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Understanding Cultural and Linguistic Barriers

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THE OFFICIAL PUBLICATION OF THE KENTUCKY NURSES ASSOCIATION

Volume 58 • No. 4 Circulation 66,000 to All Registered Nurses, LPNs and Student Nurses in Kentucky October, November, December 2010

President’s PenMy tenure as President

of the Kentucky Nurses Association (KNA) ends in October at the annual meeting of the membership. When I reflect on the past 4 years, the word “change” seems to be the best description of my tenure as President. Evidence of this change includes separation of the association from the labor movement, the sale of our historical home/office, the planning and implementation of the first two health care summits, the introduction of the annual retreat of leadership to discuss strategic and action plans for the association, the reactivation of our cabinets and committees, a complete review of the association’s policies, and a move from virtual offices to our current office suite. I leave my office knowing that the association is positioned for a period of growth!!

As I have discussed the mission of KNA with many nurses during the past 4 years, I have heard that the primary reasons nurses do not belong to KNA is that the association is not relevant, membership costs too much, and the association does nothing. I could not disagree more with these reasons.

There has never been a time in history that membership in the professional association is more relevant. I am fearful that if nurses, no matter what their specialty area, do not unite with a common voice for nursing, the future of nursing practice will be decided by outside parties. Belonging to the state professional nursing organization (KNA) connects members to other nurses in the state and to nurses nation wide through affiliation with the American Nurses Association (ANA).This summer it was an honor to serve as a delegate along with other KNA members at ANA’s House of Delegates. President

Susan Jones

Obama graced the House with his presence and his remarks about nursing would make any nurse beam with pride. What was more impressive was being part of a body of over 600 nurses from across the United States working together to pass resolutions addressing important issues such as the reduction of violence toward all nurses, reaffirming that health care is a basic human right, and supporting initiatives to facilitate the successful integration of new nurse graduates into the work environment. It is the parent association (ANA) that provides nurses with three foundation documents (Standards of Practice, the Code of Ethics, and the Social Policy Statement) that are essential to professional nursing practice. I believe KNA is as relevant today as when the organization was established over 100 years ago.

For over 40 years I have belonged to KNA and for four decades I have listened to numerous complaints regarding the cost of KNA membership. I realize the annual fee is costly; however, I believe it is a small price to pay when we as nurses are responsible for the sustainability of the profession. Also, when reduced to a daily rate, the KNA membership costs less than a soft drink a day…a small price to pay for the growth and development of the nursing profession and the protection of our nursing practice.

In regard to the comment that the association does nothing, please check out our newly created web site to learn of the exciting activities and opportunities for service and involvement for all nurses. Over 300 persons attended the first two interdisciplinary health summits addressing community health concerns on Methamphetamines (2007) and Violence in the Home (2009). Cabinets and committees have been redesigned and there is a place for all nurses to serve. Please check out the impressive program for the 2010 Convention. The theme, Every Nurse is a Leader, will be emphasized throughout the convention and the program is filled with educational sessions, networking opportunities, and avenues for leadership development.

In closing, please know that I sincerely appreciate the support and collaborative spirit of the KNA staff and Board of Directors during the past four years. Your dedication and service did not go unnoticed. Together you have established the foundation necessary to facilitate the growth of KNA. Your efforts have ensured that the association is relevant, cost effective, and will continue to work on behalf of all nurses in the Commonwealth to be the strongest possible voice for nursing and nurses.

Kentucky Nurses Associationwelcomes Our New President

As the KNA extends it’s deepest gratitude to Susan Jones for her tireless work and leadership for the KNA and RNs across the state for the last three years, we are also pleased to welcome our incoming President, Mattie Burton, PhD, RN, NEA-BC. Mattie is the Associate Dean, Health Science and Chairperson of Nursing at Shawnee State University and has served as KNA District 10 President, as a Director on the KNA Board of Directors, and she spent the last year in service as the KNA President-Elect.

Mattie brings great vision and leadership to the KNA and we look forward to her continuing KNA’s momentum and moving the association forward in all areas of policy making, practice issues leadership, nursing involvement in all areas that affect practice, and much more.

Mattie Burton

• Kentucky Nurse October, November, December 2010

INFORMATION FOR AUTHORS• Kentucky Nurse Editorial Board welcomes submission articles to

be reviewed and considered for publication in Kentucky Nurse.• Articlesmaybesubmittedinoneofthreecategories:

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District Nurses Associations Presidents 2010

#1 Carolyn Claxton, RN H: 502-749-7455 1421 Goddard Avenue Louisville, KY 40204-1543 E-Mail: [email protected]

#2 Mary Hauser Whitaker, MSN, RN H: 859-223-1893 682 Springridge Drive Lexington, KY 40503 E-Mail: [email protected]

#3 Maureen D. Kenner, BSN, RN, CPN H: 859-283-1953 1681 Glens Drive Florence, KY 41042 E-Mail: [email protected]

#4 Linda Bragg, RN, MSN, CPHQ H: 502-348-1074 4010 Mary Jo Boulevard Bardstown, KY 40004 E-Mail: [email protected]

#5 Aimee M. Thompson, MSN, RN H: 270-534-4068 330 Rosewood Drive Paducah, KY 42003 E-Mail: [email protected]

#6 Kathy A. Fields, RN, CS, MPA H: 606-598-0362 73 Donald Court W: 606-864-4764 Ext. 119 London, KY 40962 FAX: 606-598-6615 E-Mail: [email protected]

#7 Cathy Abell, PhD, MSN, RN, CNE H: 270-782-3923 637 Willow Bend Circle W: 270-745-3499 Bowling Green, KY 42104 E-Mail: [email protected]

#8 Shelly D. Chandler, MSN-S, RN H: 270-693-5185 4802 US Highway 41A North W: 270-831-9732 Dixon, KY 42409-9334 E-Mail: [email protected]

#9 Carolyn D. Land H: 859-792-8815 8601 Buckeye Road Lancaster, KY 40444 E-Mail: [email protected]

#10 Vanessa Sammons, MSN, RN 440 Highway 173 H: 606-738-4001 West Liberty, KY 42472 E-Mail: [email protected]

#11 Loretta J. Elder, MSN, RN, CAPA H: 270-667-9801 1150 Baptist Hill Road Providence, KY 42450 E-Mail: [email protected]

“ThepurposeoftheKentuckyNurseshallbetoconveyinformationrelevanttoKNAmembersandtheprofessionofnursingandpracticeofnursinginKentucky.”

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Publishing Agency, Inc., 517 Washington Street, PO Box 216, Cedar Falls, Iowa 50613, (800) 626-4081, [email protected]. KNA and the Arthur L. Davis Publishing Agency, Inc. reserve the right to reject any advertisement. Responsibility for errors in advertising is limited to corrections in the next issue or refund of price of advertisement.

Acceptance of advertising does not imply endorsement or approval by the Kentucky Nurses Association of products advertised, the advertisers, or the claims made. Rejection of an advertisement does not imply a product offered for advertising is without merit, or that the manufacturer lacks integrity, or that this association disapproves of the product or its use. KNA and the Arthur L. Davis Publishing Agency, Inc. shall not be held liable for any consequences resulting from purchase or use of an advertiser’s product. Articles appearing in this publication express the opinions of the authors; they do not necessarily reflect views of the staff, board, or membership of KNA or those of the national or local associations.

The Kentucky Nurse is published quarterly by Arthur L. DavisPublishingAgency, Inc. forKNA.Subscriptionsavailableat$18.00peryear.TheKNAorganizationsubscriptionratewillbe$6.00peryearexceptforonefreeissuetobereceivedattheKNAAnnualConvention.MembersofKNAreceivethenewsletteraspartoftheirmembershipservices.Anymaterial appearing herein may be reprinted with permission of KNA.(Foradvertisinginformationcall1-800-626-4081, [email protected].)16mmmicrofilm,35mmmicrofilm,105mmmicroficheandarticlecopiesareavailablethroughUniversityMicrofilmsInternational,300NorthZeebRoad,AnnArbor,Michigan48106.

EDITORIAL BOARD:

EDITORSIdaSlusher,DSN,RN,CNE(2010-2013)

MaureenKeenan,JD,MAT

MEMBERSTrishBirchfield,DSN,RN,ARNP(2009-2012)DonnaS.Blackburn,PhD,RN(2008-2011)

PatriciaCalico,DNS,RN,(2009-2012)SherillCronin,PhD,RN,BC(2008-2011)

JoyceE.Vaughn,BSN,RN,CCM(2010-2013)

REvIEwERSDawnGarrett-Wright,PhD,RNDonnaCorley,PhD,RN,CNE

PamHagan,MSN,RNElizabeth“Beth”Johnson,PhD,RN

DeborahA.Williams,RN,EdD

KNA BOARD OF DIRECTORS—2010

PRESIDENTM.SusanJones,MSN,BSN,RN,PhD,CNE(2009-2010)

PRESIDENT-ELECTMattieH.Burton,RN,ARNP,BC,PhD(2009-2012)

vICE-PRESIDENTK.LeraeWilson,MSN,BSN,RNBC(2009-2011)

SECRETARYPauletteAdams,EdD,MA,BSN,RN(2009-2011)

TREASURERBettyPorter,MSN,BSN,RN,EdD,ARNP,CFNP(2008-2010)

DIRECTORS AT LARGE

KathyHager,MSN,BSN,RN,ARNP,CFNP,CDE,DNPTeenaDarnell,MSN,BSN,RN(2008-2010)

MaryA.Romelfanger,MSN,RN,CS,LNHA(2009-2011)KathyL.Hall,MSN,BSN,RN(2009-2011)

EDUCATION & RESEARCH CABINETJudyL.Ponder,MSN,BSN,RN(2008-2010)

GOvERNMENTAL AFFAIRS CABINETJasonT.Shuffitt,BSN,RN,ARNP(2008-2009)

PROFESSIONAL NURSING PRACTICE & ADvOCACY CABINETGwynethPyle,RN,OCN(2009-2011)

KNF PRESIDENTJaneYounger,MSN,BSN,RN

October, November, December 2010 Kentucky Nurse •

SANELaws for Caring for victims of Sexual

Assault Have Changed.See what Kentucky is Doing to Prepare!

Farrah Guerrant, RN, BSN, SANEEphraim McDowell Regional Medical Center,

Danville, KY

Missy Rittinger, RN, BSN, CFN, SANE-ASt. Elizabeth Healthcare, Edgewood, KY

For many years victims of sexual assault have been faced with what could be one of the most difficult decisions of their life. The decision involves whether to report the assault to law enforcement and receive a complete forensic-medical exam or not report to law enforcement and bypass the forensic -medical exam. This decision must be made quickly and during a time of crisis for the victim. The victim must understand the ramifications of not reporting, i.e. any potential evidence may be lost, injuries will heal, the history of the event will not be told, potential witnesses will not be interviewed, etc. This dilemma will no longer be an issue for victims in Kentucky. In January 2009 the state of Kentucky began to implement regulations mandated by the 2005 Reauthorization of the Violence Against Women Act (VAWA). This mandate requires states to provide victims of sexual assault forensic/medical exams without requiring the victim to report to law enforcement or cooperate with the justice system. In response to this mandate, House Bill 500 was passed in 2010 Kentucky General Assembly and became effective July 15th, 2010.

