not part of the woman’s family or social
network or employed by the hospital.” At first, Drose’s husband Trae did not understand the role, value, or necessity of a doula, but by her third labor and delivery in a birthing center in Texas, he understood. At the
ing benefit, in fact, particularly for minority and low-income mothers and babies. In recent years, persistently high rates of U.S. maternal mortality have continued to alarm the medical community, and one statistic has been especially concern-
According to the American College of Obstetricians and Gynecologists (ACOG), black mothers in the United States die at 3 to 4 times the rate of white mothers—one of the widest of all racial disparities in women’s health. time, their health insurance did not cover pregnancy because they had had no plans to add another child to their family. As a recent transplant to Texas, Drose also did not yet have an OBGYN. They found a birth center located not far from their home, and after thorough research, Drose and her husband secured the services of a doula and midwife as part of the birthing center package they chose. Compared to a hospital stay, their total out-of-pocket costs at the birthing center totaled less than the costs of the same services in a hospital labor-and-delivery setting. The American Journal of Managed Care analysis found that women “with doula support have lower odds of nonindicated cesareans than those who did not have a doula as well as those who desired but did not have doula support. Increasing awareness of doula care and access to support from a doula may facilitate decreases in nonindicated cesarean rates,” thereby reducing labor and delivery costs. Doula services also have the potential to confer a much more critical benefit—a lifesav-
ing. According to the American College of Obstetricians and Gynecologists (ACOG), black mothers in the United States die at 3 to 4 times the rate of white mothers—one of the widest of all racial disparities in women’s health. Stated differently, a black woman is 138% more likely to die from diabetes than a white woman, 143% more likely to perish from cervical cancer, and 371% more likely to die from childbirth-related causes. Doula services address health inequities that contribute to the alarming rates of maternal and infant morbidity and mortality in this country. Despite improved patient outcomes attributed to doula services, overall doula service utilization remains low, with only 6% of women who gave birth in 2011 and 2012 receiving care from a doula. Furthermore, The American Journal of Managed Care found that “most doulas are white uppermiddle class women serving other white upper-middle-class women.” This may be partly attributed to substantial barriers to access to doula care, especially for low-income women and women in minority com-
munities. Listening to Mothers III: Pregnancy and Birth, the report of the Third National U.S. Survey of Women’s Childbearing Experiences, found that although only 6% of women actually received supportive care from a doula during labor, 75% of women who did not receive care from a doula had heard about this type of caregiver and care, and 27% of those who hadn’t used a doula but understood what doula care is, indicated she would have liked to have had doula care. Because health insurance programs do not typically offer coverage for these services, many women who would benefit from doula care are unable to access it. In recognition of the lifesaving and cost-effectiveness benefits from perinatal doula care, three states (New York, Oregon, and Minnesota) now cover the cost of doula services through Medicaid for low-income women. Working in North Carolina to increase the doula service utilization rate is Venus Standard, MSN, CNM, LCCE, a certified doula and midwife who trains individuals seeking certification by DONA International. Standard is also on the faculty of the University of North CarolinaChapel Hill School of Medicine and an assistant professor in the Division of Subspecialties in the Department of Family Medicine where she teaches medical school residents about doula services and their benefits for both mothers and infants. She also founded and leads an independent practice, 4 Moms 2 Be, in Greensboro, North Carolina, which offers three doula certification courses a year using a training model that follows a predetermined curriculum sanctioned by DONA International. It also includes business
management skills, since most doulas seeking certification are self-employed, independent service providers. Combined with Standard’s teaching medical residents, the doula training program creates a replicable model with the potential to increase physician acceptance of doula services while increasing maternal access—resulting in less medically-complicated labors, lower rates of cesarean births, decreased length of labor, decreased maternal depression, higher rates of breastfeeding, more positive birth experiences, and healthier birth spacing. In March 2014 (and reaffirmed in 2018), ACOG issued a consensus statement that has also been endorsed by The American College of Nurse– Midwives and the Association of Women’s Health, Obstetric and Neonatal Nurses. The consensus states: “In addition to regular nursing care, continuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes for women in labor.” The research underpinning
Kelly Drose and her children
ance, Pulse, Grimace, Activity) scores at birth. Women who report that they would like to have doula care are the same women who stand to benefit most from the known effects of continuous labor support—black women (vs. white women), women with public health insurance (Medicaid and other government-funded programs primarily serving
Improving the experience of perinatal care and the outcomes of mothers and babies systemwide is imperative—and actionable with existing technology and knowledge.
this statement stems from a substantial evidence base—including a review of randomized, controlled trials of doula support during labor, which is associated with lower cesarean rates, lower preterm birth rates, fewer obstetric interventions, fewer complications, less pain medication, shorter labor hours, and higher infant APGAR (Appear-
low-income women, vs. private insurance), and women without health insurance (vs. those with private insurance)—all of whom have higher risks of adverse birth outcomes and are least able to afford doula care or access culturally competent care. These groups of women report that they want but don’t have access to doula care, with
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limited resources a primary explanation. In other words, the association between doula support and positive birth outcomes is largest among women who are low-income, socially disadvantaged, or who experience cultural or language barriers to accessing care. Improving the experience of perinatal care and the outcomes of mothers and babies systemwide is imperative—and actionable with existing technology and knowledge. With the advent of state-funded, Medicaid support for doula services, vulnerable women and babies who have the greatest need for support and the fewest options can benefit from this cost-effective, lifesaving service. James Z. Daniels, MPA, MSc, is a consultant and writer who lives in Durham, North Carolina, and frequently contributes to Minority Nurse. Janice Bonham West, MEd, is a writer and consultant who lives in Raleigh, North Carolina.
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Nursing
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with Diabetes Tips for Coping on the Unit BY LYNDA LAMPERT, RN
“Diabetes is so prevalent in our society, and I feel as though I have a better understanding of my own patients with diabetes,” says Heather Weber, an RN who works in a busy outpatient GI department. She has type 1 diabetes, and she has experienced what it is like working as a nurse with diabetes. “I recently had a GI sickness at work, and as a result, my blood sugar dropped rather quickly after lunch,” she relates. “My coworkers noticed that I was diaphoretic and quickly sat me down, giving me some apple juice to drink. I ended up going home since I was sick with a GI bug, but only once my blood sugar was stable enough to drive. I was grateful for my coworkers’ assistance.”
