Every year, tens of millions of Americans avoid the flu vaccine. During the 2019-2020 flu season, fewer than half of U.S. adults got the shot.
The Latino population is more reluctant than most other groups to get the flu vaccine and often pays a high price with their health. An analysis by the Centers for Disease Control and Prevention of 10 flu seasons showed the Latino community had the third highest flu-related hospitalization rates of any demographic group.
As professors and researchers who study public health, we want to know why the Latino population, in particular, is so wary of the vaccine.
Here are a few reasons: Latinos worry about whether the shot is safe. They wonder if it works. They question whether it’s actually needed. Confidence in the vaccine is a major predictor of influenza vaccination among Latina women.
Getting a flu shot not only stops the spread of the flu. It might also be an indicator of who is willing to get a COVID-19 vaccine – and conversely, who is not, and why. So it is more important than ever to understand why large groups of people are reluctant to get vaccinated – and what might be done to earn their trust. We think our experience at a clinic in rural Indiana might shed some light on this important issue.
Historically Low Rates, Despite High Rewards
Reports from the 2019-2020 influenza season say that 38% of Latino adults were immunized, compared to 41% of Blacks, 42% of American Indian or Alaska Natives, 52% of Asians and 53% of whites. However, when children are included in the calculation rates, numbers for Latinos go up; Latino children are typically immunized with greater frequency than their parents.
Those receiving the shot have fewer lost work and school days. They reduce the risk of seeking medical intervention by 40% to 60%. That includes visits to crowded emergency rooms. In communities with known influenza virus circulation, vaccinations decreased pediatric hospitalizations by 41%. For adults, vaccines reduce the likelihood of admission to an intensive care unit by 82%.
Those with the lowest influenza vaccine rates are also disproportionately affected by COVID-19. Since both illnesses show some of the same symptoms, testing is needed to distinguish one disease from the other. This will divert health care personnel from other tasks. Hospitals already crowded with COVID-19 patients will be asked to make room for those with severe influenza.
This is particularly important this year, as health care providers scramble to prevent the possible “twindemics” of influenza and COVID-19. Even during normal times, the Latino community may be at increased risk of exposure to the flu virus; many have jobs in crowded work environments, like meat packing plants, warehouses and agriculture enterprises.
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A Rural Community Steps Up
The Family Health Clinic in Monon, Indiana, a rural community in White County, Indiana, has worked to build trust with the local Latino population by taking some relatively simple steps. The clinic, recognized by the U.S. government as a place that provides high-quality care to a traditionally underserved population, is staffed by nurse practitioners. Partnering with the Purdue University School of Nursing, the Family Health Clinic serves a clientele that is 52% Latino.
One important part of gaining trust was in making sure the staff were bilingual. Other strategies the clinic used to establish relationships with the Latino population included sponsoring community activities and inviting Latino participation on the clinic board. Perhaps of most importance was generating a reputation for providing a secure, affordable and respectful place for excellent health care in a setting where staff listened to and responded to questions about vaccines.
Brenda Andrade is one of the many who recently received her influenza shot there. She has five children, ranging in age from 4 months to 9 years. Andrade was willing to receive a shot because she wanted to “make sure her family is protected.”
Two more local residents, Juan and Elidia Miranda, also made the flu shot a priority. “We’ve gotten colds every so often, but not influenza,” said Juan Miranda. After talking with clinic staff, they realized the benefits of staying healthy for themselves and their families.
Community health centers like the Monon clinic have long been a trusted source of care for those who don’t otherwise have health care access. They are more than equipped to handle the reasons often given by Latinos as to why they don’t get the shot. But will this willingness to receive the flu vaccine from a trusted source translate to receiving the COVID-19 vaccine when it’s available?
The answer is likely yes. A history of having taken other vaccines is a significant predictor of future behavior, as is a vaccine recommendation from one’s trusted health care provider. Monon clinic staff have already initiated discussion of the rationale for being vaccinated, sharing available safety and efficacy data with patients.
Published courtesy of The Conversation.
Health officials in Austin are considering opening a makeshift hospital as its intensive care units fill up. Patients in North Texas are being treated in lobbies or in hallways. And hospitals around Laredo, Abilene, and College Station have three or fewer intensive care unit beds open, according to state data.
A week into the new year, hospitalizations in Texas have well-surpassed a deadly summer wave that overwhelmed health care workers in the Rio Grande Valley. Health experts have long warned of a dark winter — with a public tired of following safety precautions, a raging pandemic, and cold weather drawing people indoors where the virus can more easily spread. Add to that holiday gatherings and increased levels of travel, which health officials say are already being reflected in the growing numbers of hospitalized coronavirus patients.