In order to satisfy the requirements of this mandate, Kentucky’s Sexual Assault Response Team (SART) Advisory Council, co-chaired by the Kentucky State Police (KSP) and the Kentucky Association of Sexual Assault Programs (KASAP) came together to produce a Sexual Assault Forensic-Medical Exam Compliance Guide and Toolkit. The Toolkit will help to ensure that every hospital in Kentucky is equipped with the knowledge and supplies needed to comply with the new law. The Toolkit will provide resources, sample forms, and the supplies needed to perform the sexual assault forensic-medical exam. The intent is to support hospitals in meeting their legal obligations to perform sexual assault examinations on any patient regardless of his/her decision to report. The SART Advisory Council has addressed this and numerous other issues in the compliance guide and toolkit. It clearly outlines the changes in the state and federal law, victim’s rights to choose reporting or non- reporting, hospital’s duty to provide or arrange for secure storage of samples, HIPAA compliance and mandatory reporting laws in Kentucky. Our goal is to ensure every hospital is equipped to provide a timely, comprehensive forensic medical exam regardless of the patient’s desire to cooperate with law enforcement because that is what they deserve.

The implementation of this legislation is complex; however, the reasons for this change are fairly simple. It will increase patient’s access to health care, give patients the opportunity to have evidence collected and preserved in a timely fashion, and provide the patient time to make a decision about reporting. This allows every victim of sexual violence access to medical care for his/her injuries, prophylactic treatment for sexually transmitted infections (STI) and pregnancy, information about HIV, and necessary referrals to community resources for follow-up care and counseling.

The toolkit will be ready for distribution later this summer. For more information and to ensure your local healthcare facility receives this information contact KASAP at 502-226-2704 or Kentucky Hospital Association at 502-426-6220.

Effective June 1, 2010, Sonia Rudolph, RN, MSN, ARNP, FNP-BC has accepted the position of Nursing Division Chair at Jefferson Community and Technical College. This division includes the Associate Degree Nursing Program, The Practical Nursing Programs on the Downtown, Shelby and Carrollton Campuses, The KCTCS Online LPN-ADN Program and the new Patient Simulation Laboratory currently being created on the Downtown Campus.

The University of Kentucky College of Nursing is celebrating its 50th anniversary in 2010. The College admitted its first students in 1960 and enjoys national rankings. The UK PhD Program in nursing is ranked 10th out of 99 private and public PhD programs in nursing (2008 Academic Analytics, LLC Report). The College was ranked 40th among all schools of nursing in National Institutes of Health funding in 2009. The first-time pass rate for BSN graduates taking the NCLEX over the last nine years has been an average of 97 percent. The College’s graduate program is tied at 26th among graduate schools of nursing according to U.S.News & World Report in its 2008 edition of America’s Best Graduate Schools.

Jane Kirschling, DNS, RN, FAAN, and Suzanne Prevost, PhD, RN, COI, both of the University of Kentucky College of Nursing, were awarded $10,000 by the Robert Wood Johnson Foundation for their study, “Supporting Transition to Practice in Rural Kentucky.”

Ellen Hahn, PhD, RN, University of Kentucky College of Nursing, was among 22 persons inducted into the new Sigma Theta Tau International Nurse Researcher Hall of Fame. The award recognizes

KNA Members on the Moveleaders, mentors, scholars and role models whose research has had an impact on the nursing profession and the people it serves. She was also one of three UK health professionals inducted into the Kentucky Institute of Medicine.

Kathy Wheeler, PhD, RN, University of Kentucky College of Nursing, was recently inducted as a Fellow of the American Association of Nurse Practitioners (FAANP). The FAANP program was established in 2000 to recognize nurse practitioner leaders who have made outstanding contributions to health care through nurse practitioner clinical practice, research, education or policy.

UofL School of Nursing doctoral student Lisa Carter-Harris says minorities are under-represented in nursing, a statistic she hopes to change by teaching future students of color. A national scholarship will help her reach that goal.

Carter-Harris has received the Johnson & Johnson Campaign for Nursing’s Future - American Association of Colleges of Nursing (AACN) Minority Nursing Faculty Scholarship for the 2010-2011 academic year. The $18,000 scholarship provides financial support to graduate nursing students from minority backgrounds who agree to teach in a school of nursing after graduation. The AACN will hold $1,500 to cover expenses to attend AACN’s Faculty Development Conference in Austin, TX in February 2011.

“This is quite an honor and very competitive at the national level,” said Rosalie Mainous, PhD, ARNP, NNP-BC, associate dean for graduate programs and research, UofL School of Nursing. “Lisa is one of our points of light.”


The article “Understanding Cultural and Linguistic Barriers to Health Literacy” was originally published in the Online Journal of Issues in Nursing (OJIN) in September, 2009. It is reprinted in the Kentucky Nurse with permission from OJIN.

Kate Singleton, MSW, LCSWElizabeth M. S. Krause, AB, SM

AbstractNurses today are providing care, education,

and case management to an increasingly diverse patient population that is challenged with a triad of cultural, linguistic, and health literacy barriers. For these patients, culture and language set the context for the acquisition and application of health literacy skills. Yet the nursing literature offers minimal help in integrating cultural and linguistic considerations into nursing efforts to address patient health literacy. Nurses are in an ideal position to facilitate the interconnections between patient culture, language, and health literacy in order to improve health outcomes for culturally diverse patients. In this article the authors begin by describing key terms that serve as background for the ensuing discussion explaining how culture and language need to be considered in any interaction designed to address health literacy for culturally diverse patients. The authors then discuss the interrelationships between health literacy, culture, and language. Next relevant cultural constructs are introduced as additional background. This is followed by a description of how literacy skills are affected by culture and language, a note about culturally diverse, native-born patients, and a presentation of case examples illustrating how culture and language barriers are seen in patients’ healthcare experiences. The authors conclude by offering recommendations for promoting health literacy in the presence of cultural and language barriers and noting the need for nursing

Understanding Cultural and Linguistic Barriers to Health Literacy

interventions that fully integrate health literacy, culture, and language.

Citation: Singleton, K., Krause, E., (Sept. 30, 2009) “Understanding Cultural and Linguistic Barriers to Health Literacy” OJIN: The Online Journal of Issues in Nursing. Vol. 14, No. 3, Manuscript 4.

DOI: 10.3912/OJIN.Vol14No03Man04Keywords: health literacy, culture, cultural

competence, interpretation, limited English proficiency (LEP), linguistic competence, transcultural nursing, communication, racial and ethnic health disparities

Low health literacy, cultural barriers, and limited English proficiency have been coined the “triple threat” to effective health communication by The Joint Commission (Schyve, 2007). Nurses, who work with patients from increasingly diverse cultural groups, experience daily how these three threats offer a challenge to the effective provision of care at the system, provider, and patient levels. Over the past 15 years healthcare providers in the United States (US) have begun to address two of these threats to effective care, namely culture and language, and to demonstrate a growing awareness of the need for culturally and linguistically competent healthcare (Campinha-Bacote, 2003; Lester, 1998a, 1998b; Lockhart & Resick, 1997; Maier-Lorentz, 2008; Racher & Annis, 2007; Rees & Ruiz, 2003; Silva, 1994; Smith, 1998).

...health literacy, both conceptually and in practice, has often been siloed from interventions designed to overcome cultural and linguistic barriers. However, health literacy, both conceptually and in practice, has often been siloed from interventions designed to overcome cultural and linguistic barriers. Because health literacy is an emerging field, examination of culture and language as determinants of patient health literacy has been limited (Andrulis & Brach, 2007; Chang & Kelly, 2007; Nguyen & Bowman, 2007; Zanchetta & Poureslami, 2006). To-date, strategies to address health literacy have often

been distinct from, and at times inconsistent with, strategies to increase culturally and linguistically competent care (Andrulis & Brach). Integrating cultural and linguistic consideration with health literacy necessitates an expanded paradigm.

The purpose of this conceptual article is twofold. The first aim is to help nurses appreciate how culture and language can affect patient health literacy. The second aim is to demonstrate the need for nursing interventions that fully integrate health literacy, language, and culture. First we will describe key terms that serve as background for the ensuing discussion explaining how culture and language need to be considered in any interaction designed to address health literacy for culturally diverse patients. Next we will discuss the interrelationships between health literacy, culture, and language. We will then introduce relevant cultural constructs as additional background. This will be followed by a description of how literacy skills are affected by culture and language, a note about culturally diverse, native-born patients, and a presentation of case examples illustrating how culture and language barriers are seen in patients’ healthcare experiences. We will conclude by offering recommendations for promoting health literacy in the presence of cultural and language barriers and noting the need for nursing interventions that fully integrate health literacy, culture, and language.

Key Terms: Health Literacy, Culture, and Language

As authors we use the broadly accepted definition of health literacy developed by Ratzan and Parker (2000) and used in the 2004 Institute of Medicine (IOM) report, titled Health Literacy: A Prescription to End Confusion. In this report, health literacy was defined as “the degree to which individuals have the

Understanding Cultural continued on page 6


capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (IOM, 2004, p. 32). This definition expands upon earlier conceptual understandings of health literacy, which focused chiefly on the written word and native speakers of English. The IOM definition attributes importance to understanding health information for the purpose of decision making, which is integral to the multiple areas of health-related functioning.

We rely primarily on Leininger’s definition of culture, a definition grounded in the transcultural nursing field upon which others concerned with the importance of culture in nursing practice continue to build (Maier-Lorentz, 2008; Racher & Annis, 2007; Smith, 1998). According to Leininger (2002):

Culture refers to the learned, shared and transmitted knowledge of values, beliefs, and lifeways of a particular group that are generally transmitted intergenerationally and influence thinking, decisions, and actions in patterned or in certain ways (p.47).

Purnell and Paulanka (2008) have added to Leininger’s basic definition that culture is largely unconscious; both implicit and explicit; and dynamic, changing with global phenomena.

At a practical level, nurses must be cognizant that culture affects individual and collective experiences that are directly and indirectly related to health. Examples of cultural influences on patient health beliefs and behaviors can be found in patients’ perceptions of locus of control, preferences, communication norms, and prioritization of needs, as well as in their understanding of physical and mental illness and of the roles of the individual, family, and community. We would add the acquisition and application of health literacy skills to this list.

Language, according to Random House’s dictionary.com (n.d.) is “a body of words and the systems for their use common to a people who are of the same community or nation, the same geographical area, or the same cultural tradition”. Language in its many forms is a primary purveyor of culture, yet it does so in ways that are not always easily translated. Limited English proficiency (LEP) is the restricted ability to read, speak, write, or understand English by patients for whom English is not the primary language.

Interrelationships between Health Literacy, Culture, and Language

...culturally bound beliefs, values, and preferences a person holds influence how a person interprets healthcare messages. The concepts of culture and language formally entered discussion of health literacy with the IOM’s acknowledgement that culture affects health literacy skills (2004). More recently, Andrulis and Brach (2007) have noted that language and culture provide the experiential context for comprehension of health information. The culturally bound beliefs, values, and preferences a person holds influence how a person interprets healthcare messages. Knowing about a patient’s language and culture is key for knowing how health literate the person is in a given situation.

The seminal 2003 National Assessment of Adult Literacy (NAAL) (Kutner, Greenberg, Jin, & Paulsen, 2006) measured health literacy disparities in several culturally diverse populations of American adults. Notably, the average health literacy scores for Black, Hispanic, American Indian/Alaska Native, and multicultural adults were lower than those of White and Asian/Pacific Islander adults. Especially striking was the finding that 58% of Black and 66% of Hispanic adults exhibited “basic” or “below basic” health literacy compared to only 28% of white adults. Moreover, bilingual adults, i.e. adults who spoke a language other than English before starting school, had lower average health literacy scores than adults who spoke only English before starting school. It has been recognized that health literacy disparities contribute to racial and ethnic health disparities (Institute of Medicine, 2009), which are widely measured (Agency for Health Care Research and Quality, 2008; U.S. Department of Health and Human Services, 2002).

