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What We Talk About When We Talk About “Diversity”: An Interview with Kenya Beard

Kenya Beard

Kenya Beard

On June 18 nurse practitioner and nursing educator Kenya Beard and CHMP senior fellow Jim Stubenrauch and I will be leading Narratives of Diversity: Encouraging Cultural Responsiveness, a daylong event in which we’ll use exercises in reflective narrative to explore issues of diversity and marginalization in health care and health professions education. Our goal will be to foster awareness and generate ideas for making academic and clinical settings more inclusive (the event will be held at the CUNY Graduate Center in New York).

Kenya and I talked earlier this week about her work in promoting multicultural education as a way of increasing diversity in the health professions. Kenya has been a nurse for 28 years, in the emergency room, in a medical-surgical unit, and in home care. She got her doctorate in 2009 and for several years has been on the faculty at the Hunter–Bellevue School of Nursing, where she’s also the founding director of the Center for Multicultural Education & Health Disparities, which “seeks to promote educational reform and restructure institutions in an attempt to strengthen multicultural awareness and workforce diversity.” She is a faculty scholar at the Josiah Macy Foundation, and in 2013 the National Black Nurses Association named her nurse educator of the year. She recently received the Witten Award for Educational Excellence at Hunter College. The following is a lightly edited transcript of our conversation.—Joy Jacobson, CHMP senior fellow, @joyjaco

You’ve worked as a nurse practitioner in home care for a long time. How does your work with patients open your eyes to health care disparities?
When I became a home care nurse I had some patients who were African American grandmothers. I would say, “Miss T, you want your blood pressure under control!” I wanted them to live; I didn’t want them to be a statistic. I would go to the cabinet and say, “This soup is very high in sodium. The sodium is killing you. You have to get rid of this soup.” The next week I’d go back and see the same soup. I never said, “Tell me what’s important to you.” I had to realize I lost some of my identity. It was more like, “Now I have the credential, and let me tell you what you need to do to get better. Let me help you.” We tend to do that.

Isn’t that how a nurse helps a patient?
When I went to school the focus was on educating your patients to help them make autonomous decisions. But when you dissect it—how are we helping them make those decisions? Were we taught from an ethnocentric lens? Joseph Betancourt is a physician at the Disparities Solutions Center at Massachusetts General Hospital, and he says the first thing we need to ask patients is what the disease means to them and what they call it in their culture. We need to take the time. And we don’t have enough time. We have to take the time to listen to patients. If we don’t take the time, the outcomes are going to be what we have had for the last 60 or 70 years, which is health care disparities. A report came out a few years ago that said we spent over a trillion dollars in three years related to health care disparities.

It’s about the nurse being comfortable supporting the patient’s cultural beliefs and decisions even when they conflict with ours.  That can be a hard pill to swallow. We’re in it to save lives. We’re not taught to say, “If the person is okay with this we should support that.” Instead we sometimes imply, “Your cultural beliefs are wrong. You need to listen to me!”

You talk about multicultural education. How is that different from the traditional health professions education?
Everyone comes in for an in-service on cultural competence and they check it off like fire safety. But multicultural education is a reform model that looks at the whole institution. James Banks says it has five dimensions, the first of which is content integration. Where are we getting this content from? For example, many curriculums add on separate books for LGBT concerns and the elderly. But it can’t just be an add-on. We have to see how different populations view illness and disease.

I have classrooms that are so diverse. One student of mine who was Hispanic explained to the class that there was no way in the world her grandmother would change her diet. There was a certain staple in the grandmother’s diet that was contributing to her high blood sugar. She was okay dying at 70 because her quality of life was so great. We did a role-play where an NP said, “We’ve got to get the hemoglobin A1c below 7; she has a 7.6.” The institution isn’t getting full reimbursement unless they have those kinds of outcomes. You can’t operate unless you have full reimbursement. So the philosophy is “Treat to target! Get her under 7!” They began the role-play and my students reminded me that we have no idea what to do when a patient doesn’t listen to us. But by listening to the patient they realized—oh, she does care! It blows their mind. They come away saying, “How do I help get her blood sugar under control without disrespecting her beliefs and values?” It has to start with a healthy relationship.

Many people might assume that health care providers know how to have relationships with patients.
We have a lot of assumptions that are contributing to health care disparities. The system is set up so that nurses assume that when patients are discharged with prescriptions that they will get them filled. If someone doesn’t take his prescription and ends up coming back he’s what some ER nurses call a frequent flier. Sometimes nurses never ask patients. We’re trying to change the system because of health care disparities. Diversity, cultural competence, and health literacy—those three things are crucial to improving the health of the nation.