The dire figures come as two vaccines, produced in record time, have rolled out to health care workers in a massive undertaking so far beset by confusion and mishaps. The state has reported at least 28,545 fatalities tied to the virus, available intensive care unit beds are at a low and health experts say Texans can’t vaccinate their way out of the current surge. On January 14, the first known case of a new and more contagious coronavirus strain was reported in Texas.
“There’s Physically No Space.”
On April 6, the state started reporting the number of patients with positive tests who are hospitalized. The average number of hospitalizations reported over the past seven days shows how the situation has changed over time by de-emphasizing daily swings.
“Right now, probably half the patients I see never make it out of the waiting room… just because there’s physically no space, and when we do have space it’s limited — nurse staffing also is an issue,” said Dr. Robert Hancock, who works at hospitals in North Texas, Amarillo and Oklahoma. “We’re doing the best we can, but it’s to a point where we’re not providing the care we’d like to.”
In Central Texas, Austin-area health officials forecast the region might run out of intensive care unit beds in the coming days and could start to set up a pop-up hospital as soon as this week. They erected a health facility in the Austin Convention Center as infections soared this summer, and a solicitation obtained by The Texas Tribune in June showed health officials were recruiting volunteers to “provide hands-on care to COVID + patients.” It never took in patients.
Now, “the state is in surge. The state is in crisis,” said Dr. Mark Escott, interim health authority for Austin and Travis County. “It seems very clear to us that we are going to run out of hospital beds, and that we are going to have to stretch resources in order to meet the needs of our community,” he added.
“We’re Admitting Patients Into Areas That Don’t Typically Hold Patients”
Some hospitals in North Texas are holding patients in emergency rooms that are not designed for long-term care because there’s no space in the intensive care units, said Hancock, who is president of the Texas College of Emergency Physicians. It’s nearly impossible to transfer a patient that needs more advanced or specialized care elsewhere — for those patients: “you’re out of luck. There’s nobody that’s going to accept you,” he said.
Hospitalizations lurched upward after Thanksgiving, worsened after Christmas and Hancock expects the situation will continue to deteriorate for the next month.
The hospitals are so crowded he is sometimes treating patients in the lobby and then discharging them because there are no available beds.
Around Fort Worth, some hospitals are running out of both intensive care unit beds and regular beds, said Dr. Justin Fairless, an emergency room doctor and an assistant professor of emergency medicine at a medical school in Fort Worth established by Texas Christian University and the University of North Texas Health Science Center.
At the two hospitals where he works, there are coronavirus patients in the hallway “because there’s nowhere else to put them,” and nursing staff who typically do administrative work are helping see patients, he said. Some health care workers who have the virus have returned to work because there’s not enough staff, he said. They are approved to do so under Centers for Disease Control and Prevention guidance that permit it after symptoms have improved and a certain number of days have elapsed.
During Fairless’ shift Tuesday, patients were being treated in pockets of the hospital not normally used for patient care, like a pre-operation area used by health care workers performing an endoscopy. He sent several patients home that ordinarily would have been admitted to the hospital because of the possible risk that they’d be exposed to the coronavirus.
“We’re admitting patients into areas that don’t typically hold patients and on top of that,” he said, adding that some are being held in the emergency room for up to 48 hours because they “have nowhere else to go.”
The president of the Dallas-Fort Worth Hospital Council said hospitals in the area “have capacity issues, staffing issues and are anticipating another COVID-19 surge in late January.” Elsewhere, in Lubbock, hospitals are full, but the numbers have lessened since the area saw a crush of patients this fall.
Statewide, more than a dozen regions called Trauma Service Areas have surpassed a “high hospitalizations” marker that Gov. Greg Abbott set out and that requires businesses there to scale back capacity to let fewer patrons in. Under Abbott’s order, the business limitations kick in in regions where hospitals are more than 15% full with coronavirus patients for seven-days. The number of people allowed into businesses is reduced from 75% occupancy to 50%, and open bars must close — though many have begun to sell more food to qualify as restaurants.
A Texas Tribune analysis found those remedies set out by Abbott have done little to quash the virus in areas already seeing hospitals fill up.
In Harris County, which had to ratchet back business capacity under Abbott’s order earlier this week, Judge Lina Hidalgo said she was concerned the “threshold has not yielded the necessary change in other areas.”
“Reaching the threshold — activating the rollbacks — doesn’t in and of itself change the trajectory. That’s something that’s in all of our hands,” Hidalgo said.
In the Austin and Travis County area, where there’s been a 160% increase in new hospital admissions since December, Escott said he doesn’t think that “rollback to 50% occupancy at retail and restaurants is doing the trick.”