Researchers are working to clarify how health literacy, culture, and language affect health outcomes (Berkman et al., 2004; Salant & Lauderdale, 2003; Timmins, 2002). We suggest that nurses think about these factors not as neatly co-occurring, but rather as messily interacting in different ways, to different degrees, for different patients. Patients from cultural minority groups may be more subjected to the effects of low health literacy than patients from the dominant culture because of interactions between literacy, cross-cultural communication barriers

including language, and the experience of bias (Berkman et al.). For example, a U.S. born patient with low health literacy and hypertension might be able to communicate with nurses, navigate the healthcare system, and self-manage the disease more effectively than a recent refugee who also exhibits low health literacy and hypertension. The native-born patient would be able to rely on English proficiency and some familiarity with the U.S. healthcare system whereas the refugee would lack experiences in these areas. The ability of nurses to recognize likely interactions between language, cultural, and health literacy barriers; solicit additional information; and adapt communication approaches and care plans accordingly is important for effectively meeting the individual needs of patients.

Cultural Constructs: Background for Health Literacy Discussion

The following section presents relevant cultural constructs/concepts. These constructs, which will be referred to in the ensuing discussion of health literacy and culture, include health belief models, priority identifications, time orientations, and cultural contexts.

Andrews and Boyle (2008) present health belief models/systems that different cultural groups use to explain health and illness. Beliefs relevant to the health literacy discussion include, but are not limited to, magico-religious, biomedical, and deterministic beliefs. Magico-religious refers to belief in supernatural forces which inflict illness on humans, sometimes as punishment for sins, in the form of evil spirits or disease-bearing foreign objects. This view may be found among Latin American, African American, and Middle Eastern cultures. Biomedical refers to the belief system generally held in the US in which life “is controlled by a series of physical and biochemical processes that can be studied and manipulated by humans” (Andrews & Boyle, 2008, p.68). Disease is seen as the result of the breakdown of physical parts from stress, trauma, pathogens, or structural changes. Determinism is the belief that outcomes are externally preordained and cannot be changed. Those holding to this belief system ask questions, such as “If illness is bestowed by God, why try to prevent it or seek treatment?”

Familism and individualism determine whose needs are held as priority needs. In familistic cultures, the family is given priority over the individual. Health-related decision making and problem solving are typically done as a family unit. In contrast, individualism, favored by those living in the US, values independent problem solving and achievement.

Time orientation determines whether a person’s worldview will focus on the past, present, or future, with the latter two most applicable to health. Present orientation may preclude preventive health practices as it prioritizes survival and managing crises over warding off future problems. In contrast, much of the U.S. mainstream healthcare has a future orientation, emphasizing preventive care, new technology, progress, and change. In this orientation time is very specific and promptness is important to people. Time orientation influences situations that can be misinterpreted as numeracy deficiencies; time orientation can impact how strictly a patient adheres to an appointment time or medication instruction. People from predominantly agricultural cultures tend to be less clock-oriented than those living in industrialized cultures (Galanti, 2008; Purnell & Paulanka, 2008).

In high context cultures, members have a group orientation, i.e., closer connections with each other over longer periods of time. There is less need for formal, direct, and written communication, as communication is more about process and relationship than problem solving. In high context cultures the group has a strong external boundary, so outsiders must work harder to earn trust. Alternately, in low context cultures, such as that of the mainstream U.S, members have many superficial connections in which the goal of communication is specific and task oriented so as to clarify rules and procedures and solve problems (Giger & Davidhizar, 2008; Hall, 1981).

How Patient Health Literacy Skills are Affected by Culture and Language

Basic skills applied in health contexts form the basis of health literacy. To be health literate in the US, one needs to be able to effectively apply a variety of skills to accomplish health-related tasks that are often very demanding. Skills include reading and writing in English; speaking and listening in English; numerical computing; critical thinking;

and decision making. Culture and language affect how patients acquire and apply these skills in health situations. While applying these skills, one must be able to move with some comfort between one’s own cultural values and beliefs and those of the dominant healthcare system, which in this article is the U.S. healthcare system. One also needs familiarity with the technical, jargon-rich, biomedical vocabulary used in the English-speaking U.S. healthcare system. The following sections explore some of the necessary health literacy skills and their interconnection with cultural and linguistic skills needed by culturally diverse patients.

Reading and Writing SkillsReading and writing are the skills people often

first consider when thinking about patient health literacy. Patients need to be able to read various items, such as discharge instructions, health education materials, insurance statements, medical bills, nutritional information, and consent forms. Writing skills are needed to complete enrollment and intake forms, insurance claims, living wills, and appeal letters. Reading and writing skills vary for the many foreign-born users of the U.S. healthcare system because language structures and educational opportunities vary from country-to-country. Those who speak English as a second language may be non-literate or semiliterate in their primary language. They may also be accustomed to a different alphabet than the one commonly used in the US. These descriptors represent various skill levels, such as no familiarity with written expression or high literacy in a non-Roman-alphabet system. Each category is predictive both of the level of English proficiency that may be achieved if one is afforded the opportunity to study English and of how well one is likely to comprehend written and/or pictorial health information (Burt, Kreeft-Peyton, & Adams, 2003). There is also a subcategory of LEP patients who, while possessing some skills in reading and writing, may have a cultural tradition of folk medicine, for which information is typically conveyed orally. This can create a disadvantage when patients must transition to the reading and writing demands found in the U.S. healthcare system.

Listening and Speaking SkillsEven when an interpreter is used to facilitate

understanding...cultural issues may still interfere with the effectiveness of communication between the patient and a healthcare provider. Speaking and listening are also health literacy skills that are influenced by culture and language. Lack of English proficiency is itself a clear barrier to a patient’s ability to effectively listen and speak. Even when an interpreter is used to facilitate understanding, or when a patient for whom English is a second language appears to have competent speaking and listening skills in English, cultural issues may still interfere with the effectiveness of communication between the patient and a healthcare provider. For example, many cultures emphasize showing politeness and deference toward healthcare providers who are perceived as authority figures. High context cultures have a preference for indirect, non-confrontational styles of communication; a cultural preference for conflict avoidance can lead patients to say what they believe the healthcare provider wants them to say, or voice agreement or understanding whether or not they actually agree or understand. Asking questions and self-advocating in high context cultures might not be acceptable. Sometimes culture even influences which healthcare provider(s) a patient or family member will listen to and/or speak with. For example, there may be a preference for listening to a doctor over a nurse, or a male over a female. These cultural preferences can influence a patient’s listening and speaking practices in clinical encounters.

Numeracy SkillsNumeracy, or skill with numbers and calculations,

is also important in managing one’s health. It is required for understanding measurement and/or frequency directions, which are important for understanding medication dosing, health insurance and payment information, and test results, as well as managing one’s weight and interpreting blood levels of chemicals and hormones in the body. Although a person’s numeracy skill is most often related to available educational opportunities, some aspects of numeracy can be culturally or linguistically driven. Differences in vocabulary and measuring systems between cultures can result in serious medication

Understanding Cultural continued from page 4



errors. As Andrulis and Brach (2007) pointed out, if someone from a culture that does not use spoons is reading a medication label calling for a teaspoon of medication, the person, not realizing spoons come in different sizes, may take too much or too little of the prescribed medication. Additionally, hearing numerical information presented in English, when English is a second language, can be challenging because many numbers sound similar when spoken. For example, in English, the numbers 14 and 40 can sound very similar.

Understanding the concept of risk and/or the degree of risk of developing a disease or experiencing an adverse event involves complex, numeracy-based, health literacy skills. Determining risk is often dependent on a complicated equation including family history, personal medical history, exposures, and health behaviors. Risk is also socially, culturally, and politically constructed, and dependent on perceptions of danger, hazard, choices, and power (Harthorn & Oaks, 2003). These perspectives and perceptions vary across groups. Magico-religious or deterministic health beliefs may keep some patients from comprehending and acting on risk information.

Critical Thinking and Decision MakingCritical-thinking and decision-making health

literacy skills are required for patients to make crucial health decisions, such as selecting between treatment options, insurance plans, and care providers; deciding when to seek care and what level of care; weighing risks and benefits of health decisions, and deciding on end-of-life preferences. These skills draw upon culturally driven value and ethical systems, preferences, norms, and perceptions. A limitation of the IOM definition of health literacy is the use of the word appropriate in the definition. The IOM uses the term appropriate in regard to health decisions, but appropriateness involves culturally bound values. What the U.S. healthcare system considers appropriate health decisions can be at odds with what culturally diverse patients consider appropriate decisions. In the US it is assumed that individuals are responsible for their own health and health-related decisions. In familistic cultures, individuals may look to the nuclear family, extended family, or family head, be that male or female, to make their decisions. In some patriarchal cultures, males may make decisions for females. In addition, patients make decisions that are congruent with the health belief system(s) to which their culture subscribes. If the provider does not subscribe to the same health-belief system regarding disease etiology as does the patient, health directions may not be followed and conflict may arise between the patient and the provider. Hence, it is important that the provider consider the patient’s beliefs when providing health education and interventions (Chang & Kelly, 2007).

A Note about Culturally DiverseNative-Born Patients

This article encourages nurses also to consider health literacy, culture, and language when caring for culturally diverse, native-born patients. Much of the discussion in this article is most applicable to foreign-born patients whose language, culture, and health literacy barriers are easier to identify because of more obvious cultural and linguistic differences. The NAAL findings are a reminder that diverse, native-born patients can also struggle with health literacy. This is particularly true for the African American population. Nurses must tune into the socially transmitted, culturally based health values, beliefs, and preferences of native-born patients that may be missed in the absence of language barriers. Additionally, culture can influence the spoken and written vernacular language for native-born, English-speaking patients, including vocabulary, grammar, pronunciation, and accents.

There are many reasons why culturally diverse, native-born populations exhibit lower health literacy. One reason is because basic literacy and educational opportunities, which are lower in most native-born minority populations than in the majority population, are highly correlated with health literacy (Kutner et al., 2006). Additionally, Speros (2005), in her concept analysis of health literacy, emphasized that health-related experience is an antecedent to health literacy by noting that “individuals with adequate health literacy skills must have had a health-related experience where they were exposed to the language of health care (p. 637).” Native-born minority patients may have less experience with healthcare because historically healthcare opportunities have been

unavailable to them (Eiser & Glenn, 2007). Current healthcare opportunities may be limited by access barriers, such as insurance status. Furthermore, experiences of discrimination and stigma in the healthcare system can feed mistrust of healthcare institutions and clinicians (Smedley, Stith, & Nelson, 2003) and keep these patients from even seeking healthcare. Racher and Annis (2007) have encouraged nurses to identify and redress their own cultural biases, which become barriers to seeking healthcare for culturally diverse patients.

Rural-dwelling Americans are another native-born population for whom culture and health literacy interact. Rural populations experience negative health outcomes in a number of different areas, including unintentional injuries, oral health, addiction, mental health, and access to care (Gamm, Hutchison, Dabney, and Dorsey, 2003). While most rural-dwelling populations are White, non-Hispanic, and English-speaking, as with native-born minority groups, the acquisition and application of health literacy skills are hampered by lower than average educational attainment and basic literacy, as well as limited prior health-related experiences due to access barriers. Culturally, both Coyne, Demian-Popescu, and Friend (2006) and Giger and Davidhizar (2008) found familism, high context communication, a connection between health and religious beliefs, use of folk remedies, and distrust of outsiders, including healthcare providers, to impact health and health-related communication in rural Appalachian communities.

Case ExamplesThe following case examples connect the dots of

the preceding discussion by illustrating how culture and language can influence patient experiences within three functional domains relevant to health literacy, namely, the health system navigational domain, the clinical domain, and the public health domain (Kutner et al., 2006; Pleasant & Kuruvilla, 2008). Patient experiences illustrating health literacy challenges in each of these domains are presented below. (NOTE: These case examples are not real patients).