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ince diabetes is such a major problem amongst the population, it only stands to reason that nurses can have diabetes, as well. According to the American Diabetes Association, 30.3 million people in America have diabetes. In addition, 1.25 million adults and children have type 1 diabetes. How can nurses manage their
condition? Nurses have a difficult time eating a balanced diet due to skipping meals. They are also on their feet most of the time, putting them at risk for complications of the foot, such as ulcers. Fortunately, many nurses want to share their experiences to help others navigate the challenge of balancing diabetes and providing excellent
patient care. Diabetes educators strive to help all people who have diabetes, and they are an excellent resource for nurses who want to manage their diabetes. Nurses generally know how to handle their condition. They know diabetes front and back through the job, and they are intelligent professionals who know how to adapt
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those ideas for themselves. “I can usually slip away for a few minutes or have a coworker cover for me so that I can test and/or eat a snack,” explains Weber. “When I worked as an ICU nurse doing twelve-hour shifts, I would typically eat snacks to prevent low blood sugars as I did my charting at the nurses’ station.” Tips like this are invaluable because they are grounded in the actual experience of being a nurse with diabetes. Fran Damian, MS, RN, NEABC, works at Boston Children’s Hospital and is a staff member at Diabetes Training Camp. She has tricks that she uses, as well. “Managing well with diabetes requires good planning and being well prepared with
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extra supplies all the time,” she says. “I live a healthy lifestyle as much as possible. That includes regular exercise and a well-balanced diet. I feel best when I eat a lot of fruits, vegetables, and lean protein, and I drink a lot of water …. [I] always have glucose tablets on me in case I start feeling low.” “Our unit was pretty good if we were slammed and did not get lunch,” says Danielle Kreais, MSN, RN, CPNP-PC. She got her diagnosis and
chips for us. There was another diabetic I worked with and the advice she gave me was to make sure I always had one of those Nature Valley bars in my work bag, in the glove box of my car, and my locker. The peanut butter ones have protein and they are a carb, so it was a great combo if lunch was missed.” She continues: “She told me for lows to keep those peppermint striped candies [in your pocket] that are soft, and
Nurses newly diagnosed with diabetes would do well to carry glucose tablets at all times to prevent low blood sugar. learned to cope, all while working a busy OB unit on nights. “The manager ordered lunch meat sandwiches and
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you can chew them. They are enough to bring your sugars up, plus they don’t melt.” Nurses newly diagnosed
Although tips from nurses can be invaluable, they are nothing like the kind of focused information that can come from a certified diabetes educator (CDE). with diabetes would do well to carry glucose tablets at all times to prevent low blood sugar. Be sure to tell your manager and your coworkers what’s going on so that they can help you when needed. Snacks and water are essential to good blood sugar control. Don’t forget to use your resources, such as endocrinologists, dieticians, and diabetes educators to plan the right meals and strategies for you to use on the job. Although tips from nurses
can be invaluable, they are nothing like the kind of focused information that can come from a certified diabetes educator (CDE). These are medical professionals who are responsible for teaching all people with diabetes in all situations how to manage their lives and prevent complications. One such expert is Lucille Hughes, DNP, MSN/Ed, CDE, BC-ADM, FAADE, director of diabetes education at South Nassau Communities Hospital in Oceanside, New York, and treasurer of the American Association of Diabetes Educators. Considering some of the challenges nurses can face when dealing with diabetes on the job, she had tips for some of the most common ones. Nurses often don’t get the chance to eat during a shift, and this can severely impact blood sugar levels. “When nurses with diabetes find themselves in this situation, planning and being prepared is the best medicine,” says Hughes. “Keeping snacks on hand that are a blend of carbohydrates, protein, and fats can be a tremendous help in these situations.” “Meal planning is the secret to living with diabetes and being a healthy person,” Hughes continues. “Investing in a good lunch bag (or two) will allow you to plan and pack all the essentials to eating and snacking healthy. Being unprepared and finding yourself at the mercy of a vending machine is not a good situation to be in. It is very unlikely you are going to find a ‘healthy’ lunch or snack option.” In addition to poor nutrition, nurses also face signifi-
cant impact to their feet, and this can cause foot related complications for nurses who have diabetes. “First and foremost, investing in a good pair
“Meal planning is the secret to living with diabetes and being a healthy person,” Hughes continues.
of comfortable shoes is essential for anyone who spends most of their day on their feet,” says Hughes. “Calluses and skin evulsions due to rubbing of a shoe on a toe, heel, or ankle area can be dangerous and yet avoidable.” Here are six tips that Hughes has on how to find shoes that fit and how to determine if they are a healthy choice: 1. When trying on a shoe in the store, make sure it feels comfortable. If it isn’t comfortable, don’t buy it. 2. Many think that new shoes require a bit of breaking in and you must endure the associated pain. This is not true. If new shoes start to hurt, immediately remove them and don’t use them again. 3. Don’t think that the only shoes you can wear as a nurse with diabetes are unfashionable ones. There are many options for shoes that fit, so do your due diligence and find shoes that will protect your feet. 4. In addition to finding the right shoes, foot inspection is vital in protecting your feet. Check them every day. Use a mirror to see the bottoms and sides of your feet.
If you notice any redness, cuts, or blisters, see your podiatrist immediately. Take care of small changes immediately before they expand into something unmanageable. 5. Podiatrist. Yearly, no exceptions. More often if necessary. 6. Finally, any time you see a medical professional, ask them if they will take a look at your feet at your office visit. This could be your primary care doctor, your endocrinologist, or any other specialist you may see— within reason, of course. Many dentists would have trouble with this request. Seriously, though, any professional who looks at your feet could possibly see a problem early enough to stop it. Use these resources. Nurses spend so much time taking care of others that the self is often forgotten and ignored. Unfortunately, this is unhealthy for any nurse, but particularly troublesome for a nurse with diabetes. Yet, these challenges are not insurmountable, although they
high blood sugar under control. For your feet, planning is again essential. You must find shoes that are comfortable—no questions asked. Following these steps, nurses with diabetes should be able to function well as nurses—and many are! If you find yourself troubled by mixing diabetes and nursing, let your doctor know. They may be able to refer you to any
number of professionals who can help. The most important item, though, is to catch things early and always plan how to confront any challenges. Lynda Lampert, RN, has worked medical-surgical, telemetry, and intensive care units in her career. She has been freelancing for five years and lives in western Pennsylvania with her family and pets.
In addition to poor nutrition, nurses also face significant impact to their feet, and this can cause foot related complications for nurses who have diabetes.
may take a little work. Planning your diets and meals are key to ensuring that you will have food on hand for sudden lows. Meal planning can also help you keep your
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It Takes a Village Nurses Work to Provide Culturally Competent LGBTQ Care BY LINDA CHILDERS
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As a gay man, Austin Nation, PhD, RN, PHN, understands the health care barriers faced by many lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients. As a nurse and educator, he’s working to increase awareness and address the health disparities that continue to exist in the LGBTQ community.