“I think it was forward-thinking to set those benchmarks, but I think we have to assess the situation and identify whether or not the strategy is working or not — it’s clearly not working,” he said.
Local officials there, he added, have “reached the limits of what we can do under state law, and under the executive orders.”
Abbott’s mandates have barred local officials from taking more aggressive actions, and over the holidays he took aim at an Austin-area curfew that tried to ban late-night dine-in and beverage service for a few days to lessen the virus’ spread.
A spokesperson for Abbott said local officials have “abdicated their authority and refused to enforce existing protocols” by leaving violations unpunished, “further endangering the health and well-being of Texans.”
“Increased restrictions will do nothing to mitigate COVID-19 and protect communities without enforcement,” said spokesperson Renae Eze. “And even states with increased restrictions and lockdowns throughout the pandemic have done little to mitigate the virus, such as California and Rhode Island, which have the highest COVID-19 infection rates per capita in the world, and New York, which is leading the nation in COVID-19 deaths.”
In the meantime, hospitals in parts of the state are full with patients, and vaccine doses are being gradually doled out to health care workers and other vulnerable groups.
Fairless, the emergency room doctor, said the hospital was becoming a more and more “unsafe environment” and was excited to get a second dose of a Pfizer vaccine Wednesday. Driving to the hospital, he said: “I can guarantee I’m going to see the parking lot totally full of people.”
“I’ve gone through H1N1 and all the other flu pandemics,” he added. “I’ve never really seen it this busy — especially at these smaller hospitals.”
Published courtesy of the Texas Tribune.
This is the second part of a special two-part article on the importance of nurse preceptorship and mentoring. Click here to read Part One.
Ethical Standards, Just Culture, and the Faculty/Mentor/Preceptor – Student Relationship
Ethics and standards in nursing are principles associated with values, human conduct, and consideration for others. Nursing ethics, in particular, are ethical principles that guide practice. The principles related to nursing ethics and bioethics overall are beneficence, nonmaleficence, autonomy, justice, and fidelity. Each of these principles contributes to the foundation of nursing education and practice principles, and standards of practice devised by organizations, such as the American Nurses Association (ANA), the International Council of Nurses (ICN), and the American Association of University Professors (AAUP).
According to the ANA Code of Ethics 6.3, the nurse has a responsibility to contribute to an environment that encourages transparency, support, effective interpersonal communication, and respect.11 The National League for Nursing (NLN) indicated that another component of the guiding principles for nursing education is integrity. To exhibit integrity, it requires one to treat others respectfully while communicating courteously and positively.11 Additionally, the NLN identified diversity as an important guiding principle. The NLN position on diversity maintained that the faculty/mentor/preceptor member supports open communication, fosters uniqueness, utilizes innovative teaching strategies regardless of race, gender, religion, age, financial status, physical abilities, or other belief systems.11 The NLN indicated that to create an environment that supports diversity, inclusion, and just culture. All persons should provide open and respectful exchanges.11 This is not limited to the faculty/mentor/preceptor member.
Some of the ways that faculty/mentor/preceptor can achieve creating a just culture is to encourage the students to engage in self-reflection, promote professional practice standards within the curriculum, and be effective role models for collegial.1 Intimidation and disruptive behaviors foster medical error and create poor patient satisfaction, increase the cost of care, and cause knowledgeable clinicians to leave the workforce in search of new professions, thus increasing turnover and shortage rates. Therefore, the faculty/mentor/preceptor can engage and empower the student by creating a culture that is free from intimidation and punitive sanctions.11
Ten best practices to be used to incorporate standards into nursing practice and nursing education, which are: 1) support the nursing code of ethics; 2) offer ongoing education; 3) create an environment where nurses can vocalize concerns; 4) employ interdisciplinary and interprofessional learning; 5) enlist nurse ethicists to speak to nurses; 6) provide unit-based ethics mentors (for practice); 7) hold a family conference (in the practice setting); 8) sponsor an ethics journal or club; 9) reach out to other professional associations for resources; and, 10) offer employee or student counseling services.12 The ANA Code of Ethics, for instance, is a framework for nursing practice.11 Therefore, nurses should be familiar with this code and utilize it as a personal framework for practice.11, 12
The Impact of Negative Role Models
Negative role-modeling, horizontal violence, and aggression on the part of faculty or nurses in the clinical setting each serve to promote barriers in effective precepting and mentoring for the student or trainee. A study performed identified that barriers related to negative role modeling, such as passive-aggressive and threatening behavior and negative faculty and clinical staff attitudes, impede learning and threaten student progression and retention in nursing programs.13 Low retention rates of nursing students directly impact the matriculation of more nurses into the nursing profession, where a shortage already. Students who cannot identify with the nursing profession or fail to become socialized within the profession would eventually leave.13
Negative role models infringe upon the students’ ability to learn and contribute to a negative psychosocial learning environment.13 As the need for new nurses grows concerning an encroaching nursing shortage, effective management of the clinical setting related to students’ ability to think and effectively learn critically is vital. Negative role modeling and horizontal violence occur in both the clinical and classroom settings and have a deleterious impact on the nursing student’s ability to learn and critically think.