Case 1: Navigational Health Literacy DomainAdriana did not understand the time-sensitive

responsibility placed on parents to re-enroll children yearly. Adriana was a 25 year old high school graduate who recently moved to Connecticut from Puerto Rico with her husband and two young children to be closer to family. She was bilingual, but more comfortable speaking Spanish. Her cousin initially helped her fill out the forms to enroll the children in the state’s Medicaid plan. When Adriana called the pediatrician’s office closest to her job to establish care, she felt she was treated with disrespect as she was told that the practice was not accepting new patients on Medicaid. Feeling deterred from seeking healthcare for her children she did not continue her search to find a pediatrician. When her daughter came down with an ear infection several months later, Adriana took her to the emergency department. Adriana and her children spent the summer in Puerto Rico. Upon returning to Connecticut, a friend put her in touch with a pediatrician who was accepting new patients with Medicaid. In attempting to make an appointment, however, Adriana was surprised to find out her children were no longer covered by Medicaid. She had not complied with annual renewal procedures while she was gone.

Navigating procedures for enrolling in and utilizing public healthcare programs can feel convoluted, paperwork intensive, and bureaucratic to patients. In a study of the barriers to insuring children under Medicaid and the State Children’s Health Insurance Program, Latino parents indicated a lack of knowledge about the application process and eligibility, language barriers, difficulty with paperwork, and systems problems (Flores, Brown, & Tomany-Korman, 2005). Culturally, in familial, high context fashion, Adriana relied on family and friends to connect her with health information, even though Spanish language materials and outreach had been part of the public program. After an initial unsuccessful attempt to navigate into primary care, including perceived discrimination based on her accent and type of insurance, she decided to seek treatment for a common childhood ear infection in the emergency department, often the default source of care when challenges deter vulnerable patients from more appropriate sources of care. Adriana also did not understand the time-sensitive responsibility placed on parents to re-enroll children yearly.

Case 2: Clinical Health Literacy DomainSola, a 20 year old Cambodian woman who had

just come to the US, and her husband Deng, a 40 year old Cambodian refugee who had been living in the US for 15 years and was semi-fluent in English, were expecting their first child. Doctors told the couple that the baby’s heart rate was dangerously irregular. The couple went to several specialists who ultimately told them that the baby had an abnormally large valve in his heart. A cardiology nurse drew a picture of the heart with its chambers and valves to show the couple. Deng was astonished, stating that he couldn’t believe the heart had different parts inside of it. The doctors proposed giving Sola a beta-blocker to slow the baby’s heart rate. Sola, new to western medicine, didn’t know what to think about the treatment being proposed. Fortunately the problem corrected itself later in the pregnancy, so she did not need to make a decision while concerned about what a beta-blocker might do to her and her baby.

[Sola and Deng] did not know that Sola had a right to an interpreter and the responsibility to ask questions of her care providers. Sola and Deng, who were semiliterate in their primary language and who had been raised in a familistic, high context, deterministic culture, had not learned about human anatomy in Cambodia. They struggled to understand the potentially serious heart problem that their unborn child faced. Their exposure to doctors in their native country had been limited. They did not know that Sola had a right to an interpreter and the responsibility to ask questions of her care providers. They felt lost without extended family around to help with making these important decisions.

Sola and Deng’s issues are common for people with LEP who lack awareness of the culture of the U.S. healthcare system. While they may know how to seek and participate in healthcare in their native culture, many of these people do not have an understanding of what the U.S. system expects of them as patients in terms of practicing preventive behaviors, compiling and providing one’s personal medical history, adhering to treatment, being proactive in one’s care, and finding ways to pay for care. Nor are these patients necessarily aware of what they can expect from care providers, such as the right to an interpreter or the right to a second opinion.

Depending on their culture of origin, LEP patients with low health literacy may avoid printed health materials, not only because they are printed in English, but also because they are presented in a printed rather than an oral manner. They may also avoid printed materials because of the illustrations showing people who do not resemble them and/or because of the pictures of body parts presented in isolation, which they may never have seen before. In one study, Hunter (2005), a nurse health educator, found cervical cancer education pamphlets were not relevant to her target audience of Mexican immigrant women’s learning needs because of the reading level and because of culturally linked issues of language, content, structure, and visual images.

Case 3: Public Health Literacy DomaiDebra was a 38 year old African American woman

with a tenth grade education living in Houston. She was one of thousands of people living with HIV to be displaced by Hurricane Katrina. Despite a mandatory evacuation decree from Louisiana’s governor and New Orleans’ mayor, Debra had decided to stay in her home. Later, in a temporary shelter, a nurse who was part of the medical response team partnered with Debra to ensure her medication needs were met and to transition her into primary and specialty care. This proved challenging due to the unavailability of Debra’s medical records and the complex medical history that she struggled to recount.

Debra’s story is an example of how culture and health literacy interact for native-born minority patients. Preparedness for a public health emergency, especially for patients like Debra with existing medical conditions, calls for the implementation of future-oriented health literacy tasks. Preparedness tasks include generating plans, procuring medical supplies and extra medications, and constructing personal health records. In the face of an impending public health threat, people must think critically and make decisions as they work to decode low-context information and weigh the risks and benefits of acting on health directives. Communicating risk is challenging for health professionals and accurately interpreting risk is challenging for these patients. Elder et al (2007), in a qualitative study of African Americans’ decisions not to evacuate New Orleans




before Katrina, found that many did not accurately perceive the risk of staying and were confused by inconsistent evacuation recommendations. From a cultural standpoint, the investigators found that African Americans who did not evacuate tended to be optimistic that they would be okay because of religious faith, did not trust law enforcement to protect their property, and often decided to remain with extended family members who were unable to leave.

Recommendations for NursingFar too often providers rely on uninformed

approaches to assess the health literacy of their patients. The realities of today’s healthcare environment require solutions that are practical and effective. We offer the following recommendations to help nurses and all healthcare providers enhance the health literacy of our patients whose backgrounds reflect diverse cultures and languages. The following paragraphs include suggestions related to self assessment, patient assessment, professional education, interdisciplinary collaboration, patient advocacy, educational settings, and interpreters/cultural brokers.

First and foremost nurses should continually develop their ability to practice cultural self-awareness so as to better recognize their own cultural and linguistic assumptions and biases (Purnell & Paulanka, 2008; Racher & Annis, 2007). We would add the ability to recognize health literacy assumptions and biases as part of cultural awareness. To-date, provider self-assessment in the area of health literacy has not been a routine part of nursing practice; there is a need for cultural competence self-assessment tools that incorporate health literacy.

Far too often providers rely on uninformed approaches to assess the health literacy of their patients. Schlichting et al. (2007) found that 63% of providers in community health center settings reported using “gut feelings as a clinician” to estimate patient health literacy. Gut feelings can be imprecise and influenced by unconscious biases. Because health literacy depends on cultural and linguistic factors, there is a need for patient assessment tools that can efficiently collect information on patient health literacy, linguistic ability, and cultural beliefs (Andrulis & Brach, 2007) so that providers do not rely on gut feelings, but rather on assessed data. Nurses can work with other healthcare providers to develop patient assessment tools, as well as strategies that use these tools, to strengthen the healthcare provided. Broad-based patient assessments will enable nurses to explicitly incorporate health literacy into transcultural nursing practice.

New educational settings for patients, nursing students, and practicing nurses that address the interconnections between language, culture, and literacy are needed. This training could involve partnering with a local, adult education center. Adult learners in these centers are eager to practice health literacy skills, such as preparing and asking health-related questions and receiving appropriate health guidance, with nurses in a supported setting. The learners, in turn, can share their cultures and their experiences of accessing health care with nurses.

Nurses can also facilitate partnerships with colleagues in medicine, social work, and public health. All health-related disciplines are struggling to communicate health messages to client populations for whom language, culture, and literacy can be barriers. One approach could involve forming an interdisciplinary learning collaborative on health literacy, culture, and language, in which to share approaches to improving patient care.

Health literacy advocates are needed to motivate healthcare organizations to address patient- communication barriers. Nurses are in an excellent position to serve as such advocates by describing how impaired communication negatively affects patient safety and outcomes, noting how the Joint Commission and federal standards support improvements, and illustrating how decreasing health literacy barriers can bring down legal costs related to communication breakdowns and medical errors (Joint Commission, 2007, 2009; Office of Minority Health, 2001; Minnesota Health Literacy Partnership, 2007). Nurses are encouraged to pursue self-directed learning using the free, web-based resources presented in the Table to develop knowledge and advocacy skills.

Nurses are also well qualified to develop patient forms and educational materials that are appropriate from cultural, linguistic, and literacy standpoints. They are encouraged to develop these materials for the most common patient populations they encounter.

Nurses should make appropriate use of trained medical interpreters and cultural brokers. Andrulis and Brach (2007), and Jackson-Carroll, Graham, and Jackson, (1998) have stressed that interpreters should be cross-trained in cultural competence and health literacy in addition to medical interpretation training. A skilled interpreter will be able to help nurses understand the patient’s cultural perspectives. Chang and Kelly (2007) have reminded us that patients’ cultural beliefs about interpreter use should be considered so as to avoid potential communication barriers. Purnell and Paulanka (2008) have offered additional tips for effective use of interpreters.

ConclusionUnderstanding a patient’s level of health literacy

requires an assessment of the patient’s linguistic skills and cultural norms and the integration of these skills and norms into health literacy strategies for the patient’s plan of care. The challenges related to this integrative process are daunting considering all the other challenges nurses face in providing daily care to their patients. Likewise, the menu of opportunities for improvement can seem long and under resourced. However, nurses can begin to make a difference by working to integrate cultural, linguistic, and health literacy considerations into daily efforts to effectively communicate with culturally diverse patients. It is important to recognize, though, that over the coming years, quality care will not be the mere inclusion of health literacy alongside cultural and linguistic competence. Rather it will be an expanded paradigm that involves the substantive integration of all three in ways that are practical for nurses to implement and that make a difference in the patient experience.

AuthorsKate Singleton, MSW, LCSWE-mail: [email protected]

Kate Singleton is a trauma social worker and an addictions counselor at Inova Fairfax Hospital in Falls Church, Virginia. In both of these positions she helps patients from diverse populations who face a variety of health literacy challenges. Kate previously worked in the adult literacy field as an English as a Second Language (ESL) instructor, curriculum developer, and teacher trainer. It was while working in ESL that Kate became aware of the health literacy needs of adults with limited English proficiency, as her students shared stories of their attempts to access care and communicate their needs in the United States (U.S.) healthcare system. Kate created Pictures Stories for Adult ESL Health Literacy, one of the most popular items on the Center for Applied Linguistics website, to give LEP and low literacy students and teachers a starting point for talking about complex healthcare problems and solutions. The Picture Stories are used widely across the US and abroad to instruct incoming refugees about the U.S. healthcare system. Kate also created the Virginia Adult Education Health Literacy Toolkit, to provide adult educators with information and tools for addressing health literacy education. Kate’s published works were among the first to draw the attention of the health literacy field to the specific health literacy needs of vulnerable populations. Kate continues to consult, present, and publish literature regarding the health literacy needs of limited-English speakers, bridging the fields of adult education, social work, and healthcare.