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n assistant professor of nursing at California State University, Fullerton (CSUF), Nation lived through the 1980s AIDS crisis, and has worked with many patients in the HIV/ AIDS community. While he acknowledges an HIV diagnosis is no longer a death sentence thanks to increased funding and better treatment, Nation has also seen how young gay black and Latino men continue to be disproportionately affected by HIV/AIDS. The Centers for Disease Control and Prevention (CDC) report that 1 in 2 black men and 1 in 4 Latino men will be diagnosed with HIV during their lifetime. “We’re not reaching all of the people we need to reach,” Nation says. “In order to get to zero new HIV infections, we need to figure out how to engage these populations.” While treatments have transformed HIV into a chronic but manageable illness, many people are not aware of how prevention efforts that use antiretroviral treatment, and preexposure prophylaxis (PReP), an HIV-medication that when taken consistently, can lower the risk of getting infected by
more than 90%. Despite being widely available, the CDC notes that while two-thirds of the people who could benefit from PrEP are black or Latino, they account for the smallest amount of prescriptions to date. To that end, Nation has worked to address the tenuous relationship many people of color and members of the LGBTQ community have with the health care system. Statistics from the Kaiser Family Foundation show that LGBTQ patients often face challenges and barriers in accessing health services including stigma, discrimination, the provision of substandard care, and outright
tion says. “By knowing whether a patient is gay, lesbian, transgender, straight, or bisexual, and how to best communicate, nurses can identify potential health disparities and care for their patients more effectively.” On the CSUF campus, Nation has also been a part of the university’s Faculty Noon Time Talks, discussing health care disparities within the African American community. In addition, he is working with faith leaders to adopt a more inclusive environment for LGBTQ individuals who may be reluctant to come out and subsequently don’t receive HIV testing or prevention counseling.
“We’re not reaching all of the people we need to reach,” Nation says. “In order to get to zero new HIV infections, we need to figure out how to engage these populations.” denial of care because of their sexual orientation or gender identity. “I’ve led LGBTQ cultural competency trainings to teach nurses and nursing students how to provide inclusive services and care for LGBTQ patients,” Na-
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“I also teach a public health course at CSUF where we discuss vulnerable patient populations including the LGBTQ community,” Nation says. “I try to integrate real-world experiences into the course curriculum.”
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“Many health care providers work under the assumption that all patients are heterosexual,” says Ober. “It’s important to create a welcoming environment for LGBTQ patients in order to educate them on cancer risk factors and ensure they receive preventative screenings.” Nation believes that all nurses can help to achieve diversity and meaningful inclusion, whether they are part of the LGBTQ community or an ally. “Have a voice and be an advocate,” he says. “One person can make a difference.”
Navigating Cancer Care with LGBTQ Patients As an oncology nurse and LGBTQ advocate, Megan Ober, RN, MS, BSN, OCN, a case manager at the Palliative Care Clinic at the UC Davis
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Comprehensive Cancer Center in Davis, California, often finds herself bridging the gap between providers and LGBTQ patients. “Many health care providers work under the assumption that all patients are heterosexual,” says Ober. “It’s important to create a welcoming environment for LGBTQ patients in order to educate them on cancer risk factors and ensure they receive preventative screenings.” Ober says LGBTQ patients often feel they are being judged
and are reluctant to share their sexual orientation or gender identity out of fear of being turned away from health care providers. This distrust can lead to some LGBTQ not seeing a doctor regularly for checkups and screenings, delaying diagnoses and not receiving information on treatments that might help either their physical or emotional health. Over the years, Ober has given presentations to staff on LGBTQ disparities in cancer care and risk factors that lead to greater cancer incidence and later-stage diagnoses. These disparities include: • Anal cancer. It’s rare in the general population, but 34 times more prevalent in gay men. • Cancer screenings. According to the American Cancer Society, lesbians
and bisexual women get less routine health screenings than other women including breast, colon, and cervical cancer screening tests. • Breast cancer. Lesbian women have higher rates for breast cancer including nulliparity (never having given birth), alcohol and tobacco use, and obesity. • Cervical cancer in transgender men. Since most transgender men retain their cervixes, they are also at risk of cervical cancer but are much less likely to obtain Pap smears and regular cancer screenings. While it can be difficult for nurses to begin a conversation about a patient’s sexuality and sexual health, Ober says it’s important for providers to ask in order to care appropriately for LGBTQ patients.
“Rather than assuming all patients are heterosexual, I recommend nurses introduce themselves and ask a patient how they would like to be addressed, their chosen name, and their preferred pronoun,” Ober says. “There’s a great training video on YouTube called ‘To Treat Me You Have to Know Who I Am’ that showcases a mandatory employee training program that was launched for health care providers in New York.” Ober also cautions against assuming the personal info on a patient’s chart is correct. Often, people who are transgender may identify as a different gender than the one listed on their electronic medical record. “Rather than greeting a patient with a title such as Mr. or Ms., I encourage nurses to ask patients how they would like to be addressed,” Ober says. “Shifting from a heteronormative model to one that is more inclusive acknowledges that patients and families aren’t all the same. The woman sitting by your patient’s bedside may be her wife, rather than her sister or friend.”
sitive care to LGBTQ patients.” Stover says while many nurses across the country are doing great work in creating an inclusive environment in their
downloadable PDF created by GLMA as a good starting point for nurses who are seeking advice on how to communicate with LGBTQ patients using
hospital units and establishing trust and rapport with LGBTQ patients, there are still many nurses and providers who have not received education on LGBTQ health issues. “It’s important for nurses to strip themselves of preconceived notions, judgements, and assumptions,” Stover says. “Our job is to provide the best possible care, regardless of a
sensitive language. The document also includes guidelines for forms, patient-provider discussions, and more.
Learning about LGBTQ patients isn’t a topic that is always covered in nursing school. A national survey conducted in 2014 found that 43%
Between 23-63% of respondents indicated either never or seldom teaching LGBTQ health, although a majority of respondents felt LGBTQ health should be integrated into the nursing courses they teach. In 2013, Columbia University Medical Center in New York launched the LGBT Health Initiative, based at the Division of Gender, Sexuality, and Health at the New York State Psychiatric Institute and the Columbia University Department of Psychiatry in association with the Columbia University School of Nursing. The goal of the initiative is to bring together research, clinical care, education, and policy to fight stigma and improve the health of the LGBTQ community. Janejira J. Chaiyasit, DNP, AGNP-C, an assistant professor at Columbia University School
patient’s age, ethnicity, gender, or sexual orientation.” She cites the Guidelines for Care of Lesbian, Gay, Bisexual, and Transgender Patients
of nursing faculty who taught in bachelor’s degree programs across the United States reported limited or somewhat limited knowledge of LGBTQ health.
of Nursing and a nurse practitioner at ColumbiaDoctors Primary Care Nurse Practitioner Group, says students at the Columbia School of Nurs-
“If a patient doesn’t feel comfortable, how can we expect them to divulge their personal health concerns to us, and, in return, enable us to give them the best care?” Chaiyasit says.