The Continuous Need
There is a driving need to develop the knowledge and skills necessary to meet the demands and interpersonal issues evident in today’s patient populations.14 Today’s faculty members, mentors, and preceptors will need to address the needs of a changing society, act as change agents for progress, and be skilled and knowledgeable of technological advances. Further, today’s students need creative learning environments that encourage ethical standards, promote effective interpersonal behaviors, and educate students in rendering multidisciplinary care. The future of health care delivery systems will rely on a multidisciplinary approach to rendering safe and effective care. With the management of care serving to emerge as a critical component in health care delivery, nurses must exhibit leadership and skill in interdisciplinary and collaborative practice to improve health care delivery and quality.
Thus, the faculty mentor and clinical preceptor must incorporate methods to increase interdisciplinary collaboration, education, practice, and exchanges. Furthermore, both are charged with preparing current and future nurses for growth in their respective roles as members of the interdisciplinary health care team. Nurses are being called upon to fill expanding roles and to master technological tools, information management systems while collaborating and coordinating care across teams of health professionals. Therefore, they must work diligently to prepare future nurses for the challenging clinical environment that awaits them.
11American Nurses Association (ANA). (2001). Code of ethics with interpretive statements. Retrieved from http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics.pdf
12Wood, D. (2014). 10 best practices for addressing ethical issues and moral distress. Retrieved from http://www.amnhealthcare.com/latest-healthcare-news/10-best-practices-addressing-ethical-issues-moral-distress/
13Hawthorn, D., Machtmes, K., & Tillman, K. (2009). The lived experience of nurses working with student nurses in the clinical environment. The Qualitative Report, 14(2), 227-244. Retrieved from https://nsuworks.nova.edu/tqr/vol14/iss2/2
14Wilcock, P. M., Janes, G., & Chambers, A. (2009). Health care improvement and continuing interprofessional education: Continuing interprofessional development to improve patient outcomes. Journal of Continuing Education in the Health Professions, 29(2), 84-90. doi:10.1002/chp.20016
Nurse of the Week Ellen Mulkerrins, BSN. RN, OCN has always stood out for her empathy, compassion, and standards of care. The Daisy Award winner cares for cancer patients at Memorial Sloan-Kettering—with emphasis on the word “care”–and as Michelle Sottile, BSN, RN, OCN said in a moving tribute, “I personally saw Ellen’s true gift when she cared for my own family member. Nothing was too much for her to make sure my family member was comfortable, monitored closely and, especially, could laugh, making his hospital stay easier. Her compassion, kindness and dedication will never be forgotten.”
“All her patients are left smiling, asking for pillows to brace their fresh surgical incisions as they try not to laugh.”Virginia Pfeifer, B.S.N., RN, OCN, CWOCN, Memorial Sloane Kettering
Life as a New Yorker certainly hasn’t diminished Mulkerrins’ capacity for empathy. She is known for her ability to “sense unspoken needs” of her patients, as well as for her sensitive treatment and support of those who are in pain or are dying. And, as Sottile makes clear, Ellen Mulkerrins will gladly go the extra mile (or two) to lift patients’ spirits and brighten the last days of those who are not going to recover.
One of Mulkerrins’ patients needed all the brightness his nurse could muster. He checked in with a security… action figure—a Hulk doll he carried as he wrestled with his disease and his fears. Mulkerrins quickly became another source of security and comfort as she gained his trust. As he pondered his deteriorating condition and the growing unlikelihood that he would survive, he spoke to her of his partner, saying that he deeply regretted not having formalized their relationship by getting married. So the OCN took on a side-gig, as a wedding planner.
Mulkerrins orchestrated a ceremony that allowed her patient to tie the knot in the hospital. (He entrusted his Hulk doll to her for the duration). There was music; two nurses walked the wife-to-be down the make-shift “aisle,” and some witnesses were so moved that they followed the tradition of crying at a wedding.
One of Mulkerrins’ colleagues vividly described her effect on the unit. A fellow Sloan-Kettering nurse, Virginia Pfeifer, B.S.N., RN, OCN, CWOCN, said, “To Ellen, caring for patients is not just a job but a passion. She treats each patient as if they were her own family. There is no request from a patient that is too big for Ellen. If there is anything she has taught our staff over the years, it’s that the small things count. All her patients are left smiling, asking for pillows to brace their fresh surgical incisions as they try not to laugh. No matter how difficult the day, Ellen’s passion and joy for the patients and their families is evident.”