Elizabeth M. S. Krause, AB, SME-mail: [email protected]

Elizabeth Myung Sook Krause is a Senior Program Officer at the Connecticut Health Foundation (CT Health), the state’s largest private foundation dedicated to improving the health of the people of Connecticut. As Senior Program Officer, she manages CT Health’s ten year strategic objective to reduce racial and ethnic disparities by improving the patient-provider interaction. Her responsibilities include developing programmatic initiatives, reviewing proposals, monitoring a multi-million dollar grant portfolio, and providing technical assistance to grantees. She is a graduate of the foundation’s year long leadership fellowship designed to build a cadre of skilled leaders committed to eliminating racial and ethnic health disparities. Previously, she worked with the Public Health Prevention Service of the Centers for Disease Control and Prevention (CDC). Her tenure with CDC included assignments with the National Center for Injury Prevention and Control and the CDC Foundation where she worked on traumatic brain injury, program evaluation, emergency preparedness, and mobile mammography. During her two year field placement with the Colorado Department of Public Health she was instrumental in developing Colorado’s Office of Health Disparities. Ms. Krause holds an AB from Smith College and an SM (Master of Science) from the Harvard School of Public Health. While at Harvard she studied health literacy with Rima Rudd, her graduate advisor, and went on to initiate successful health literacy programs at the Colorado Department of Public Health and the Connecticut Health Foundation.

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Zanchetta, M., & Poureslami, I. (2006). Health literacy within the reality of immigrants’ culture and language. Canadian Journal of Public Health, 97(S2), S26-S30. Retrieved on May 4, 2009 from http://journal.cpha.ca/index.php/cjph/article/download/1523/1712

Table. Web Resources on Culturally and Linguistically Competent Care and Health Literacy (compiled by authors).

Note: The availability of web resources that take an integrated view of literacy, culture, and language in healthcare is limited. These suggested resources underscore the authors’ call for the development of more integrated models and materials.

• BridgingtheCulturalDivideinHealthcareSettings

www11.georgetown.edu/Cultural_Broker_Guide_English.pdf

• CulturalCompetencePracticeandTraining www.diversityrx.org/HTML/MOCPT1.htm• CulturalDiversityinHealthcare www.ggalanti.com• CulturalOrientationResourceCenter www.cal.org/co/publications/profiles.html• CulturalProfilesProject www.cp-pc.ca• CulturedMed https://culturedmed.sunyit.edu• Ethnomed http://ethnomed.org• HarvardSchoolofPublicHealth:Health

Literacy Studies www.hsph.harvard.edu/healthliteracy• HealthandLiteracySpecialCollection http://healthliteracy.worlded.org/• JointCommissionReport:WhatDidtheDoctor

Say?: Improving Health Literacy to Protect Patient Safety

www.jointcommission.org/NRrdonlyres/D5248B2E-E7E6-4121-8874-99C7B4888301/0/improving_health_literacy.pdf

• NationalInstituteforLiteracyHealthLiteracyDiscussion List

ww.nifl.gov/mailman/listinfo/Healthliteracy• Providers’GuidetoQualityandCulture http://erc.msh.org/mainpage.cfm?file=1.0htm&

module=provider&language=English• TransculturalNursingSociety www.tcns.org/• VirginiaAdultEducationHealthLiteracy

Toolkit www.aelweb.vcu.edu/publications/healthlit/

© 2009 OJIN: The Online Journal of Issues in Nursing Article published September 30, 2009


• Kentucky Nurse October, November, December 2010Up-Date On Nurses Long-

Term Care Insurance Program Benefits And New Features

Great news for the Kentucky Nurses, regarding this serious subject of your Long-Term Care program! As the administrator of the LTC

program, I can tell you we have unprecedented features of importance for the

Nurses and their Families.

As we know so well, the need for Long-Term Care can happen at any time. You may think you are in good health today, but, an unexpected illness, accident, or the natural aging process, can leave us unable to perform those everyday activities we take for granted. Every day we witness that Medical Science is “ramping up,” with one medical breakthrough after another, increasingly stabilizing us and extending us to older age. It’s a good bet that you’ll live longer than previous generations in your family, but, is it a good bet that you’ll be able to afford those extra years?

We all insure our most valued assets: our homes, our cars, our lives. Then why not insure our retirement plans against the devastating costs of Long-Term Care needs? The likelihood of one of a couple having need for Long-Term Care services has increased to 72%. And this percentage continues to grow, again, because of Medical Science. Its human nature to avoid thinking about growing older, but consider, 42% of the people receiving LTC services, are under the age of 65.

Knowing that the likelihood of needing Long-Term Care is very high, it is natural for us to want a comprehensive program that covers all levels of care, but to primarily want every opportunity to have Home Health Care, instead of Facility Care.

It is important to note, with the Nurses primary LTC program, unlike other programs, you can choose your own Care-Giver and it may be a family member, or friend. This is very significant, because it means the Home Health Care benefits can be paid directly to you in your home in cash. This gives you the very best opportunity to stay in the comfort of your home, instead of a facility, by having the option to choose a family member, or friend, to be your Home Health Care Provider.

With the recent proposed changes in Health Care and Medicare, both programs have become very gray. It’s difficult to determine exactly what benefits they are going cover in the future. With your Nurses discounted Long-Term Care program, you and your family will know precisely the benefits that it will provide now and in the future.

For more information on the features and benefits of the discounted Long-Term Care Program for the Nurses and their Families, just call 800-550-4582 and a Long-Term Care Planning specialist will be glad to answer all your questions on this important subject.

L. Robert Wear, CLTCAdministrator for the KNALong-Term Care Program

2010 ANA BYLAWS AMENDMENT 1.

Article VII, Section 4 – The 2010 ANA House of Delegates voted by 97.9% to amend:

Article VII: Congress on Nursing Practice and Economics, Section 4. Term of Office (current)—

Appointment and election of congress members shall be for a four-year term or until successors have been appointed or elected. Congress members are not eligible to serve consecutive terms. Members having served 24 months or more shall be considered to have served a full term.

ToAppointment and election of congress members shall be for a four-year term or until successors have been appointed or elected. Appointment and election of members will be done in such a way as to stagger terms of membership. No elected or appointed member may serve more than two consecutive terms on the congress. Members having served 24 months or more shall be considered to have served a full term.

Rationale: The change allows the ANA Board to make appointments in such a way as to ensure staggering terms. (The amended language is bolded.)

Source: 2010 ANA BYLAWS AMENDMENTS PROPOSAL BOOK.

Submitted By: Betty M. Porter, District 10


Article I. Purposes, and FunctionsThe 2010 ANA House of Delegates by 94.5%

voted to amend: Article I. Purposes, and Functions, Section 3. Functions (Current)—

The functions of ANA shall be to—k. ensure a collective bargaining program for

nurses.l. ensure a workplace advocacy program for

nurses.To

The functions of ANA shall be to—k. support the CMAs’ right to engage in

collective bargaining and workforce advocacy for nurses.

l. delete wording.

Rationale: The amendment endorses the CMAs’ right to use diverse advocacy methods for RNs. It encompasses two broad approaches to workforce issues and is intended to be a unifying functional statement for ANA. (The amended language is bolded).

Source: 2010 ANA BYLAWS AMENDMENTS PROPOSAL BOOK.

Submitted By: Betty M. Porter, District 10

2010 ANA BYLAWS AMENDMENT

Proposed Amendments to the ANA Bylaws 2010Extension of ANA Officers’ Terms

Amend Article V, Section 6.a, by deleting the words “biennially” and inserting “at a biennial

2010 Delegate Reportsmeeting of the ANA House of Delegates”; delete the word “two” and insert the word “four” after the word “for”; and add the following proviso, “This change will commence with the 2012 election of the treasurer and second vice president and the 2014 election of the president, first vise president and secretary.”

Much discussion was heard both in favor and against this amendment. The House voted AGAINST this amendment (76%).

Submitted by: Nancy McConnell, District 1


Amend Article V, Board of Directors, Section 5, Responsibilities, to authorize the ANA Board to establish membership pilot programs in between ANA House of Delegates.

The Board of Directors shall—

hh. For the purpose of retraining and/or increasing membership and on a pilot basis, the Board of Directors may establish membership categories, due rates and payment options that may differ with HOD policies and bylaws. Such pilot programs with the written agreements of involved CMA and shall not exceed the longer of two years or until the conclusion of the next scheduled House of Delegates after the completion of a pilot.

This resolution passed.

Amend Article II, by adding a new section 6, Associate Members, and renumbering the remaining sections.

This resolution was postpone indefinitely.Submitted by: Maggie Miller, District 1

Reference Report 1: Hostility, Abuse and Bullying in the Workplace Background information:

This reference report was submitted by the Federal Nurses Association and co-sponsored by the ANA Center for Ethics and Human Rights Advisory Board, the Center for American Nurses and the Texas Nurses Association. The sponsors pointed out that since 2006 when the ANA House of Delegates (HOD) overwhelmingly supported a resolution aimed at addressing workplace abuse and harassment of nurses, these problems have continued to escalate. ANA is urged to reaffirm and further strengthen the 2006 resolution by reiterating that all organizations in which nurses practice, learn, teach, research and lead, must take appropriate action following incidents of hostile, abusive and bullying behaviors.

Therefore Be It Resolved that the American Nurses Association will:

• Reaffirm and fully support the existingprinciples from the 2006 resolution related to workplace abuse and harassment of nurses and the promotion of healthy work and professional environments for all nurses; and

2010 Delegate Reports continued on page 11


• Workproactivelytoreducethegrowingproblemof workplace abuse, harassment and bullying of nurses and the serious consequences, including severe reprisal and retaliation; and

• Explore collaborative solutions with otherdisciplines and organization to leverage resources for research and education.

Action:Following discussion with overwhelming

positive comments, the resolution passed the HOD with a 99.5 % of the voting members of the HOD supporting the resolution. Suggested implementation activities include publishing a statement to increase awareness of the problem, condemn abuse of all nurses, advocate for policies to address the problem, campaign for codes of conduct in the workplace to prevent nurse abuse, and work proactively with the U.S Congress to increase awareness and together create strategies to address this serious problem in the workplace.

Estimated Cost of Implementation: $35,000-$49,999

Submitted by: M. Susan Jones, District 7

Reference Report 2: Editorial Cleanup of Dues Policy 2.108 “Assessment of ANA Dues from CMAs.”

Background information:This report and resolution was submitted by

the ANA Board of Directors, recommending the removal of outdated language regarding Associate Organizational Members (AOMs) from the ANA, dues policy as AOMs are no longer a part of the ANA structure. Following limited discussion, the resolution was passed with 96.7% of the voting members of the HOD supporting the resolution.

Estimated Cost of Implementation: $0-$499Submitted by: M. Susan Jones, District 7

Reference Report 3: Addressing Health Literacy Through Patient Literacy, submitted by the Louisiana State Nurses Association, observes that healthcare reform is a monumental paradigm shift, which aims to transition the nation’s healthcare from a reactive delivery system to a patient-centered preventive/predictive model. Patients need a good understanding of their health status as well as an understanding of their provider’s instructions. Health literacy becomes an issue when patients do not understand these matters and their role in health decisions and actions. Patient education addresses the problem of poor health literacy. The nation’s patients and consumers of healthcare services need

nurses to drive initiatives to address health literacy concerns.

Summary of Discussion:

All delegates commenting were supportive of the report.

A suggestion was offered on wording to strike ‘created to begin’ in the first resolve and insert ‘collaborative’ between ‘nursing’ and ‘initiatives’.

It was suggested that a Resolve statement be added: “Promote the utilization of existing research findings to strengthen health literacy knowledge and skills in nursing school curricula and the workplace.” Another delegate, as well, pointed to the role of research in promoting optimal health.

A delegate commented that the term ‘burden’ in the Resolve statement suggests that health care is ‘something negative’ and suggested that the word ‘cost’ or a non-judgmental term be used.

