Nurse of the Week Elizabeth Anh-Trinh Stulac, RN/BSN is an established nurse leader working toward a Ph.D., but she remembers where she came from. So, earlier this month she went back home to Elk River, Minnesota to share a message with graduating seniors at tiny Ivan Sand High School, the alternative learning center she graduated from herself in 2008.
“It is not a secret that when you go to an ALC school, sometimes people view you as being a bad kid, an outcast, or not smart enough to make it in a traditional high school. I am here to tell you: That is false.”
Stulac, who later graduated from college Summa Cum laude and in the top 15 percent of her class, is studying for a doctorate in transcultural nursing while working as a charge nurse in the Mayo Clinic’s COVID-19 intensive care unit. Her older sister, now a nurse practitioner, was a high school dropout who eventually earned her GED. Thus, Elizabeth Anh-Trinh Stulac knows just how grave an error it can be to make assumptions about someone’s capabilities.
When the latest Ivan Sand grads gathered on June 7 for their graduation ceremony, she urged them to believe in themselves and get in touch with their own leadership skills.
First, the alumna told them, don’t buy into stereotypes of Alternative Learning Center students! “Here I was at the Mayo Clinic, the No. 1 ranked hospital in the world, and they were telling me the strengths that I brought to their organization.” The RN, who is also Mayo’s Rapid Response Team Nurse and chairs two committees (in her spare time), flatly informed the 2022 class: “It is not a secret that when you go to an ALC school, sometimes people view you as being a bad kid, an outcast, or not smart enough to make it in a traditional high school. I am here to tell you: That is false.”
The 2008 Ivan Sand grad can speak from experience: “Through the many leaders that I have worked with throughout the years, I have come to realize that one of the greatest predictors of success is your perception of yourself. I am here to tell you all today, as you graduate from Ivan Sand Community School that you are not an outcast, you are not a bad kid, and you are not the many things society has made you believe about yourself. But in fact, you are a class of potential leaders.”
After stressing the importance of assessing yourself on your own terms and not those imposed on you by others, the RN told the class of future leaders to write down their short-term and long-term goals,” and determine what they need to do to achieve them. Then, with a hat tip toward the Mayo onboarding process, Stulac added, “I would also recommend identifying your own personality type, and the strengths that each of you carries individually.”
And never assume defeat. Her sister, Stulac says, “is one of the smartest people I know.” ALC students learn early that “Life is messy.” After all, “Not all of you come from traditional families. Many of you are working to help support your families. Opportunities are not given equally to each person. But the feeling that you get when you achieve your goals, having overcome those barriers, is worth the hard work and worth the bad days — because you will have many bad days. Success does not come free; you must work hard for it.”
With her NP sister’s example in mind, as she concluded Stulac reminded them, “Your success is not only your own but the people who look up to you. I know that some of the greatest leaders are here among us tonight, and I am so excited for you and the impact that you will make on the world that we live in, and what you will achieve!”
A good message for all graduates to live by. Fort the full story on the graduation ceremony, see here.
The $125 million donation by Leonard A. Lauder, Chairman Emeritus of The Estee Lauder Companies, to create this first-of-its-kind, tuition-free Program is the largest gift ever to an American nursing school. Mr. Lauder is a Penn alumnus. The gift comes at a time when the COVID-19 pandemic has magnified the nation’s acute shortage of primary care providers, and persisting inequities in access to quality healthcare.
“This is the most timely and consequential gift not only for our university but for our country. It is unprecedented in its potential to address America’s most critical need of providing primary health care to all who currently lack it by investing in nurses,” said former Penn President Amy Gutmann.
“Growing the number of nurse practitioners who are prepared and committed to working in underserved areas is the most practical and inspiring way to ensuring a healthier country. I am grateful and honored that Leonard would make this gift to Penn Nursing, and thrilled to know that it will have an immediate impact that will last far into the future.”
Nurse practitioners are leaders on the front lines of care, a role never more important as Americans confront a primary healthcare shortage in their communities. With their advanced clinical training and graduate education, nurse practitioners have the knowledge and skill to supervise and manage critical aspects of care in a decision-making capacity, from patient diagnosis, to ordering and interpreting tests, to prescribing medication. Nurse practitioners deliver high-quality primary care to people of all ages, such as treating common illnesses, managing chronic conditions, and providing preventive care that helps patients stay healthy.
Nurse practitioners are also able to take on key leadership roles, from managing and operating walk-in or community clinics to leading interdisciplinary teams within health systems. The new Program will better the lives of patients and communities most in need, while providing a pathway for the many nurses interested in advanced education who may not otherwise have the means to pursue it.
Structure: Leonard A. Lauder Community Care Nurse Practitioner Fellows will enroll full-time in a two-year, rigorous Primary Care Nurse Practitioner Program at Penn Nursing.
Community Practice: Fellows will complete at least 50 percent of their clinical education at community partner sites in the greater Philadelphia area that provide direct patient care, an invaluable experience that will prepare Fellows to meet the complex needs of patients and families throughout their careers. Every Fellow will be expected to commit to practice or service in an underserved community for two years after graduation.
Recruitment: Penn Nursing will select 10 Fellows to begin classes this fall, growing the program enrollment through 2026 when it will reach its annual target enrollment of 40 Fellows, continuing in perpetuity. By 2027, the program will have enrolled 140 excellent nurse practitioner students. Fellows will need to show a demonstrated commitment to working in underserved neighborhoods, where they are needed most, and to promoting health equity.
Tuition: All participants in the program will enter the workforce free of graduate school debt, receiving student aid to cover their tuition and fees and thereby eliminating any potential financial barriers for nurses and others who wish to enroll. Fellows with greater financial need will also receive stipends to help with living expenses.