For more details on Ellen Mulkerrins, see Michelle Sottile’s article in CureToday.com. And for a feast of outstanding oncology nurses, see CureToday’s 2020 issue of Extraordinary Healer ® (PDF file).
Teaching, precepting, mentoring, guiding, or instructing are all used interchangeably when describing the role that one takes to teach another in any setting. Effective and passionate role models, who are willing to guide another to learn in the work or school environment, are pivotal to the success of an organization.
Mentoring or teaching in the academic nursing setting serves to promote the advancement of nurses in both clinical and academic work environments. Precepting in nursing, which most often occurs in the clinical setting, promotes the use of role modeling and shadowing to build specific skill-sets required for the specialized field of nursing. Guiding and instructing in the nursing academic and work settings consist of mentoring, precepting, role modeling, and input from staff in administrative positions.
Nurses Teaching Nurses
As an operating room nurse, I was blessed to have a wonderful nurse preceptor. She was extremely generous with the knowledge that she had gained over a very long nursing career. Her willingness to spell out each procedure using visual diagrams and thorough explanations helped me to excel. She taught me the surgical procedures, the instruments to be used, the technique to follow, the descriptions of the temperaments of the surgeons for whom I would work, and the way to deal with difficult personalities of the environment. She approached each surgical case with a tenacity of spirit and a drive to provide the very best possible care for each patient…every time. To this day, she embodies the truly compassionate art associated with nurses teaching nurses.
I have been blessed with learning the challenging and unique aspects of nursing from some incredible nurses. I have also learned valuable lessons from those who gave credence to the adage that nurses eat their young. Despite the challenges of navigating the stress associated with those lessons, I have continually modeled the positive behavior of strong nursing preceptors to contribute to the profession. Part of being a strong nursing preceptor or educator is having the ability to recognize the talent around us. When I was working as a clinical educator, I knew that there was a plethora of talent around me. There was a proverbial treasure trove of experience and untapped potential everywhere I went. It was my job to provide education and guidance while ensuring that competencies were met. However, I also felt that it was my responsibility to tap into the potential around me. I encouraged nurses to develop short presentations to share with the staff on topics that impacted their work environments and patient populations. The unofficial program was called simply, “Nurses Teaching Nurses.” Who better to speak to the department about significant issues and patient concerns, than the nurses who had to deal with it every day?
We have so very much to learn from one another. It is so important that we are open to sharing our experiences and to be willing to teach others. Not only does the simple act of sharing what we know serve to help the patients that we serve; it improves the work environment.
When Should We Seek Guidance?
Asking for help and guidance is an important component of learning. The relationship between the student and the faculty member or clinical preceptor should find its foundation in open communication and mutual respect. The faculty member, academic administration, clinical preceptors, and leaders are required to facilitate a learning environment that promotes a just culture, is conducive to learning, and aids students achieve desired didactic and clinical outcomes.1 Likewise, the nursing profession is required to abide by professional standards and a code of ethics. These standards and codes of ethics serve as a guiding force throughout the nursing career. In all of the interactions, nurses have while caring for patients and representing an institution.
What About Mentoring?
Students require strong mentoring to understand his or her potential role as a nurse. Further, faculty members, mentors, and preceptors also require mentoring to be effective leaders in the classroom and clinical areas. Providing active mentorship during the novice educator’s transitioning phase is a helpful strategy that is useful for enhancing effective transitioning for the new educator.2 Therefore, effective mentoring programs provide a strategy for improving retention in nursing.2 Further, equal importance is placed upon the facilitation of positive mentor/preceptor-to-student relationships while they transition into the role.
The National League for Nursing (NLN) created an excellence model to identify eight core elements necessary to attain and maintain excellence in the nursing profession. Additionally, the NLN stressed that the nurses need to understand the principles that are fundamental to their profession, use technology to manage and find information, and be leaders and agents for change.3
The American Association for the Colleges of Nursing (AACN) indicated that the United States faces a major nursing shortage and increased workforce opportunities in the next eight years.4 In 2011, the National Academy of Medicine (NAM) (formerly the Institute of Medicine (IOM)) recommended that all nurses have a Bachelor’s of Science in Nursing (BSN) by the year 2020.5 The NAM’s recommendations create an emergent need to increase the nursing faculty and staff nursing workforce. Nursing is one of the many vocations in which a growing need for improvement of workforce retention exists.