A commenter pointed out what seems to be an inconsistency in the report and asks if another reference can be cited on the issue. One of the Whereas statements indicates:

Whereas, the proportion of healthcare is expected to increase the gross domestic product (GDP) and poor health literacy runs an annual price tag of hundreds of billions of dollars;

WHEREAS, nursing is the largest professional group in the healthcare industry and registered nurses professionally and ethically commit to serve and protect patients through the role of patient advocate;

And the report notes:According to the Institute of Medicine, poor health

literacy generates an annual cost of $73 billion (Committee on Health Literacy, 2004).

New Comments:One delegate expressed concerns about the

ability of RNs to accurately assess a patient’s health literacy.

Delegates noted that improving health literacy may reduce the nation’s health burden and improve the quality of care and quality of life.

Another delegate noted that much of the current research reflects an interdisciplinary approach and collaborative efforts are required to address this issue.

The Reference Committee recommends that the ANA House of Delegates approve this proposal as revised.

Recommendation 3:

Madam Chair the Reference Committee moves that:

WHEREAS, nursing is the largest professional group in the healthcare industry and registered nurses professionally and ethically commit to serve and protect patients through the role of patient advocate; and

WHEREAS, the American Nurses Association (ANA) identifies Education as Standard 9 in the Nursing: Scope and Standards of Practice (2004); and

WHEREAS, poor health literacy has been documented to have negative effects on patient health, quality of life, and resources and Nursing has a long history of supporting patients in meeting their healthcare needs, physically, mentally, and emotionally; and

WHEREAS, the proportion of healthcare is expected to increase the gross domestic product (GDP) and poor health literacy runs an annual price tag of hundreds of billions of dollars; and

WHEREAS, The Joint Commission’s 2009 National Patient Safety Goals identify patient education as an evidence-based strategy to improve patient safety; the Patient’s Bill of Rights includes seven (7) statements which address the patient’s right to know about their personal health problems, health status, treatment, alternative care options, and continuing care requirements (US Department of Health and Human Services, 1999); and

WHEREAS, the American Nurses Association encourages the practice of current and future nurses, proficient patient education that promotes patient respect, dignity, safety, rights, and health autonomy gained through empowerment with personal health knowledge:

THEREFORE BE IT RESOLVED that the American Nurses Association shall:

Promote collaborative nursing initiatives to address health literacy problems; and

Utilize existing research findings to strengthen health literacy knowledge and skills in nursing school curricula and the workplace; and

Promote nursing research efforts to identify evidence-based practices that promote optimum health literacy.

Suggested Implementation Activities: NoneEstimated Cost Of Implementation: $75,000-

$99,999.Amendment approvedVote for Resolution # 3:Yes: 93.2%No: 6.8Submitted by: Kathy K. Hager, District 1

Reference Report 4: Safety and Effectiveness of Reprocessed Single Use Devices, submitted by the New York State Nurses Association, identifies the need to ensure that the nursing profession

2010 Delegate Reports continued from page 10



understands the research, clinical practice and ethical issues surrounding the use of certain single use devices (SUDs) in the practice of healthcare. The U.S. Food and Drug Administration (FDA) has stated that certain SUDs can be reprocessed with reasonable safety and effectiveness. Environmental organizations, such as Health Care Without Harm, have endorsed the appropriate reuse of SUDs. It is important for nurses to understand the ethical and safety issues related to the appropriate reuse of these devices based on research and evidence.

Summary of Discussion:There were two comments of support.

More specifically, one delegate indicated ‘even if cost is of importance, it is necessary that best practices and manufacturer’s recommendation for reprocessing be followed.’

New Comments:

The discussion included:

• Concern for medical waste and theenvironmental impact

• Patientsafety• Manufactureraccountability• Samepatientordifferentpatientuse• FDA regulations that potentially misclassifies

SUDs• Theneedforclarificationofwhatdevicescould

be reprocessed• Propercollectionofitemstobereprocessed

There was general support for patient safety and the reduction of medical waste, but multiple comments reflected a lack of clarity about the issue.

The Reference Committee recommends adoption of the revised reference proposal.

WHEREAS, the reprocessing of single use devices is increasingly becoming more commonplace in the nation’s healthcare facilities; and

WHEREAS, in 2008 the US Federal Drug Administration’s analysis of its own Adverse Events Database found ‘no causative link between a reprocessed single use device (SUD) and reported patient injury or death’; and

WHEREAS, there exists a significant body of research literature from peer reviewed journals supporting the conclusion that certain SUDs can be safely reprocessed; and

WHEREAS, some of America’s premier healthcare facilities as listed in the US News and World Report of the nation’s best hospitals in 2008 support the practice of reprocessing of SUDs; and

WHEREAS, there is significant cost savings associated with the use of reprocessed devices; and

WHEREAS, it is estimated that tens of thousands of tons of medical waste can be diverted from landfills by reusing SUDS, thus reducing the environmental impact of the original devices; and

WHEREAS, registered nurses have expressed a need for more information about the safety and efficacy of reusing reprocessed SUDs; and

WHEREAS, registered nurses are concerned about the collection methods being used in some healthcare facilities for the used SUDs and the appropriateness of institutional reprocessing policies and procedures; and

WHEREAS, the American Nurses Association supports reducing the quantity and toxicity of healthcare waste from the manufacturing, purchase and use of products and materials by improving end-of-use product management;

THEREFORE BE IT RESOLVED that the American Nurses Association supports:

Ongoing research efforts in public health, environmental health and nursing to better understand the ethical and safety issues associated with utilizing single use devices; and

The dissemination of research on the practice of using reprocessed single use devices, including the impact on patient outcomes and the environment.

Vote for Resolution #494.1 yes5.9 noSubmitted by: Kathy K. Hager, District 1

Reference Report 5: Mentoring Programs for Novice Nurses

This report submitted by the Massachusetts Association of Registered Nurses focuses on the overwhelming challenges that novice nurses experience when entering the workforce. While some institutions do have preceptor or orientation programs, the emphasis is usually placed on the development of skill-based competencies and meeting organizational priorities. Novice nurses report difficulty transitioning from novice to professional nurse in spite of the programs. Mentoring programs are different in that they are framed to empower the relationship between the novice and the experienced nurse to promote nurse retention and the development of successful nursing careers.

During the discussion of the report, one delegate wanted to be sure that the mentor not have a history of negative behavior and that personalities of both mentor and mentee must be taken into consideration. Another promoted that educating the mentor to the role, such as was done in the ANA pilot project would be a good idea.

The HOD Reference Committee moved that:WHEREAS, novice nurses’ first year in practice

have been identified as a critical important time for successful transition to the professional role; and

WHEREAS, the issue of burnout and the need for improved retention among the nursing workforce, in particular recent nurse graduates, is a national issue and concern; and

WHEREAS, investments in successful mentoring programs, in which strong nursing values and professional development can be nurtured, will not only benefit individual nurses but also contribute to the creation of a stronger, more committed nurse workforce; and

WHEREAS, well designed mentoring programs support the growth and development of novice nurses in their transition to professional practice and provide opportunities for leadership development; and

WHEREAS, the importance of mentoring in the nursing profession has been identified but model mentoring programs have not been developed; and

WHEREAS, the American Nurses Association is dedicated to ensuring that an adequate supply of highly skilled and well-educated nurses is available and is committed to meeting the needs of nurses as well as healthcare consumers;

THEREFORE BE IT RESOLVED that the American Nurses Association will:

Reaffirm its support of initiatives to facilitate the successful integration of novice nurses into the work environment; and

Partner with CMAs, IMD and other nursing organizations to develop mentoring program demonstration projects; and

Disseminate the findings of the mentoring program projects.

The HOD voted: Yes 474 95% No 25 5% Abstain 0

The four-page action report with a reference list will be mailed to all interested KNA members by the writer of this summary. Contact [email protected]

Submitted by: Mary Gail Wilder, District 8

Reference Report 6: Revision Of House Of Delegates Policy “Representation Of CMAs In The ANA House Of Delegates’—Change In CMA Status

Up to this time, there has been no policy about this issue. Thus the HOD passed the resolution that the apportionment of delegates to the HOD needs no recalculation or allotment if a CMA or CMAs leave ANA voluntarily or involuntarily between the time that the CMAs are provided their allotment of delegates and the time that the HOD takes place; and, if a new CMA is recognized by the ANA BOD between the time that the CMAs are provided their allotment of delegates and the time that the HOD takes place, a base level of 3 delegates will be apportioned to the CMA as long as the total of number of delegates provided to the CMAs does not does not exceed 600.

Submitted by: Dr. Maggie Miller, District 1

Reference Report 7: Revision Of House Of Delegates Policy “Representation Of CMAs In The ANA House Of Delegates—Clarification Regarding Dues Paid For Members Without Governance Rights

The resolution passed: CMA and Individual Member Delegate (IMD) representation in the ANA HOD be based on a percentage of ANA total dues income paid by the CMA and the IMD on behalf of individuals with governance rights in ANA as specified in the ANA Bylaws. Dues income does not include rebate payment made to ANA by the CMA for in-state only direct members or funds remitted by the CMA or the IMD to ANA as part of a dues repayment plan or other financial assistance package.

Submitted by: Maggie Miller, District 1

Reference Report 8: Continuation of the Automatic Dues Escalator

Background Information: Submitted by the ANA Board of Directors, this report acknowledges that the automatic dues escalator was passed by the 2004 House of Delegates (HOD) with the stipulation that it sunset in 2010 to assure that its efficacy would be reviewed by the HOD. As this program has been successful and the process has worked well, it is recommended that this sunset clause be removed, allowing the program to continue after 2010.

Therefore Be It Resolved that the American Nurses Association:

House of Delegates amends its policy on “Assessment of ANA Dues from CMAs” paragraph 8 by striking the clause “the American Nurses Association agrees that this automatic dues escalator will sunset in 2010” and allowing the automatic dues escalator to continue in its current form.

Much discussion occurred regarding this issue. The House passed this report with 96% in favor. No amendments were necessary.

Estimated Cost Of Implementation: $1,000 - $4,999


Reference Report 9: Healthcare for Undocumented Immigrants

Background Information: This report and resolution was submitted by the New York State Nurses Association, noting that current healthcare legislation does not include health coverage provisions for the United States’ estimated 12 million undocumented immigrants, resulting in an immigrant population that experiences multiple and variable barriers accessing healthcare services. It recommends reaffirmation of ANA’s position that all individuals living in the United States, including documented and undocumented immigrants should have equitable access to essential health services.


• Reaffirmitspositionthatallindividualslivingin the United States, including documented and undocumented immigrants, have access to healthcare; and

• Educate nurses regarding the wide-rangingsocial, economic, and political ramifications of undocumented immigrants’ lack of access to healthcare services.

Action: Following discussion following several amendments, the final resolution as stated above passed with 78% of the voting HOD members present supporting the resolution.

Estimated Cost of Implementation: $10,000-$14,999

Submitted by: M. Susan Jones, District 7




Reference Report 10: Social Networking and the Nurse

Background Information: Submitted by the North Carolina Nurses Association, this report draws attention to online social networking sites as the fastest growing application on the Web which is creating beneficial opportunities for its users, yet may also create problems. The full impact of the new social networking has not been determined. Professional nurses are reminded of the need to comprehend and to use the online social networking wisely as they maintain patient and organization confidentiality in order to continue to be the most trusted profession.


Support the application of ANA’s foundational documents—Code of Ethics for Nurses; Nursing’s Social Policy Statement and the Nursing: Scope and Standards of Practice—to the use of social networking; and

Encourage and support research on the use of social networking as it relates to nursing.

The House passed this report with 97% in favor. No amendments were necessary.