Continued Education Leads to Better Health Outcomes
Nurses Lead the Way with Change Caitlin Stover, PhD, RN, chair of the national Gay and Lesbian Medical Association (GLMA) Nursing group says both nurses who identify as LGBTQ and those who are allies can work to create an inclusive environment for LGBTQ patients. “I’m an ally that joined GLMA and now I’m chair of the organization,” Stover says. “There are so many resources out there that can help nurses become better patient advocates and deliver culturally sen-
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Resources to Bring Better Care to LGBTQ Patients For nurses who want to educate themselves further about LGBTQ health topics, the following information can help: • Lavender Health has held virtual coffee hours for nurses working with LGBTQ populations. Their website offers events, resources, and more to help both providers and members of the LGBTQ community promote wellness. • The National Resource Center on LGBT Aging offers cultural competency training for staff at nursing homes and others who care for seniors. They also have downloadable guides on creating an inclusive environment for LGBTQ seniors. • The U.S. Department of Health and Human Services offers a free downloadable guide, Top Health Issues for LGBT Populations Information and Resource Kit. • On a national level, organizations such as the National Alliance of State and Territorial AIDS Directors (NASTAD) has partnered with the Health Resources and Services Administration’s HIV/ AIDS Bureau (HRSA-HAB) to launch HisHealth. org, a free online tool that helps nurses and other medical staff learn how to engage HIV-positive young black LGBTQ patients and young black transgender patients by taking a whole-health approach to wellness. • Organizations such as the Human Rights Campaign and their Healthcare Equality Index can help with training and best practices such as making changes to electronic medical records and hospital paperwork to incorporate sexual orientation and gender identity and criteria that hospitals can use to become Equality Leaders. • The National LGBT Health Education Center has a free downloadable guide, “Providing Inclusive Services and Care for LGBT People: A Guide for Health Care Staff.” The guide discusses using preferred pronouns and preferred names, understanding diversity and fluidity of expression, making LGBTQ patients feel comfortable, common health issues among the LGBTQ population, and much more.
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ing receive training on LGBTQ cultural competency as part of their studies. “We highlight the unique health disparities, risks, and health needs of the LGBTQ patient population to increase awareness, so that our future providers and care takers will offer appropriate care and ask the right questions,” Chaiyasit says. At Columbia, Chaiyasit has seen how promoting inclusivity and culturally competent care has led to better patient care and health outcomes, and how training staff and students adequately prepares them to care for LGBTQ patients. “If a patient doesn’t feel comfortable, how can we expect them to divulge their personal health concerns to us, and, in return, enable us to give them the best care?” Chaiyasit says. And despite progress that has been made nationally, Chaiyasit says there’s a continued need for nurses to learn about the differing health needs of the LGBTQ community. “LGBTQ patients have a lot of health disparities and changing the preconceptions of health care delivery for this community is a way to close
the gaps—reducing ER visits, reducing the time to access health care for medical and psychosocial issues, and increasing the rate of preventative health screenings,” Chaiyasit says. “For example, many health care professionals are unaware of the health needs for trans patients, specifically these patients’ needs for transition-specific hormone therapy care and maintenance to achieve the desired gender features. This is really important as it impacts physical and mental health as a whole.” In addition to nurses becoming more aware of gender-neutral language, many hospitals have begun customizing their patient intake forms to ensure they are LGBTQ-inclusive. “At Columbia, we piloted intake form questions, which were ultimately implemented across the Nurse Practice Group, that allow patients to select, or even write in, their preferred gender identity pronouns,” Chaiyasit says. “A complete patient history helps to ensure each patient gets the care and services they need.” Linda Childers is a freelance writer based in California.
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Academic Forum
Continuous Glucose Monitoring Systems Reducing Hypoglycemia and Improving Patient Health Outcomes BY SRINIDHI LAKHANIGAM, BSN, RN, CCRN, CMSRN
According to the Centers for Disease Control and Prevention (CDC), diabetes is the seventh leading cause of death in the United States. Type 2 diabetes is one of the most commonly occurring chronic diseases, which affects about 90-95% of those diagnosed. According to a 2018 study published in Health and Quality of Life Outcomes, there were over 415 million adults between 20-79 years living with diabetes globally. The American Diabetes Association estimates that over $327 billion is the annual cost of diabetes care in the United States alone.
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serious complication of diabetes is hypoglycemia, a blood sugar level less than 70 mg/ dL. Hypoglycemia comes on suddenly and patients display symptoms such as profuse
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sweating, tremors, irritability, altered mental status, loss of consciousness, among others. Hypoglycemia has several adverse effects including cardiac arrhythmias, seizures, and can be fatal in severe cases. The
fear of inadvertent hypoglycemia is among the biggest barriers patients face while working towards glycemic control. Hence, one may conclude that frequent hypoglycemic incidents are disruptive to the
normal life, and may result in injury, increased medical costs, loss of wages, and the need for constant monitoring by another person. Real-time continuous glucose monitoring (CGM) may provide an ideal solution for individuals with a high risk of hypoglycemia. CGM measures glucose levels continuously via a transdermal glucose sensor and sends data to one or more monitoring devices. It is configurable to alert the user and/or designated provider
Academic Forum
The American Diabetes Association estimates that over $327 billion is the annual cost of diabetes care in the United States alone.
when blood glucose levels are too high or too low. In a 2017 study, David Rodbard, MD, demonstrated that the use of CGMs resulted in significant reduction of hypoglycemia risk and improved patients’ quality of life. Since the invention and subsequent improvement of the quality of monitoring and reporting, CGM systems have become very reliable tools for real-time monitoring of blood glucose and prevention of dangerous hypoglycemia. CGM systems also help reduce health care costs and improve quality of life and productivity of patients.
down with issues related to accuracy, delayed transmission, and patient teaching. Rapid advancements in technology have influenced development of highly accurate, versatile, and user-friendly CGM machines. In 2015, the American Association of Clinical Endocrinologists and American College of Endocrinology included CGM systems into their clinical practice guidelines. Three medical device manufacturers—Abbott Laboratories, Medtronic, and Dexcom Inc.—have emerged as leaders in today’s CGM marketplace at a global level.
time blood glucose monitoring of diabetic patients and prevention of abnormal glycemic highs and/or lows and its accompanying complications. Multiple studies have successfully demonstrated that diabetic patients are at a risk of undetected hypoglycemia. According to a 2017 study published in Diabetes Technology & Therapeutics, 22% of sudden unexpected deaths in persons under 40 with type 1 diabetes were due to hypoglycemia. The study concluded that using CGM systems helped reduce hypoglycemia and improve glucose control. Inadequate glycemic control is associated with complications that lead to reduced quality of life, work absenteeism, increased hospitalization, among others. Fear of hypoglycemia and its associated costs may discourage patients from adhering to a treatment plan formulated by their primary care provider. And yet, the Diabetes Technology & Therapeutics study estimated an annual savings of $936-$1,346 per person in hypoglycemia
And yet, the Diabetes Technology & Therapeutics study estimated an annual savings of $936-$1,346 per person in hypoglycemia prevention with the use of CGM systems.