In the wake of a nursing faculty shortage, there is a need to retain current faculty and recruit new faculty. Academic institutions and health care facilities are responsible for the retention of nursing faculty. An important component of maintaining work environments conducive to retention of the nursing faculty workforce is associated with the provision of adequate mentorship. The Health Resources and Services Administration (HRSA) indicated that the primary problems facing healthcare are: financial constraints, healthcare workforce shortages, the changing needs of an aging population, which have prompted a national dialogue on the need for new healthcare models to meet the healthcare demands of the 21st century, facilitation of working nurses’ abilities to participate in continuing education programs and increasing healthcare information technology demands. Medical schools, institutions, practitioners, and students will be required to create strategies for coping with the increased volume of new information and changing patient demographics.6
Improving the Student-Faculty/Mentor/Preceptor Member Relationship through Mentoring
Mentoring is a critical component to the success of a program and the nurse. Mentoring is a relationship between a seasoned and novice professional that aids in developing the novice individual to be a productive component of the team. The goals of mentoring are to assist the novice faculty member in overcoming obstacles encountered in daily work, improving individual productivity, and increase employee satisfaction.7 Mentoring is effective for the faculty member and contributes to the increased awareness on the part of the student via interaction, sharing of enthusiasm, and formulation of new insights that contribute to the advancement of teaching styles.
There are many issues to consider when mentoring or receiving mentorship. The nursing profession has a responsibility to remain vigilant regarding influences that change the direction of not only the profession but in nursing education. Further, nursing educators must work to adapt the changes in a curriculum to model the changes that occur in society, political climate, demographics, economics, workforce trends, and any external or internal issues that may influence change in the way nurses deliver care.8 For change to occur in a curriculum and to build meaningful learning experiences for students, nursing educators need to prepare the nursing student by continually analyzing those forces that impose change and encouraging interpersonal dialogue between students and in the student-faculty/mentor/preceptor relationship.8 Therefore, there is a need for academic administration to construct methods for assessment and to provide the tools to monitor changes as they relate to curriculum design and redesign. Imposing change without assessment and communication will create an ineffective learning environment.
Types of Mentoring Processes and Strategies
Other researchers contend that mentoring effectively enhances cultural diversity in the profession of nursing and academia. Four effective mentoring strategies to encourage academic success consist of communication, professional leadership, confidence-building activities, and students. Further, successful mentoring programs are dependent upon a strong organizational infrastructure.9 Shadowing is another method of mentoring. The literature indicated that shadowing is now a tool for medical residents. The assignment of medical residents to nursing staff, as each makes patient rounds, serves to educate the resident about the role of the nurse.10 Sternszus et al. ‘s 2012 study served to identify the importance of residents as role models, and the impact role modeling had on undergraduate medical students.10
1National League for Nursing (NLN). (2021). Core values. http://www.nln.org/about/core-values
2Culleiton, A. L., & Shellenbarger, T. (2007). Transition of a bedside clinician to a nurse educator. MEDSURG Nursing, 16(4), 253-257.
3National League For Nursing (NLN). (2006). Excellence in nursing education model. http://www.nln.org/newsroom/news-releases/news-release/2006/11/03/excellence-in-nursing-education-model-unveiled-at-2006-nln-education-summit-230
4American Association of the Colleges of Nursing (AACN). (2014). Nursing shortage fact sheet. Retrieved from http://www.aacn.nche.edu/media-relations/NrsgShortageFS.pdf
5Institute of Medicine (IOM). (2011). The future of nursing: Leading change, advancing health. (pp. 221-254). Washington, DC: The National Academies Press. Retrieved from http://books.nap.edu/openbook.php?record_id=12956&page=221
6Health Resources and Services Administration (HRSA). (2010). Addressing new challenges facing nursing education: Solutions for a transforming healthcare environment. Retrieved from: http://www.hrsa.gov/advisorycommittees/bhpradvisory/nacnep/Reports/eighthreport.pdf
7Kapustin, J.F. & Murphy, L.S. (2008). Faculty mentoring in nursing. Topics in Advanced Practice Nursing 8(4).
8Veltri, L. M., & Warner, J. R. (2012). Forces and issues influencing curriculum development. In In D.M. Billings & J.A. Halstead (Eds.), Teaching in nursing: A guide for faculty (4th Ed., pp. 92-104). St. Louis, MO: Elsevier Saunders.
9Wilson, V., Andrews, M., & Leners, D. (2006). Mentoring as a strategy for retaining racial and ethnically diverse students in nursing programs. Journal of Multicultural Nursing & Health (JMCNH), 12(3), 17-23.