Estimated Cost Of Implementation: $1,000 - $4,999


The ANA Treasurer‘s Report to the 2010 ANA House of Delegates

The significant declines in the investment market during 2008 and early 2009 were tough on ANA and ANA Retirement portfolios. In 2009, the investment market rebounded but not enough to offset the negative impact on ANA’s net assets in 2008. The 2010 operating budget is essentially a breakeven budget and the ANA Board continues to monitor the economic conditions and strive to maintain fiscal stability.

An overview of ANA’s financial status for 2008 through 2010 are provided in a table titled: Overview of ANA Financial Results 2008-2010.

Overview of ANA’s Financial Results2008-2010

$ in thousands

2008 2009 2010 Audited Audited Budget

Operating Revenue $29,832 $30,359 $31,710 Expense $26,183 $30,395 $31,708 Operating Surplus (Deficit) $3,649 ($36) $2

Non-Operating Distribution from ANCC – – – Investment Gains (Losses) ($2,071) $1,124 – Prior Period Adjustment* ($1,074) – – Pension Related ($8,454) $1,661 – Non-Operating Surplus (Deficit) ($11,599) $2,785 –

Change in Net Assets ($7,950) $2,749 $2Reserve Ratio 22.8% 30.1% 30.1%

*A Prior Period Adjustment was recorded to reflect deferred revenue for member dues which are paid in the current year but a portion or all of the dues remitted will be recognized in the following year.

2008

Overall, ANA had a negative $7.9 million change in net assets for the year. The increase in net assets from operating activities was $3.6 million and was primarily by increases in membership dues revenue and the distribution of funds from the American Nurses Credentialing Center (ANCC). This positive increase from operations was offset by $11.6 million in non-operating losses primarily driven by investment losses on the ANA investment and the ANA Retirement Plan portfolios.

2009Overall, ANA’s net assets grew by 51.7%, due to

an improvement in the investment portfolio and a reduction in the unfunded liability for the ANA Retirement Plan. The result from operations for the year was a deficit of $36 thousand.

Reserve RatioIn June 2002, the ANA Board of Directors

established a minimum goal of 25% for reserves with a desired reserve level of 50%. ANA’s reserves are defined as the unrestricted net assets that to sustain the organization during economic downturns or other unexpected events with negative financial consequences. At the end of 2008 the reserves for ANA dipped below 25% to 22.8%. Due to investment gains in 2009 the reserve balance at the end of 2009 increased to 30.1%. Since ANA did not budget for projected gains or losses on the investment portfolio and budgeted a breakeven bottom line from the operations, the reserve ratio at the end of 2010 is projected to remain at 30.1%.

Source: ANA Treasurer’s Report to the 2010 House of Delegates.

Submitted by: Betty M. Porter, District 10



Kentucky Can win Under Federal Health Care Reform

Reprint from Op-ed Lexington Herald Leader on August 9, 2010

The Patient Protection and Affordable Care Act of 2010 offers significant opportunities for Kentuckians to receive high-quality, affordable health care. We are a small, rural, relatively poor, conservative state where change is often resisted, rather than embraced, thus it is likely that implementing the new law in our state will be challenging and difficult. I am concerned that resistance to change, coupled with insufficient vision and knowledge of what is possible may lead us to squander this opportunity.

The new law offers many financial incentives to assist in transformation of our health care delivery system. If we use the new money and resources to try and solve persistent problems with the same ‘old ways’ of doing things, we are not likely to see improvement in the quality or cost of healthcare in our state. Thus, it is important that nurses, physicians, health policy makers, legislators, and citizens are informed and up to date on the promising health care initiatives that are currently underway in many states and counties across the country.

One such initiative is the Patient-Centered Health Home (PCHH) for delivery of integrated, primary care. Forty-four other states have initiated demonstration projects to test this new model in various forms. The preliminary findings for cost savings and improved quality of care are impressive enough that CMS, the

organization that oversees Medicaid and Medicare, has recently released a call to states to participate in a three year pilot program to set up patient centered health homes. In the PCHH model, emphasis is placed on every patient having a designated doctor or nurse clinician to coordinate their care across various specialists and services. It is a collaborative, rather than authoritarian top down approach, where health professionals work in multidisciplinary teams to provide care of the ‘whole person,’ and patients and families are included as partners when making decisions and setting up treatment plans.

While we have many dedicated health professionals and pockets of great success in overcoming barriers to health in Kentucky, overall the status quo is not working very well for us. Kentucky lags behind the majority of other states in most measures of health. We are more likely to have cancer, diabetes, mental and physical disability with poorer outcomes than people who live in most other states. The reasons, be they environmental, psycho-social, cultural and/or biologic, are complex and poorly understood, and frankly irrelevant at this juncture. We can blame individuals, or government, pharmaceuticals, or TV, but in truth this is ‘our’ problem. All of us are vulnerable to early death, injury and illnesses that in many cases could be prevented or treated more successfully in a high functioning health care system. Regardless of the reasons for our ‘unhealthy state’, we have a window of opportunity to make real and lasting changes to improve the system that we all rely on. To access and use wisely the funds and resources the new law offers, we need informed leadership, commitment and vision, not just in Frankfort, but in every community

and county across the state. Nurses play a crucial role in informing others about health related issues.

Yes, there is a lack of specificity in some of the law’s provisions, but this is not necessarily a reason for fear or criticism of the law. This flexibility can be beneficial, because it allows states like ours to tailor the provisions in the law with the methods and means we choose to meet our unique needs. This makes the need for local leadership and involvement of citizens in the implementation of the law even more important. Where are the legislators who care about this issue? Is our governor looking ahead?

I realize some of our citizens oppose the legislation, and some will use their time and energy to block its implementation. Despite this opposition, I feel certain that the vast majority of us want a healthcare delivery system that is safer, cheaper, less fragmented, easier to access, less frightening and more conducive to healing. Perhaps more than any other, safety is the issue that affects us all. When I hear someone claim we have the best system in the world, I assume they have not experienced a major illness or injury in the last decade.

Today the ‘reported’ cases of deaths due to hospital acquired infection, injury and medical error are the equivalent of several major jet liners crashing every week. If the deaths caused by our broken health system were as obvious as those of a poorly engineered airplane, or inefficient airline, I know the citizens of our state would be demanding change and reform of the system. Instead of resistance to reform, the majority of us would be asking, ‘what can I do to stop the unnecessary loss of so many lives?’

To become involved in this important effort, I urge you to google the website of the Friedell Committee for Health System Transformation or the Foundation for a Healthy Kentucky. From these sites you can access resources to learn about the characteristics of high functioning healthcare systems, the values Kentuckians have identified to guide reform in our state, and the important role of citizens and communities in changing our health system. Some say, ‘there is no stopping an idea whose time has come’. There are major opportunities for reform before us (some of the deadlines for state initiated funding are within months). As nurses, let us work together to create the very best healthcare system for ourselves, our families and generations to come, not just because there is a new law, but because it is the right thing to do and because the system has been broken for a very long time.

Judy Myers PhD, RNCo-chair Work Group on Patient-Centered Health

HomeFriedell Committee for Health System

Transformation1433 St. James Court, Louisville, KY 40208Phone 502-939-6165

Personal Opinion


Kathy Bergman, M.S.N., R.N.C., C.N.S.Faculty, Department of Nursing, College of

Health ProfessionsNorthern Kentucky UniversityHighland Heights, Kentucky

The Northern Kentucky University (NKU) College of Health Professions continues to strengthen links between the school and the regional healthcare community with its Nursing Leadership Clinical Practicum. The practicum is a capstone offering developed for future nursing leaders as they make the transition from academia to their professional careers. The practicum, which has been offered for several years, has been enthusiastically embraced by preceptors who work with students as they develop leadership skills while undertaking projects at large and small institutions throughout the region. A critical care nurse leader at St. Elizabeth, Edgewood, Kentucky who has been a preceptor for several NKU leadership students, noted that “I learned from the students and was constantly amazed at the creativity and energy of the next generation of nurses.” Senior nursing students benefit by observing leaders in everyday roles. A recent NKU graduate who now practices nursing at St. Elizabeth, Fort Thomas, Kentucky stated “Through this course, I learned how to be a leader through a great role model who showed me that hard work and dedication can pay off and make a positive difference in many people’s lives. I believe that by placing nursing students in an environment with a leadership figure, we will greatly enhance the nursing profession when students graduate and begin their careers as RNs.”

During the 16 week practicum, students are expected to participate in clinical leadership activities for a minimum of six hours/week at one of a select group of institutions, including most of the major hospitals in the tri-state area. The list of partner institutions is changed each semester based on community needs and student interests. NKU

College of Health Professions continually seeks new partners and mentors for its students, as it is a great opportunity to create mutually beneficial relationships. During the practicum students observe the leadership/managerial activities in a hospital or community setting under the guidance of a preceptor (generally a leader with a BSN degree) who works at the setting. The student is assigned to a clinical group with a member of the NKU faculty who facilitates and oversees the experience and grades the student’s work product. The end result of the practicum is a “Change Project.” Students, in consultation with the faculty and preceptors, select a project that will be useful to the agency and challenging for the student. Ideally, each project results in a positive program, enhanced expertise and/ or favorable outcome for the institution and the student. Recent change projects include health fairs (some bilingual to assist the Hispanic community), social/educational events for disadvantaged children, educational suppers for abused women, program assistance for veterans, and brochures have been created tackling such diverse topics as embracing grief, and post- traumatic stress disorder.

While focusing on clinical education, the course seeks to combine the leadership competencies learned from experienced preceptors with academic concepts and theories taught in traditional classes. Leadership fundamentals are reinforced with readings from textbooks and weekly assignments. Students are required to document clinical activities in a weekly journal which is submitted to the faculty electronically on a weekly basis. In addition, the students answer questions prepared by the course instructors and submit these answers, along with the journal entries, each week. These questions deal with basic leadership principles and seek to integrate clinical observations with readings. Faculty communicate with, and provide support to the preceptors and students through meetings and correspondence. The practicum culminates with

students presenting their change project during a poster day which is open to the NKU and local communities. The goal of this activity is to allow students to build on their knowledge as well as to positively influence their partner organizations.

This course has generated positive feedback from students, preceptors and institutional representatives and has fostered opportunities for many students to gain employment. While the course is carefully organized, the nature of clinical education is always fluid. A critical care nurse leader elaborated that “Some of the experiences were planned, and some were spontaneous, but the students were always prepared to soak it all in.” NKU believes this course is essential given the trends which face our profession. Indeed, dramatic changes within the health care industry make this an important time for nurses to have leadership skills. Nurses must deal with fast discharges and sicker patients; tight budgets and high expectations. The leadership course at NKU takes advantage of the valued contributions of preceptors and focuses on their leadership skills. A recent NKU graduate stated, “I think the leadership practicum is something that every nursing student should experience. Not only does it bring awareness to the impact that nurses can have in improving patient care and/or decreasing workload for their staff, but it also sets an example for beginning/novice nurses on how to take action to bring about positive change.” We hope that change projects promote a positive impact on our community through building engagement, creativity, critical thinking and professional relationships between students and professionals, helping develop nursing leaders. To aid in the positive contribution the practicum provides to NKU and the community, a database and corresponding compilation of change projects have been created to be used as a reference, available via the NKU College of Health Professions. NKU looks forward to many successful projects in the future, as we build the nursing leaders of tomorrow and a stronger healthcare community for today.

Personal Experience

Accent On ResearchDATA BITS

Do You Hear what I Hear?Physiological monitors are supposed to help

clinicians continuously “watch” patients and alert nurses when help is needed. When alarm frequency is high, however, nurses are at risk for becoming desensitized to the very alarms that are intended to protect their patients. A 2006 American College of Clinical Engineering survey of more than 1300 health care professionals showed that most respondents believe that “nuisance” alarms occur frequently (81%), disrupt patient care (77%), and can reduce trust in alarms, causing clinicians to disable them (78%). The probability of responding to an alarm is lower if the false alarm rate is high. In other studies, researchers reported a high percentage of false positive alarms, stating that alarms result in a change in the management of the patient less than 1% of the time.