type 1 diabetics on real-time CGM systems demonstrated a marked improvement in glycemic control and enhanced of quality of life in the form of reduced incidences of hospitalization, work absenteeism, and lesser fear of hypoglycemia. Furthermore, recent advances in wireless and data-enabled cellphones have enabled medical technology corporations to improve the functionality and accuracy of CGM systems. Modern CGM systems can now send information to the patient and designated caregivers when the blood glucose levels are too high or too low. CGM systems help promote safety and efficacy of glycemic control for both type 1 and type 2 diabetics and reduces the risk of hypoglycemia significantly. The benefits of CGM systems are yet to be completely utilized by health care providers and patients due to lack of awareness, suspicion about the safety, efficacy, and cost of these systems. Using CGM systems may lead to long-term financial savings and improved quality of life for patients. It is up to primary care providers to educate patients and families to benefit from available technologies and improve their health. Srinidhi Lakhanigam, BSN, RN, CCRN, CMSRN, has been an RN since 2012 and is currently in the Doctor of Nurse Anesthesia Practice program at the University of Alabama, Birmingham.
A Brief Introduction to CGM Systems
CGM’s Role in Preventing Hypoglycemia and Improving Quality of Life
The first CGM system hit the market in 1999. Early CGM systems were bogged
The main idea behind the introduction of CGM systems was to achieve enhanced real-
prevention with the use of CGM systems. A recent randomized controlled trial published in The Journal of Clinical Endocrinology & Metabolism found that
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Second Opinion
Suboxone: The Wonder Drug? BY SPENCER MILLER, RN
The 57-year-old woman is standing in the hall outside of the exam room. She is agitated. “I’m waiting for the doctor. I’m freezing! My back is killing me!” I note she is pale, unable to stand still, and has a sheen of perspiration on her forehead. She is in withdrawal. I get her a blanket and ask her to wait in her room. The pain clinic nurse is downstairs at the pharmacy getting the patient’s prescription for Suboxone for induction. Induction is the process of starting the patient on medication and finetuning the dose.
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n hour later the patient is back in the hall calling me, “Thanks for the blanket!” She is smiling. Her color is back. She is clear eyed, calm, and collected. What happened? Suboxone. Suboxone is a combination of buprenorphine and naloxone that is used to treat opioid addiction. Buprenorphine is a partial agonist of the μ-opioid receptor with a high affinity and low
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rate of dissociation from the receptor. In English, the buprenorphine molecule sticks to the opioid receptor in the brain, but only partially activates it. Then it stays there for a long time, blocking it from opioids, before dissociating. What this means for the addict is that they get enough opioid receptor activation that they don’t get sick from withdrawal. They can function normally with less of the problematic
effects of a full agonist like morphine or heroine. The addition of naloxone, a full opioid antagonist (blocker), keeps the Suboxone pills from being crushed and injected. Though naloxone has a strong effect when given parenterally (by injection), its effect when given by mouth is negligible because it is poorly absorbed sublingually. Suboxone disintegrating tablets are given under the tongue. So, what is this wonder drug all about? In 2000, federal legislation (Drug Addiction Treatment Act of 2000) made
office-based treatment of narcotic addiction with schedule III-V drugs legal. Until then, the only option for addicts was abstinence-based treatment or methadone clinics. The ever-increasing rates of drug overdose deaths in the United States showed this was not working. At first, only MDs specially approved by the Department of Health and Human Services could prescribe medications to treat addiction. In 2016, President Obama signed the Comprehensive Addiction and Recovery Act allowing nurse practitioners and physicians assistants to prescribe schedule III-V drugs for the treatment of addiction. Previously, they could prescribe these medications to treat pain but not to treat addiction. What does this mean for the addict? For starters, Suboxone and similar drugs are now more widely available. Until recently, the only way for a heroin addict to keep from getting withdrawal sickness was to use more heroine. These patients were considered toxic to regular doctors because their disease lead to ever-increasing doses, seeking medications from multiple providers, decreasing levels of health, and ultimately death. Now that there is an option other than going cold turkey,
Now that there is an option other than going cold turkey, the addict without some kind of pain diagnosis can get access to health care whereas before they would avoid it because of the stigma of being an addict.
Second Opinion the addict without some kind of pain diagnosis can get access to health care whereas before they would avoid it because of the stigma of being an addict. Because Suboxone is a partial agonist with high affinity to the μ-opioid receptor, it decreases the ‘high’ if the patient continues to use narcotics causing the patient to lose interest. It offers the benefit of allowing the addict to function in life, decreases the likelihood of death from respiratory depression, and increases the quality of life because there is no need for the addict to ride the wheel of withdrawal—drug seeking, using, running out, and then seeking again to the exclusion of every joy of life. What happens when a person starts buprenorphine? After a largish battery of tests, the prospective recovering addict will be asked to abstain from narcotics before induction to Suboxone. How long before the first dose the addict has to abstain depends on the person’s addiction. Longer acting drugs like methadone could be 24 hours. Shorter acting drugs like morphine could be as little as six hours. The person should be in the early stages of withdrawal. The reason for this is the “partial” part of partial agonist. The buprenorphine molecule will muscle other narcotics off the receptor site where it was fully activating the receptor. Now, the higher affinity buprenorphine is sitting there doing half the work that the heroine was doing and this leads to symptoms of withdrawal. Giving a person a drug that puts them immediately into withdrawal will turn them off to it completely. You won’t see that person again. Higher success rates are tied
with higher levels of symptoms of withdrawal before induction. Now instead of precipitated withdrawal, the person has relief from symptoms of withdrawal even if they are not getting high. A person who has been successfully inducted to Suboxone therapy will find almost immediate relief. The terrible body aches, muscle pain, abdominal pain, depression, diarrhea, and cravings evaporate. Our patient might just have found a new way to live, free from the constant need to find more narcotics. She can focus on her life instead of her disease. Most of the clinic patients have jobs. They want desperately to be productive members of society for themselves and for their families. Buprenorphine therapy coupled with lifestyle interventions provided by mental health professionals, self-help groups like Narcotics Anonymous, and patientinitiated interventions (like taking a class or going back to school) are part of the success
desired treatment goals. Someone facing a jail sentence or travel overseas that needs to detox from opioids quickly may be on a tapered dose of Suboxone for just a few days or weeks. Other people may decide that the burden of staying on Suboxone is worth not having to go through withdrawal and choose to stay on a maintenance dose for the rest of their life. The addiction specialist will help guide the patient through the decision process. Many patients decide to stay on the medication as a hedge against relapse since buprenorphine has a higher affinity for opioid receptors than street drugs. This coupled with the very slow rate of dissociation means that a person would have to stop the buprenorphine well in advance of restarting heroine or other opioid in order to get high. What does this mean for health care? For one, at least some addicts who eschewed health care in the past can now get treatment for this disease.