10Sternszus, R., Cruess, S., Cruess, R., Young, M., & Steinert, Y. (2012). Residents as role models: Impact on undergraduate trainees. Academic Medicine, 87(9), p 1282–1287. doi: 10.1097/ACM.0b013e3182624c53
Part Two of this article will publish tomorrow.
Nearly overnight, the coronavirus pandemic transformed health care, including perinatal care. Anticipating more and more COVID-19 patients, hospitals needed to create space quickly, both to manage the influx of patients with the disease and to protect non-infected patients from exposure to SARS-CoV-2.
Elective surgeries were postponed, telehealth was utilized when possible, and some care shifted to outpatient with remote monitoring. One procedure that cannot easily be postponed or managed remotely, though, is childbirth. And, even as the pandemic dramatically reshapes parents’ expectations of labor and delivery, the coronavirus is colliding with crises already affecting pregnant people and new mothers and parents — namely, the struggles to reach families in rural or remote areas and to prevent the unnecessary perinatal deaths of Black people.
Melicia Escobar, BSN, MSN, CNM, WHNP-BC, believes this complex moment in perinatal health is one that nurse-midwives, trained to move through a crisis without forgetting the client at the heart of it, are more than prepared to meet.
“This is why I think midwife leaders are really shining in this time, across academic settings, medical centers, and home birth, because that’s what we’re trained to do,” said Escobar, a certified nurse-midwife (CNM) and Women’s Health Nurse Practitioner (WHNP) and Clinical Faculty Director of Georgetown University’s Nurse-Midwifery/Women’s Health Nurse Practitioner (WHNP) and WHNP programs.
Intentional support provided by antenatal and birthcare providers is essential in helping families navigate this crisis safely — as well as mitigating the potential negative effects that the pandemic’s social and economic consequences could have on perinatal health in the future. Escobar considers these and offers action steps for supporting people in pregnancy, birth, and the postpartum period below.
Parents Have Fewer Choices About the Birth Experience
Parents tend to have better outcomes when they are empowered to make choices about their birth experiences.
“Having options, offering unbiased guidance around those options, and listening to clients is so important. When people have options for where to birth, for example, and have information to weigh pros and cons, then they know where they should be,” said Escobar. “They know what’s best for them. We just need to listen.”
Consider one key decision parents have to make: Where should I have my baby? In many rural areas, birthplace options can be extremely limited. Options for out-of-hospital care may be rare, and even when parents choose an in-hospital birth, they may only have one hospital accessible to them. Some community hospitals have discontinued childbirth services completely, forcing families who want a hospital birth to travel elsewhere for care.
A CNM in Philadelphia, Escobar set the scene of the pandemic’s early days: “People were afraid of being in a hospital and exposing themselves or their babies to COVID-19. They were also afraid of being subject to hospital policies around COVID-19.”
At some hospitals, one such regulation was limiting the number of support people allowed at the birth to reduce providers’ exposure. But there was an unintended — and unjust — effect, as detailed in the article “Reflecting on Equity in Perinatal Care During a Pandemic” in Health Equity: “A policy of no support persons unduly impacts marginalized communities and implicitly reinforces the ‘sacrificial’ or expendable status of Black and Indigenous parents, who have long borne the consequences of mistreatment and abandonment in their health care experiences.”
Protecting parents’ options and respecting their choices surrounding the birth experience is especially important in a crisis. Options should be safe, affordable, and respectful — in other words, a real choice among viable options.
Whether because of the coronavirus or biased, inequitable treatment, “it’s not really a choice when going into the hospital can mean real and present danger,” said Escobar.
Existing Risk Factors May be Compounded, Especially for Women of Color
Prior to the pandemic, pregnant and birthing people in marginalized groups were already at higher risk of complications and death, as explored in [email protected]’s “How Does Race Impact Childbirth Outcomes?” Perinatal mortality rates are highest among Black women in the United States, as are rates of severe maternal morbidity (SMM), an unexpected labor and delivery outcome that may create significant short- or long-term consequences for a person’s health.
~42 non-Hispanic Black women die for every 100,000 live births, compared to 13 deaths for non-Hispanic white women.Source: CDC, “Pregnancy Mortality Surveillance System.”
70 cases of severe maternal morbidity events, or “near misses,” occur for each maternal death of a non-Hispanic Black woman.Source: The American Journal of Managed Care, “Racial Disparities Persist in Maternal Morbidity, Mortality and Infant Health.”
~4.2% of non-Hispanic Black women experience a severe complication compared to 1.5% of white women.Source: American Journal of Obstetrics and Gynecology, “Site of Delivery Contribution to Black–White Severe Maternal Morbidity Disparity.