What about access? What’s happened as a result of improved access to health care for minorities?
Healthy People 2010 and Healthy People 2020 were all about access and quality care. And the ACA is broadening access for minorities. But if I have chest pain at the age of 48 and someone with blonde hair does too, she’s likely to have better outcomes. Why is that? We have to have conversations people aren’t prepared to have, about race, power, and privilege.

You can’t superimpose new initiatives onto old systems and just say “Do it.” Just like we couldn’t impose desegregation on educational systems without some negative ramifications. I am a product of that. They could bus you in but the teachers didn’t have to like you. I was told, “Just be glad you have an opportunity to have the books that the others have.” We had access but at what cost? I remember my first-grade teacher. One day she told us not to erase anything. I went to erase and she said, “Hey, I said no erasing!” And she bit my pencil eraser off with her teeth. My parents said she probably thought I was cheating. They always told me I had to look down at my paper: “Some teachers will think in order for you to get the A you must have cheated.”

I went to a public school where students were bussed in and where some teachers didn’t want to teach us. Are we doing the same thing with health care 50 years later? We talk about diversity, but if we impose it on a system that’s not ready for it, we’ll have tremendous chaos. A provider might get labeled for having bad outcomes from CMS [the Center for Medicare and Medicaid Services]. That person might look at the patient and think, “My outcomes are bad because of you.” I have seen it happen in education. I was at a meeting where someone said their nursing-exam pass rate was low because “we let them in.” My back got all sweaty. I wanted to say, “Hello, I’m in the room, I heard you!” I now welcome those moments. We can’t change anything unless we bring out what people really believe.

How can we encourage people to start examining their beliefs? I imagine not everyone welcomes that opportunity.
Banks talks about prejudice reduction. We all come with biases and we’ve got to expose them. If I’m raised in a household where my parents are saying, “Some of your teachers won’t want to teach you. They might think your scores will make them look bad,” now my lens is jaded. I think: were my parents right? Your beliefs and experiences are going to determine what you see as your reality.

We are all going to have different experiences. There’s no right or wrong; our differences shouldn’t tear us apart. Respect and empathy mean you don’t have to like it, just understand how a person could think that way. We need to build an environment to allow faculty to look in the mirror and ask: what’s working? What’s the hidden curriculum? You have your teaching philosophy. But are you asking your students what they need to succeed? If you do they might say, “I can never find him during office hours” or “When I asked her to explain she said I need to look it up, that I should know it.” What are your biases and assumptions?

Have you worked with doctors as well as nurses around these issues of diversity?
When I did a workshop on cultural competency recently none of the physicians came. When I asked one of my colleagues why, she said that physicians had to put cultural competency in the curriculum years ago. Some think it’s old hat, but health care disparities are still happening. We need to have a discourse on cultural competency in the clinical setting and we need to do it as educators.

People need to talk about diversity initiatives. I’m not there to be the citadel of knowledge. People need a platform to engage in a discourse that allows them to talk and vent. They are in institutions where they sometimes feel marginalized, and they want to be part of a movement that empowers everyone.

How do you help people handle the discomfort that can come up when we start to talk about diversity?
Bob Kegan has written about the orders of consciousness. As children it’s all me me me. But in the fifth order of consciousness it’s not all about you. You’ve shifted to asking what’s best for you and for other people. Most adults never reach the fifth order. But this order is along the lines of Gandhi and Martin Luther King, people who see beyond themselves and see their role in society as making a positive difference. That’s about 5% of the population. The first step is raising awareness.

Kegan plays this movie clip where one man kills another in a religious war and feels tremendous guilt that the son is now an orphan. Gandhi tells the man that he should raise this young boy. But he has to raise him in the religion of his father. That’s what being at that higher order of consciousness is about. Being able to see our interdependence on others and realizing that by helping others we help ourselves. But how do institutions foster patient-provider relationships that recognize our interconnectedness?

Advancing Primary Care in Haiti

The first group of family nurse practitioner students in Haiti

The first group of family nurse practitioner students in Haiti

This guest blog was written by Carol Roye, PhD, RN, FAAN, Professor of Nursing at Hunter College.

We’re making progress on rebuilding primary care in Haiti!

A group of Hunter-Bellevue School of Nursing faculty went to Haiti in June 2010, after the earthquake.  Knowing that the School of Nursing in Port-au-Prince had collapsed, we went  to see how we could help the school.  What we found was a system of nursing education in disarray.  Nurses, in the public schools of nursing, have only a diploma level education.  Yet, nurses provide almost 90% of the health care in Haiti.  They do this without adequate education.