Buprenorphine therapy coupled with lifestyle interventions provided by mental health professionals, self-help groups like Narcotics Anonymous, and patient-initiated interventions (like taking a class or going back to school) are part of the success story of a growing number of recovering addicts.
slowly, as treatment becomes available and success stories become commonplace. As the DEA and FDA work to get a handle on the 70,000 overdose deaths per year by educating doctors and enforcing distribution laws, these drugs will become harder to get. During the 12 months prior to July
What does this mean for health care? For one, at least some addicts who eschewed health care in the past can now get treatment for this disease.
2017, overdose deaths fell in 14 states for the first time during the opioid epidemic, according to the Centers for Disease Control and Prevention. In the rest of the nation, at least the numbers have leveled off. Greater access to Narcan (brand name of naloxone, one of the drugs in Suboxone), and more treatment options for addicts will hopefully drive these numbers lower over time. It’s not time to celebrate, but at least there is a glimmer of hope. The priority is to keep addicts alive until they can (or they are ready to) get treatment for their disease. Spencer Miller, RN, is an emergency room nurse who has worked at
story of a growing number of recovering addicts. What’s it like to come off Suboxone? Eh, probably a lot like getting off heroine. Same withdrawal profile or pretty close. Patients wanting to get off all narcotics, including Suboxone, can be weaned off gradually depending on their
At some point, most addicts will desire to get off narcotics. Having a real treatment option available instead of a far-away methadone clinic or withdrawal will work to drive these patients into recovery. Another thing is that it’s possible that some of the stigma of addiction will be lifted, at least
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various hospitals in Florida, Georgia, and California as a traveler. He currently lives in Sunnyvale, California.
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Second Opinion
Medical Cannabis Use in the Hospital Setting BY NIKKI DENSON, PhD(c), MSN, ACAG-NP
Medical cannabis or medical marijuana, as therapy, has gained national attention in recent years. According to a 2014 WebMD/Medscape survey, 67% of doctors believe marijuana should be a medical option on a local level and 56% support legalization nationwide. New medical cannabis laws are now in effect in 50% of the United States, and more and more hospitals are seeing patients that are certified to use this type of therapy. Some hospitals, like the Mayo clinic hospital in Rochester, Minnesota, permit the use of medical cannabis among patients that are registered with the state’s program as long as it is in the original container. However, in Maine, hospitals across the state prohibit the use of medical marijuana. In New York, an ICU patient with a recommendation to use cannabis and vaporized THC and CBD daily for pain management was denied the use in the hospital. Instead of cannabis, the patient was administered fentanyl. So, what if a patient does not want to take opioids? 34
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y not allowing a patient to use cannabis in the hospital setting, the acute care nurse practitioner is denying the patient’s right to self-medicate. How fair is this to patients who are using cannabis and have experienced the positive effects of regular use? It is a medical and human rights issue. Physicians and nurse practitioners do not prescribe or dispense medical cannabis; they make recommendations according to the state law. Unfortunately, the acute care
Second Opinion nurse practitioner’s hands are tied. Depending on the nurse practitioner’s hospital, he or she could or could not write and order for continuation of the current cannabis order during the hospital stay.
By not allowing a patient to use cannabis in the hospital setting, the acute care nurse practitioner is denying the patient’s right to selfmedicate.
Controversies have surfaced with ethical, legal, and societal implications connected to the use, safe administration, and dispensing of medical marijuana. Currently, marijuana is categorized as a Schedule I controlled substance by the Drug Enforcement Administration (DEA). According to the DEA, a Schedule I controlled substance is defined as having a high potential for abuse with no currently accepted medical use in the United States. Finally, although some states have legalized cannabis use, marijuana is still illegal under the federal law as a Schedule I drug. This is a concern for some hospitals, as well as the health care providers, because they are afraid they might lose their federal license. So, again, what is the acute care nurse practitioner to do? Should she or he honor the patient’s right to self-medicate or adhere to the hospital’s current policy?
Cannabis Use in the Hospital Cannabis and cannabinoid, THC, are considered extremely safe for human use. According
to the DEA, no deaths have ever been recorded from cannabis use. Many studies have shown that it is impossible for a person to die from a cannabis overdose. However, safe and effective therapeutic use of cannabis dates back to 2737 B.C. Recent research suggests that cannabis possesses beneficial traits that aid in the treatment of a variety of clinical issues. The issues include neuropathic pain relief, glaucoma, spasticity, nausea, and movement disorders like Parkinson’s disease. Besides that, marijuana is known to be a powerful appetite stimulant, which would be a great addition to treatment for patients suffering from cancer, HIV, AIDS wasting syndrome, and dementia. According to a 2014 study published in the International Journal of Eating Disorders, synthetic cannabinoids were effective in treating an-
orexia. Medical cannabis could also play a role in various gastrointestinal health conditions such as Crohn’s disease. Recent research indicates that cannabinoids can help protect the body from certain types of malignant tumors. Finally, prescribing cannabis instead of opioids could decrease the current epidemic. If a patient has been deemed to use medical cannabis, they should be able to continue the therapy while in the hospital. Abruptly stopping the medication could lead to a setback in the disease process or chronic pain. The anticipated outcomes of cannabis use in the hospital are: • Patients currently receiving the benefits from medical marijuana use can continue without any interruption to the therapy; • The patient will not be exposed and/or forced to take opioids;
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• Physicians and nurse practitioners will feel more comfortable allowing their patients to continue the use of medical cannabis in the hospital setting; • Decreased hospital stay and readmission. Allowing the patients to selfadminister medical cannabis in the hospital setting would be respecting their autonomy.
Prohibit Cannabis Use in the Hospital Opposed views of medicinal cannabis use in the hospital are due to the uncertainties associated with the use of marijuana in the medical environment. One concern is the grade or quality of marijuana being used by patients is unknown if the patient grows it themselves, which is illegal. The amount and concentration of delta-9-tetrahydrocannabinol (THC), which is the main cannabinoid, differs due
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Second Opinion to dosing, quality, and quantity. So, health care providers would not be able to know exactly how much the patient has taken. The next concern is clinical efficacy. Some argue that most of the clinical evidence of efficacy involves inhalational medical cannabis that is derived from patient selfreporting or case reports by the physicians. There are currently some synthetic THC preparations available for oral administration; however, the optimal marijuana administration doses and routes have not been determined. This leads to the last concern of adverse reactions. Any health care provider who is prescribing medical cannabis should be monitoring their patients for drug interactions and any long-term effects that might occur. Medical cannabis may interfere with the absorption or metabolism of concomitant drugs. Long-term use and cognition as well as the potential effects of prenatal exposure are also an issue. The health care provider also needs to closely monitor the elderly for the adverse effects on other health conditions that affect the cardiovascular, respiratory, and immune systems.
hospital? For example, some patients are allowed to bring their medications from home. If the patient was to bring his or her own medical cannabis into the hospital, how would the hospital store it, distribute it, and clinically evaluate it? Other issues of medical cannabis in the hospital setting include: prescriptions with clear dose, dosing time, route, documentation, and the effects of second-hand smoke, if applicable. Finally, the hospitals would need to seek legal counsel for medical marijuana use for the protection of other patients as well as the staff providing care for those patients.