Some methods of adapting perinatal care during the pandemic could ultimately prove harmful to women, especially women of color, according to the aforementioned Health Equity article. For example, some providers have encouraged early inductions and elective cesarean births (C-sections) to help manage “hospital census and staffing.”
However, these procedures often require increased close contact between patients and providers, increasing the risk of COVID-19 exposure. They can also lead to longer inpatient stays, creating a higher risk for both the parent and newborn.
“Given that women of color already experience higher rates of inductions and cesareans, these policies are likely to further exacerbate the disparities in outcomes,” wrote the article’s authors.
Traumatic Experiences Could be Worsened
Most people bring trauma into the childbirth experience to begin with, said Escobar. COVID-19 adds another layer of stress and fear that may be especially difficult for expectant parents.
~14% of women are affected by perinatal depression.Source: National Institute of Mental Health, “Perinatal Depression.”
~9% of women experience post-traumatic stress disorder (PTSD) after childbirth caused by real or perceived trauma during delivery or postpartum.Source: Postpartum Support International, “Postpartum, Post-Traumatic Stress Disorder.”
“Then there’s a second-layer trend where Black, Indigenous, and people of color (BIPOC), who already enter our health system at a disadvantage and carrying trauma, are forced to choose between COVID risk and a system in which they perceive they are unsafe due to racism and bias,” said Escobar.
“The baseline level of trauma that Black birthing people in particular experience is already so high,” said Escobar. “For folks opting to stay out of care or seeking out-of-hospital birth, it is very easy to understand the logic: Why compound things by introducing either of those two factors, COVID risk and racism?”
Action Steps for Supporting Maternity Care in a Crisis
Giving birth during a pandemic can be traumatic, especially for those who have already experienced trauma in the health care system. With trauma comes fear. When people — both patients and providers — start making fear-based decisions, “that’s when you start getting bad outcomes,” Escobar said.
Still, a negative outcome does not have to be traumatizing. Listening to and empowering the person giving birth can transform the experience.
“There have been clients I’ve been caring for in labor who have had obstetric emergencies, like postpartum hemorrhages or uterine abruptions, where my perception was that the experience was probably traumatic for them,” said Escobar.
However, the patient tells a different story. “Afterwards when we were debriefing, one of those clients said to me, ‘Thank you so much. That was the most empowering experience in my life,’” she said.
Escobar believes the difference between a traumatic childbirth and a difficult but empowering birth is in listening, sharing information, and partnering together even in the midst of a crisis. When people start from a place of listening to expectant parents, they can understand and mitigate their fears. They can work through or around the trauma to comfort the client and overall have better outcomes — even if the childbirth has scary elements.
Below, find suggestions for providers, loved ones, and communities to better listen to and support women in pregnancy and the postpartum period during the coronavirus pandemic and beyond.
- Adopt a midwifery-model mindset: Nurse-midwives are trained to stay calm in difficult births, create an action plan, and move through it with the person “always centered,” said Escobar.
- Treat listening and clear communication as vital clinical skills, as essential as doing an abdominal exam or listening to heart sounds.
- Listen to the client, especially when discussing sexual health history and gender-based violence.
- Find ways to communicate empathy and understanding, even through layers of personal protective equipment.
- Share information and partner with the patient throughout their care, especially in potentially traumatic childbirths.
How Can Family and Friends Offer Support When You’re Expecting During a Pandemic?
Reserve judgement and honor the choices being made around childbirth and coronavirus precautions.
- Before visiting, ask about the family’s comfort level with in-person interactions, and again, avoid adding to guilt or shame about those precautions.
- Identify alternative ways to be helpful, such as sending takeout meals or taking care of yard work.
- Consider offering financial support if needed and requested.
- Check in if you have not heard from a new parent and ask if they need any support or reassurance.
- Extend compassion to new parents in the postpartum period. “We’re going through a collective grieving process in this pandemic,” said Escobar. “That loss and fear juxtaposed with the excitement, joy, and hardship of transition is a really intense nexus.”
How Can Communities Better Preserve Perinatal Health in a Crisis?
Develop a trauma-informed approach to every level of health administration and public service, from intake to birth to discharge.
- Consider how to address the external factors that affect pregnant and birthing people and their families. “Pregnant people don’t exist in isolation,” said Escobar. “They have housing needs, they have food needs.”
- Have a nurse-midwife on maternal health leadership teams. “It improves outcomes, culture, and patient satisfaction everywhere,” said Escobar.
- Create policies that make perinatal care more holistically accessible. For Escobar, accessibility includes having a hospital to go to that offers safe, effective, unbiased, and respectful care.
Citation for this content: [email protected], the online Women’s Health Nurse Practitioner program from the Georgetown University School of Nursing & Health Studies