We created a non-profit organization, Promoting Health in Haiti, dedicated to improving nursing education in Haiti.  We saw a very clear need for nurse practitioners — nurses with advanced education in providing primary care.  It took a few years, but on Sept. 26 we began a Family Nurse Practitioner Master’s Program in Léogâne, Haiti.  We are providing classes at an existing 4-year nursing school, Faculté des Sciences Infirmières de l’Université Épiscopale d’Haïti à Léogâne (FSIL), which is supported by the Haiti Nursing Foundation.  This is a huge step forward for nursing in Haiti, and will bring health care to the Haitian people, most of whom have no access to care.

If you want to read more, or support this program, go to www.promotinghealthinhaiti.org

Carol Roye, EdD, RN, CPNP, FAAN, Professor of Nursing, Hunter College, City University of New York

Narrative Writing for Health Care Professionals: Upcoming CE Events

We’re pleased to announce two upcoming continuing education events for nurses who are interested in writing reflective narratives. Both events are co-sponsored by the Center for Health, Media & Policy and Hunter-Bellevue School of Nursing, Continuing Education, and are open to all nurses, nursing faculty, nurse researchers, and nursing students. All are welcome, regardless of prior experience with writing. Joy Jacobson and Jim Stubenrauch, co-founders of CHMP’s program in Narrative Writing for Health Care Professionals, will lead the events. (For more information on the instructors, please visit this page.)

The first event, Narratives of Diversity, is a one-day conference that will focus on issues of diversity and marginalization in nurses’ personal and professional lives, academia, and health care organizations. Participants will gain experience in using reflective writing as a way of processing emotionally charged events to reduce stress and burnout. We will also explore strategies for bringing a raised awareness of diversity and marginalization to one’s community, workplace, or school.

Deborah Washington, PhD, RN

Deborah Washington, PhD, RN

The keynote speaker will be Deborah Washington, PhD, RN, director of diversity for patient care services at Massachusetts General Hospital and a clinical instructor at the MGH Institute School of Nursing. In an interview, Dr. Washington said, “The advantage of working with a diverse workforce is that you work with people who understand specific cultures, beliefs, and attitudes. This translates into better patient care and a greater sense of satisfaction from patients and families with that care.”

The second event, Telling Stories, Discovering Voice: A Writing Weekend for Nurses, is a three-day retreat that will engage participants in an intensive process of reflective writing. We will use creative techniques to sharpen and enliven personal and professional writing, and through group feedback and discussion, participants will gain a new appreciation of the power of their own voices and new tools for sustaining a writing practice. The keynote speaker will be Karen Roush, MSN, RN, clinical managing editor at the American Journal of Nursing and founder of The Scholar’s Voice, through which she mentors writers in the health sciences.

SAVE THE DATES!

Narratives of Diversity will be held on Tuesday, June 25, from 8:00 AM to 5:00 PM
in the Faculty Dining Room at Hunter College (68th Street Campus)
695 Park Avenue, New York City.
Contact hours: 7
Fee: $150 before June 1st; $165 after June 1st; Students (with valid ID) $99
Group discount: $125/person available for groups of 6 or more from one institution.
Registration: By phone: 212.650.3850
On the Web: https://ceweb.hunter.cuny.edu/cers/CourseBrowse.aspx
Enter course code: NARDIV

Telling Stories, Discovering Voice: A Writing Weekend for Nurses will be held
Friday through Sunday, July 19-21 (Fri. 8:00-6:30; Sat. 8:00-5:00; Sun. 8:30-2:30)
at the Hunter-Bellevue School of Nursing (Brookdale Campus)
425 E. 25th Street, New York City
Contact hours: 16.5
Fees and registration information to be announced.

Sleep Smarter, Nurses!

This guest post was written by Jasmin Zaman, a student at the Hunter-Bellevue School of Nursing and the Macaulay Honors College at the City University of New York. Last fall Jasmin took a course in narrative writing for nursing students at Hunter taught by CHMP senior fellows Joy Jacobson and Jim Stubenrauch.

11:46 PM … 12:45 AM … 3:30 AM …

Here we go again. As I toss and turn I lose my hopes of getting eight hours of sleep. It’s Tuesday night. That means tomorrow morning I have to meet my classmates at the lobby of the Hunter dorms to make it to our 7:55 AM meeting for clinicals next door. We have our psychiatric rotations at Bellevue, and I am desperate to catch up on as much sleep as I can.