My Position Cannabis has been a hot topic in the legal and medical arenas for a while now. Cannabis continues to be a subject for debate on the national and international level. According to Newsweek, most of the states in the United States have approved some type of use of marijuana, and 60% of Americans support legalization. To legalize or not, and is it recreational or just medicinal—those are the questions. Marijuana/cannabis has been used for centuries for
A major challenge for the hospital is determining how to incorporate medical cannabis into patient care.
A major challenge for the hospital is determining how to incorporate medical cannabis into patient care. Would medical marijuana be treated like other medications that the patient uses while at the
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its healing properties. To date, the benefits of medical marijuana include gout, malaria, nausea, rheumatism, slows the progression of cancer cells, seizures, and Alzheimer’s, to name a few. And yet, the
Controlled Substances Act of 1970 classified marijuana as a Scheduled I drug despite the fact that there haven’t been any confirmed deaths and/or epidemics caused by marijuana. So, of course, controversies have surrounded the use of medical marijuana. It is odd that the United States would allow individuals to freely smoke cigarettes and drink alcohol—known causes of death—but will not legalize the use of marijuana, recreational or medicinal. Marijua-
ever, how many health care providers can say they have witnessed a death due to an overdose of marijuana? If it is truly fear that is driving their apprehension, then more research needs to be conducted now. Why are so many patients being forced to take an opioid when cannabis is less harmful and habit-forming? It is this writer’s humble opinion that cannabis should be legalized in all states and worldwide for recreational and medicinal use. If a patient is
It is odd that the United States would allow individuals to freely smoke cigarettes and drink alcohol— known causes of death—but will not legalize the use of marijuana, recreational or medicinal.
na is not legalized because the government cannot capitalize on it. People can freely grow their own and do not need the government. This causes issues with the revenue. Further, the editorial board of The New York Times argues that marijuana is more connected to the African American communities and so, if it is not legal they can incarcerate more African American males. On a medical note, the pharmaceutical companies would also lose money if more and more patients started using medical cannabis. Less people would need the traditional medicine treatment, leading to less dependency or long-term medication as well as less risk for addictions of such medication as opioids. They say more research is needed to really know and understand the effects and/or side effects of cannabis; how-
deemed appropriate to take cannabis, the hospital should allow it. Of course, proper documentation is necessary. The hospital should have the right to determine the route at which cannabis is administered, even self-administration. To respect the autonomy of the patients as well as the utilitarian for the majority, the hospital should allow the use of marijuana with some stipulations, policies, and procedures in place. Nikki Denson, PhD(c), MSN, ACAG-NP, is a nursing faculty member for an associate degree nursing program and a PhD student at Barry University.
Health Policy
Ensuring Equitable Access to Safe and Clean Water Through Advocacy and Legislative Action By Janice M. Phillips, PhD, FAAN, RN
Recollections of the Flint water crisis are still vivid in the minds of many Americans. Responses to this crisis in the winter of 2014 needed to be swift and comprehensive. And while it may be hard to believe that access to clean, adequate, and equitable water in America remains at risk, advocates for environmental justice call for continued vigilance in ensuring access to safe and clean water. In this column, we discuss the need to ensure equitable access to this life-sustaining resource through advocacy and legislative action with Katie Huffling, RN, MS, CNM, who is the executive director of the Alliance of Nurses for Healthy Environments. Katie Huffling, RN, MS, CNM
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Ms. Huffling, tell me a bit about yourself and how you became involved in addressing environmental health issues? I trained as a nurse-midwife at the University of Maryland School of Nursing. While there, I had the great fortune to meet Barbara Sattler and Brenda Afzal. They were leading the only environmental health center at a school of nursing in the country. Through their mentorship, I learned about the many ways that environmental toxicants could affect reproductive health
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and the health of the growing fetus. It is an area that many of us received little or no content on in nursing school, yet they can have significant negative health impacts across the lifespan. I became very passionate about environmental health issues and when the opportunity arose to work on this full time with the Alliance of Nurses for Healthy Environments, I jumped at the chance! We are the only national nursing organization focusing solely on the intersection of health and the environment. I now work
with nurses and nursing organizations around the country on a number of environmental health issues such as climate change, clean air and water, toxic chemicals, and inclusion of environmental health into nursing curriculum.
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Can you give me an example of an environmental health issue that is affecting health right now? Clean water is one of the greatest public health advancements of the 20th century. As
nurses, we recognize clean water is essential to health and a basic human right. It is also essential for providing nursing care. Nurses rely on water to wash their hands, give newborns their first baths, and is essential for the clean linens utilized throughout health care. Here in the United States we have an expectation that when we turn on the tap clean, healthy water is going to come out. Unfortunately, for many throughout the country this is not the case. Every year, millions of Americans experience
Health Policy waterborne illnesses. Waterborne illnesses are caused by a variety of sources, including waterborne pathogens such
(CWR). This rule was only finalized after an intensive stakeholder process in which they held over 400 meetings and
As nurses, we recognize clean water is essential to health and a basic human right. It is also essential for providing nursing care. as viruses or bacteria, human or animal waste, heavy metals such as lead or arsenic, or industrial pollutants. Certain populations may also be more likely to be exposed to unsafe drinking water, including lowincome populations and some communities of color.
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I know you have been a champion for environmental justice for some time now. What are some key legislative priorities with regard to clean and safe water? To address a number of urgent clean water issues, the U.S. Environmental Protection Agency (EPA) proposed an update to the Clean Water Act, originally passed in 1972. The Clean Water Act needed to be updated due to the great expansion of knowledge regarding upstream sources of pollution. Researchers now understand how important protecting headwaters and other upstream water sources are to clean water downstream. There was also confusion concerning which waters were protected by the Clean Water Act. This followed two Supreme Court Decisions in 2001 and 2006, directly impacting the drinking water for 1 in 3 Americans. In 2015, the EPA and the Army Corps of Engineers finalized the Clean Water Rule
received over 1 million comments, 87% of which were in favor of the rule. The Clean Water Rule clarifies which “waters of the US” will be regulated under the Clean Water Act. These include traditional navigable waters, tributaries, a small number of waters that have a significant nexus to traditional navigable waters, interstate waters, or territorial seas, and also exempts certain waters such as puddles, ornamental ponds and rain gardens, and continues certain farm exemptions. After the rule was finalized, a number of plaintiffs sued the EPA. The rule was suspended by the Sixth Circuit court until the outcome of these suits. This stay was overruled in Feb-
low-income communities and communities of color—who already face disproportionate exposures from other environmental hazards—may be most impacted. These communities, along with rural communities, are more likely to have poor infrastructure that is not able to handle contaminants in the water. These communities also may not have the resources to upgrade their water systems. They may also be more likely to rely on well water that can be more susceptible to pollution from upstream sources.