Excessive numbers of cardiac monitor alarms and fear that nurses have become desensitized to these alarms were identified as a safety concern by nurses in a 950-bed, academic medical center in the northeast. The purpose of their unit-based quality improvement initiative was to quantify the frequency of cardiac monitor alarms on a single unit and to perform small tests of change to improve management of monitor alarms. The medical progressive unit, a 15-bed unit with 30 nurses, was selected as the pilot area because of its diverse population of patients with various medical conditions that generate many types of alarms. Progressive care patients generally have wide fluctuations in vital signs, are at risk for hemodynamic instability, and are extremely active during the day.

During a 17-month period, the unit carried out several small studies and implemented policy

changes that would systematically reduce the number of false alarms in the unit. The project started with data collection for baseline analysis of number as well as types of alarms that were sounding. Nurses in the unit were asked to fill out a questionnaire to assess monitor knowledge and unit noise level. The nurses were then educated on the best practices for managing alarms. The importance of customizing alarms, as well as troubleshooting common monitor problems, was stressed. The next change was a revision of the default settings programmed into the monitors. The final change was to upgrade the monitoring system to enable nurses to view alarming patients’ vitals signs from a split screen mode from anywhere in the unit. This allowed for nurses to be able to respond quickly when necessary.

In May of 2007 the post intervention survey was completed and compared with previous results. During an 18-day period prior to the study, the number of alarms totaled 16,953, equating to 942 alarms per day or 1 critical alarm every 92 seconds. The total number of alarms after the study interventions was 9,647, which is a 43% reduction in critical physiological monitor alarms in just 1 year. The reduction in the number of alarms could be attributed to adjustment of monitor alarm defaults, careful assessment and customization of alarm parameter limits, and an implementation of an interdisciplinary monitor policy.

This unit based quality improvement initiative successfully decreased nuisance alarms. Alarms are important and potentially lifesaving, although they can also compromise patient safety if they are often false-positive. These nuisance alarms may cause a delay in reaction time or even reduce the possibility of nurses responding. As healthcare technology continuous to advance, it is obvious that this technology is only helpful when properly used. As nursing shortages become greater in the future,

the healthcare field will likely be forced to rely on monitors more heavily and in more areas of the hospital. Patient lives will be at less risk if nurses are educated on the equipment they work with and when the monitors are set to alarm at appropriate parameters. The authors suggest that to sustain change each unit must be held accountable for maintaining a zero tolerance for nuisance alarms and troubleshooting these alarms as soon as they are discovered.

Source: Graham, K. C., & Cvach, M. (2010). Monitor alarm fatigue: Standardizing use of physiological monitors and decreasing nuisance alarms. American Journal of Critical Care, 19(1), 28-34.

Submitted By: Wendy Johnson, Barbara McClaren, and Rebecca Volz, BSN Students at Lansing School of Nursing and Health Sciences, Bellarmine University, Louisville, KY.

Data Bits is a regular feature of Kentucky Nurse. Sherill Nones Cronin, PhD, RN, BC is the editor of the Accent on Research column and welcomes manuscripts for publication consideration. Manuscripts for this column may be submitted directly to her at: Bellarmine University, 2001 Newburg Rd., Louisville, KY 40205.

Teaching Nursing Leadership Through Precepted Change Projects


Home Study Courses Offered by the Kentucky Nurses AssociationHome Study Courses include a written booklet,

fun activities, and an open-book post-test for CE credit. The test, regular grading, and CE Credit are included in the course price. Tests are hand graded by Susanne Hall Johnson with individual feedback on your test. Course must be completed and returned within 3 months of receipt to receive credit.

❑ Assessment of the Families at Risk: High Risk Parenting (AFR) (3) Reviews family assessment and strategies for helping families when child or parent is at medical risk. (6 contact hours) $59.00

❑ Management by Objectives for Nurses (MON) (9) Use the management by objectives technique in your nursing practice to manage a project, group, or professional growth. (6 contact hours) $48.00

❑ Marketing Nursing at the Bedside (MN) (9) Increasing the image, respect, and reputation of the nurse, your unit, and your agency by marketing yourself as a nurse directly to the patient, family, client, physician or management. (6 contact hours) $48.00

Audiotape CoursesAudiotape courses are taught by Suzanne Hall

Johnson and include a booklet with fun activities and audiotape(s). The post-test and CE credit are optional for the audiotape courses. Select just the course, or the course plus the test / credit below. Tests are hand graded by Susanne Hall Johnson with individual feedback on your test.

❑ Increasing Nurses’ Time in Direct Care (DIR) (2) (6 contact hours, 3 tapes and booklet: $65.00. ❑Additional $19 for optional test/credit.)

FACULTYSuzanne Hall Johnson, MN, RNC, CNS is the

Director of Hall Johnson Consulting and the Editor of Nurse Author & Editor. She is a Clinical Nurse Specialist, UCLA graduate with honors, and a Distinguished Alumni from Duke University. (Copyright 2003 Suzanne Hall Johnson)

To order, please check the box in front of the Home Study or Audiotape Course(s) you want to purchase, complete the information below, and return with your check, money order or credit card information to:

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KENTUCKY NURSES ASSOCIATIONCALENDAR OF EvENTS

2010-2011October 201013-16 American Psychiatric Nurses Association Annual Meeting, Louisville

20 11:30 AM Specialty Day at KNA Convention, Louisville, Kentucky

4:30 PM Pre-Convention Board of Directors Meeting (Holiday Inn, Hurstbourne Parkway)

21-22 KNA Convention, Louisville, Kentucky (Holiday Inn, Hurstbourne Parkway)

21 3:00 Education & Research Cabinet

3:00 Governmental Affairs Cabinet

3:00 Professional Nursing Practice & Advocacy Cabinet

November 201011 6:30 PM District 4 Meeting, Location TBA

15 Materials due for January/February/March 2011 Issue of Kentucky Nurse

16 5:30 PM District 7 Meeting, Location TBA

25-26 Thanksgiving Day Holiday – KNA Office is Closed

December 2010 20-31 Christmas Holiday – KNA Office is Closed

January 20111-2 New Year’s Day Holiday – KNA Office is Closed

3 KNA Office Reopens

February 201114 Materials due for April / May / June 2011 Issue of Kentucky Nurse

15 5:30 PM District 7 Meeting, Location TBA

March 20114 “Surviving Your First Year In Practice”, Knicely Center, Bowling Green, KY

April 201119 5:30 PM District 7 Meeting, Location TBA

*All members are invited to attend KNA Board of Directors meetings (please call KNA first to assure seating, meeting location, time and date)

TheHumanTouch

Copyright 1980Limited Edition Prints

byMarjorie Glaser Bindner

RN Artist

Limited Edition Full Color PrintOverall size 14 x 18

Signed and numbered (750)—SOLD OUTSigned Only (1,250)—$20.00

Note Cards—5 per package for $6.50

Framed Prints areSigned and Numbered—$180.00 each

(Framed in Cherry Wood or Gold

THE PAINTING

“The Human Touch” is an original oil painting 12” x 16” on canvas which was the titled painting of Marge’s first art exhibit honoring colleagues in nursing. Prompted by many requests from nurses and others, she published a limited edition of full color prints. These may be obtained from the Kentucky Nurses Association.

The Human Touch

Her step is heavyHer spirit is highHer gait is slowHer breath is quickHer stature is smallHer heart is big.She is an old womanAt the end of her lifeShe needs support and strengthFrom another.

The other woman offers her handShe supports her armShe walks at her paceShe listens intentlyShe looks at her face.She is a young woman at theBeginning of her life,But she is already an expert in caring.

RN PoetBeckie Stewart*

*I wrote this poem to describe the painting, The Human Touch by Marge.” Edmonds, Washington 1994

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Professional Nursing in KentuckyYesterday Today Tomorrow

The historical narrative, Professional Nursing in Kentucky: Yesterday, Today, Tomorrow, is a KNA Centennial Project. Research and authorship was a collective effort of the KNA Centennial Publication Committee. The content was derived from published and unpublished documents in public and private archives of Kentucky schools of nursing, hospitals, colleges, universities, health agencies, libraries and historical societies. Selected photos and individual anecdotes lend a personal touch.

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KNA Centennial videoLest We Forget Kentucky’s

POw NursesThis 45-minute video documentary is a KNA Centennial Program Planning Committee project and was premiered and applauded at the KNA 2005 Convention. “During the celebration of 100 years of nursing in Kentucky—Not To Remember The Four Army Nurses From Kentucky Who Were Japanese prisoners for 33 months in World War II, would be a tragedy. Their story is inspirational and it is hoped that it will be shown widespread in all districts and in schools throughout Kentucky.

POW NURSESEarleen Allen Frances, Bardwell

Mary Jo Oberst, OwensboroSallie Phillips Durrett, Louisville

Edith Shacklette, Cedarflat

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Centennial Medallion

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KENTUCKY NURSES ASSOCIATION MEMBERSHIP APPLICATION200 Whittington Parkway, Suite 101, Louisville, KY 40222-4900(502) 637-2546 Option 2 * (800) 348-5411 * Fax: (502) 637-8236

www.kentucky-nurses.org

wELCOME NEw MEMBERSThe Kentucky Nurses Association welcomes the following new and/or

reinstated members since the July/August/September 2010 issue of the KENTUCKY NURSE.

District #1 Recruited ByBrenda Eilleen AbellLinda J. AndersonMartin H. Anthony WebsiteKasey E. BaileyCathy Lee CatonEvangeline Ann Ceridan Kathy HagerElvira S. DicksonBarbara DimercurioSandra L. HolmesVicki Lee JefferyCarla M. JuddJason MartinShawn R. MeimanKathryn M. MershonLesley K. MottleyLois K. ObertCarol L. PaytonCatherine RobersonLori A. TummondsMiki Lee Woodard

District #2Susan Denise BinghamJulia P. BlackburnNorma J. ChristmanOveta L. Fleenor Linda Dempsey-HallNatalie Lynn HickamDeborah L. KuntzSuzanne S. PrevostKelly S. SimpsonSherry Lynn Wilson

District #3Sheila Ann CarrollMargie L. HuberMark Aaron Washam

District #4 Recruited ByRebecca H. DeatonTracy HallLee Ann Mitchell

District #5Cindy AdamsJoseph D. BenberryTeresa Rae White

District #6Patricia Ann MesserRachel Nicole Smith

District #7Lorraine B. BormannVirginia LaMoyne GoadKimberly Marie JonesAshley Dawn LoganAllison D. McCutchenJacqueline K. PardueGladys M. Sublett M. Susan Jones

District #8Scherrie LaDon Butler

District #9Carolyn D. Land

District #10Robin Ann CarpenterTerry Lynn FisherKellie Lorene Hohenecer

District #11Janice Jill NoffsingerArdith Elaine O’RourkeSondra Upton PriceElaine Birrell Young

KNA would Like To Thank The Sponsors For Their

Generous Support Of The 2010 Convention

Anchor HealthcareArthur L. Davis Publishing Agency, Inc.Baptist Hospital EastBellarmine UniversityCentral State HospitalEastern Kentucky University College of Health

SciencesFederal Medical CenterIndiana Wesleyan UniversityKNA District 1Kentucky Health Access Branch, Department of

Public HealthKentucky Nurses FoundationKentucky Organ Donor Affiliates, Inc.MetLifeThe Gideons InternationalUniversity of Kentucky College of Nursing

president’s pen · impressive program for the 2010 convention. the theme, every nurse is a...

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