I was against caffeine when I first entered college but on Tuesday morning I haul my fatigued body to the nearby caffeine watering hole—Dunkin Donuts. My mother always warned me about the evil grasp of coffee and energy drinks, as she believed they were the culprits of my unexplained heart palpitations.

Nursing student Jasmin Zaman and friend

Nursing student Jasmin Zaman and friend

Suffering from insomnia is something I have come to accept. I share this constant battle with my classmates, and it is comforting to know I am not alone. We become so consumed by the day’s activities and by tomorrow’s schedule that it is almost bizarre to just stop—and sleep. Not sleeping the day before clinical days, especially, is a recipe for disaster. An internal disaster. My body fights itself to understand the cause of this sleep deprivation. Without the stimulant effects of coffee my body shuts down. I have often caught myself dozing off on the floor. But if I move into the maintenance phase of caffeination with stimulants like Red Bull or other energy drinks, I’m contributing to my sleeplessness throughout the night.

Studies have shown that the classic theory of sleeping one-third of the day does not correlate with feeling well-rested. Factors such as age and lifestyle contribute to the quality of sleep and feeling rested. It does not matter how much sleep you get, but rather the quality of it. Quality over quantity is best. Rapid eye movement, or REM, sleep, considered one of the most crucial stages of the sleep cycle, is “the only phase of sleep during which the brain is as active as it is when we are fully conscious, and seems to offer our brains the best chance to come up with new ideas and hone recently acquired skills,” says David Randall in a an op-ed, “Rethinking Sleep.”  Read more

And all this while giving medications too?

Ann Campbell, RN-BC, MPH is a hospice nurse at an inpatient palliative and hospice care program in New York, and is currently an NP student at Hunter Bellevue School of Nursing. She is a research associate for the CHMP.

In nursing, we often joke about needing a feeding tube or urinary catheter ourselves. In the 14-hour workday we are often so focused on patient needs that sometimes it’s a luxury to take a break for food or even use the bathroom.

Every nurse I know wants to help people; patients and their loved ones know this from firsthand experience. However, nurses function within the confines of a system driven by economic, political, and legal forces. The challenge to turn caring into policy can seem insurmountable.

As a public health policy masters student at Columbia University, the topic of nurses in leadership positions triggered a memorable discussion. One classmate, when asked if she thought a nurse could become a CEO of a hospital or other health care organization, responded with a resounding “no.”  Nurses lack the necessary clinical and leadership training, she argued. My classmate raised a provocative question; are nurses prepared to become leaders in the redesign of healthcare?

I believe that nurses are uniquely equipped to lead. In fact, a nurse now leads the Center for Medicare and Medicaid Services (CMS).  And many others are CEOs of health care organizations.

Nurses must have the necessary tools and knowledge to influence this complex system. Obviously, the nursing role has evolved dramatically since the days of Florence Nightingale. Modern nursing education deeply involves sciences, and benefits from accomplished theorists and instructors. There are several masters’ level degrees that prepare nurses for clinical, administrative, and educational leadership. Moreover, two doctoral level advanced degrees are available: the research-focused PhD and the clinical leadership DNP.

The clinical leadership Doctor of Nursing Practice (DNP) coursework has been refined by evidence from the Institute of Medicine (IOM) reports: To Err is Human: Building a Safer Health System (1999), Crossing the Quality Chasm (2001), and Health Professions Education: A Bridge to Quality (2003). DNP clinicians are trained in health policy, scientific underpinnings of practice, organizational/systemic leadership, analytics, health information technology, and interdisciplinary collaboration. These tools can be utilized to produce quality healthcare delivery models.

Development of the DNP curriculum has been so effective that the American Association of Colleges of Nursing (AACN) took a position in 2004 recommending that all APNs be doctorally-prepared. While this is what AACN wanted, the plan will not go into effect by 2015.

Despite this progress, nurses must prepare for the challenges ahead. This includes caring for the 32 million newly insured patients with implementation of the Affordable Care Act over the next 10 years as well as a rapidly aging population. An estimated 1.2 million new nurses are needed by 2020. It also includes developing a strategy for changing the mindset of those who do not understand the leadership capacity of nurses.

The IOM report on the Future of Nursing sets forth clear goals for nurses to lead in this dynamic environment:

  1. Practice to the fullest extent of the scope of their education and training
  2. Achieve higher levels of education and training through an improved education system that provides seamless progression
  3. Provide opportunities for nurses to assume leadership positions and to serve as full partners in healthcare redesign and improvement efforts
  4. Improve data collection for more effective workforce planning, information infrastructure, and policymaking

The implications for practice, research, and advocacy are extensive.  With the right education, nurses will lead innovative transformations in healthcare into the future.


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