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Turning to implications for nursing, why and how can nurses get involved in addressing this issue? The EPA has announced they plan to permanently repeal the CWR; however, this repeal has not been finalized yet. If they repeal this rule, the drinking water for over 117 million Americans could be negatively impacted. Once this official announcement occurs, the nursing voicing will be crucial to protecting this vital public health regulation. There
By actively engaging on clean water issues, nurses can help policymakers and the public make the connection that clean water is essential to health. ruary 2018. During this time the Trump Administration announced they were going to suspend the rule until 2020. This suspension was overruled by the courts in August and the CWR must now be enforced in 26 states. The issues that the CWR addresses are very important to environmental justice communities. If the rule is repealed,
are many ways nurses can be active in this policy arena: • Watch the new webinar from the Alliance of Nurses for Healthy Environments for one-hour free CE that reviews the CWR and provides opportunities for action (https://envirn.org/the-cleanwater-rule). • Sign this petition to Acting Administrator Wheeler ask-
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ing to him to keep the CWR in place. • Call your Senators and Congress people and ask them to support the CWR. • Engage your professional nursing organizations—write a newsletter article and ask them to write a letter to Acting Administrator Wheeler or to Congress. As the most trusted profession, when our nursing organizations actively engage on issues such as clean water, Congress listens. The most vulnerable among us are harmed by dirty water. By actively engaging on clean water issues, nurses can help policymakers and the public make the connection that clean water is essential to health.
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Are there additional resources we should be aware of? The American Nurses Association’s Principles of Environmental Health for Nursing Practice with Implementation Strategies (which is available online here). The Alliance frequently offers webinars (many with free CE) on a variety of environmental health topics. We’re free to join and if you sign up for our newsletter you will be notified of upcoming webinars and opportunities for action. To learn more, visit https:// envirn.org. Janice M. Phillips, PhD, FAAN, RN, is an associate professor at Rush University College of Nursing and the director of nursing research and health equity at Rush University Medical Center.
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The Funny Bone COMPILED BY MICHELE WOJCIECHOWSKI
Let’s face it—when you’re a nurse, funny stuff happens to you or your coworkers a lot. To relieve stress, it’s fun to share them. What follow are stories from people in the nursing field—nurses, students, retirees, etc. The names, initials, and some details have been changed to protect privacy. Enjoy!
All Dressed Up One day I ran into a man and his wife at the grocery store. He greeted me in a warm, friendly way and gave me a big hug. Then he introduced his wife. All the while I’m wondering, “Who in the world is this man?” and “How do I know him?” He could tell I didn’t recognize him. Finally, he said, “Don’t you remember me from the hospital? I was your patient.” “Yes, but I don’t recall your name,” I fudged. When he told me his name, I responded, “Oh, of course. I just didn’t recognize you with your clothes on.” —H.G., RN
Oldies but Goodies I do storytelling sessions at an upscale assisted living place. Here are some fun things that happened with some of my clients. One day, I came in early and saw one of my students, Lilly, reading a book on anti-aging.
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Lilly is still beautiful, and her makeup is flawless. I am in my late 50s, and I could use some advice from Lilly, because Lilly is—are you ready?—102 years old. It’s evident that she knows something about anti-aging— and she’s still reading up on it! During one of my storytelling sessions, one of my students, Amelia, got several disruptive phone calls. I gently reprimanded her. “Oh, Amelia, you have such a busy life!” I quipped. “Sorry,” said Amelia, 91. “When I get old, I will retire and then you can count on my full attention.” One day we talked about how children—sons in particular—forever stay mommas’ boys, no matter their ages. “Yes, that’s true,” said Christina, 93. “My 70-year-old son texted me yesterday saying, ‘Ma, I got kidney stones!’ And I texted back, ‘Yeah! I got them too!’” —N.P, RN
Signed Epstein’s Mother As a school nurse, I deal with little kids and their lit-
tle fibs all the time. One day, I was asking a first grader if his teacher had really given him a pass to come see me. He insisted that she had. Then he handed me the note. “He has a hed egg and a cov,” it read. “It’s really from her,” he said. Sure, it is. —L.L., RN
I Vant To Bite Your Neck While I was at the nursing station of our hospital’s acute geriatric psych unit, one of the patients came shuffling up to the door with his walker. The station is enclosed for safety, and this wasn’t uncommon, as people come up and knock on the windows and doors all the time. That day, a well-dressed and kind psychiatrist with a thick foreign accent answered the door. “What can I do for you?” he asked. The patient looked down at his feet and then replied, “I…um, I’m pretty sure I am a vampire.”
The psychiatrist looked down his nose and pushed he glasses up before responding. “Well, I am pretty sure that you are not a vampire. I think it is lunchtime. Come with me. We will test this theory and have the garlic bread sticks. With that, he left the station and began to walk down the hall with the patient to the lunchroom. (In case you’re wondering, he was not, indeed, a vampire.) —B.B., RN
A Patient Thinks He’s in a Bar I used to work in the neurology unit of a hospital. One day, one of my patients, who had a brain tumor, looked at me and remarked, “You know, you’re really a great barmaid with a big ass.” Even though I couldn’t offer him a rum and Coke, I took it as a compliment. —E.K., RN
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Bro, I’ve Got the Munchies Working in the Emergency Department has gotten more interesting in Colorado since marijuana was legalized. In fact, so many patients have shown up after eating too many edibles (with marijuana in them, of course), that some of my coworkers have suggested that we should make a special waiting room decked out in lava lamps, velvet posters, and music from the 1960s and ‘70s, where these patients can ride out their high. Snacks would be made available to appease any hunger. And, of course, we know that they are doing the right thing because eating too many edibles can lead to a high that is absolutely frightening, but in most cases, the problem resolves itself in a few hours. But this “special” room could make them feel comfortable while they wait. Dude… —A.G., RN
Growing Pains At the hospital where I work, I was doing an admission once, and I asked the patient if he had any allergies to medications. “I’m allergic to Advil,” he replied. Um… I asked him to describe the reaction he had when taking it. “It makes my left arm shrink,” he said. Um… I looked at him, and he replied, “But if I smoke a little, it goes back to normal length. I didn’t want to ask him what he needed to smoke to fix his arm. —R.W., RN
CDC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Daily Nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Indiana Wesleyan University . . . . . . . . . . . . . . . . . . . . C2
UC Davis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
University of Alabama . . . . . . . . . . . . . . . . . . . . . . . . . 43
University of Kentucky . . . . . . . . . . . . . . . . . . . . . . . . . 42
University of Pittsburgh . . . . . . . . . . . . . . . . . . . . . . . . 29
University of Portland . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Vanderbilt University . . . . . . . . . . . . . . . . . . . . . . . . . . 44
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