Program Leadership: Penn Nursing will name the first endowed Leonard A. Lauder Community Care Nurse Practitioner Professor, who will oversee curriculum innovation, support of community sites, and program implementation.
Penn Community Partnership: Penn Nursing will provide support for select community partner sites to support the clinical education of Fellows while providing professional development and networking opportunities and access to School and University resources.
“Penn Nursing has a long history of advancing science, promoting equity, practice excellence, and preparing leaders. That’s why Mr. Lauder’s gift is so meaningful. The synergy between Penn Nursing and the Program will improve the health of underserved patients and families, by uniquely preparing primary care nurse practitioners, who will work with them in their communities. The sustained investment in the education and careers of primary care nurse practitioners and communities is unprecedented. We are excited by the opportunity to lead this important Program and to extend its impact beyond Penn Nursing,” says Penn Nursing Dean Antonia Villarruel. “We are deeply grateful to Mr. Lauder for recognizing and investing in this critical need, and for partnering with us in this ambitious endeavor.”
NPs are “key” to health care in underserved communities
Stephen P. Fera, Executive Vice President of Independence Blue Cross, which is one of the community partners that will be involved in the new initiative, noted that nurse practitioners are key to improving individual and community care. Said Fera: “Bolstering the nurse practitioner workforce is a means to improve access to care and strengthen the health care safety net provided by health centers. This is a key priority of the Independence Blue Cross Foundation and our partnership with Penn Nursing has been synergistic in efforts to prepare nurses to work in community-based settings. The Program will build and strengthen our individual and collective efforts toward improving the health and well-being of communities.”
“Now more than ever, the country needs greater and more equitable access to quality primary care—and highly-skilled nurse practitioners are the key to making that happen,” said Leonard A. Lauder. “The program will ensure that more Americans receive the essential health care services that everyone deserves, and I’m so pleased to be working with Penn Nursing on this initiative. I look forward to welcoming our first class of future nurse practitioners this fall. I know their expertise will be matched only by their commitment to serving our communities.”
BSN student Valeria Soria Guzman has been translating for her parents for as long as she can remember. She knows three languages so far – and is learning two more – and she aspires to use her polylingual abilities to increase access and equity for health care patients through the nursing field.
“It’s so hard when you’re sick and when you’re at your lowest point and to not have somebody who understands you,” says Guzman. “To not have somebody who can share that compassion with you in your own language is difficult.”
Guzman moved to the U.S. from Mexico with her family when she was two years old. She is a first-year nursing student at the Bill and Sue Gross School of Nursing at the University of California Irvine (UCI), and she is also the first in her entire family to attend college.
After learning English in the third grade, Guzman found that her background in Spanish made it easy for her to pick up other languages as well. Aside from English and Spanish, Guzman also knows French, is working on American Sign Language and has just begun to dip her toes into Portuguese. As a child, Guzman became her family’s translator at more than just the grocery store – she found herself translating at medical offices, filling out complicated documents with her limited children’s vocabulary of English, and trying to get both her parents and the physicians to understand each other.
“I feel like that’s why I want to go into nursing specifically so that I can walk a patient through the treatment and help them along the way, even if they don’t speak the language,” she says.
Guzman is constantly seeking opportunities at UCI to help those facing a language barrier, especially in the medical field. Currently, she works on the translating team for a research study that is looking for ways to help dementia patients through technology.
“A lot of their patients are lower income and Spanish-speaking only,” Guzman says. “So what I do is translate documents, like ones from the research, into Spanish so the researchers can have focus groups with these Spanish-speaking participants.”
Guzman sees the accessibility of documents in languages other than English as a major point in achieving accessible care. In the future, she plans to use her abilities to serve non-English speaking communities wherever she is most needed. She especially wants to serve areas lacking in non-Spanish speakers, even if it means leaving the large Spanish-speaking community that she values so much behind.
“The thing I’ve missed most since coming to UCI is speaking Spanish in a community setting, and I feel like that’s why I like to seek out a bunch of different Spanish speaking opportunities because I want to have that again,” says Guzman.
In a diverse area in Alabama where 40% of the population is below the poverty line, nursing is a life-changing career path that provides financial stability and promising opportunities. However, in 2018, the University of West Alabama’s Division of Nursing had a 77% NCLEX pass rate, which is below the national average and the minimum for continued program accreditation.
With the students’ nursing careers and the program’s accreditation on the line, the department leaders created a plan to increase UWA’s NCLEX pass rate to continue to provide nursing education and opportunities for their students. In 2021, the UWA Division of Nursing’s first-time NCLEX pass rate rose to 100%.
Incorporating Online Test Prep Played Major Role
To increase UWA’s NCLEX pass rate, department leaders provided students with additional support in the form of mentorship, grants, and adopted online NCLEX online test prep tools from UWorld. A year later, the UWA nursing program’s pass rate rose to 84%, which was a promising start.
Following the initial improvement, the UWA faculty decided to make test prep a program policy rather than just a recommendation. By making the practice questions required, we could help students build essential test-taking habits throughout the semester, while also seeing what the NCLEX questions are like and learning the material. Online test prep became 5% of a student’s overall grade in Advanced Adult Health and Critical Care, a course students take in the final semester of the nursing program. To meet assignment requirements, students had to complete a minimum of 2,000 questions and achieve an overall score of 65% correct. Most students had to take between 3000 and 6000 test items to achieve the benchmark for the percentage of correctly answered questions. Students had five to six weeks to complete this assignment.
Ultimately, every student in the spring 2021 semester passed their NCLEX on the first attempt, making UWA the only program in the state of Alabama to achieve a 100% pass rate.
When students are given the right tools and are incentivized to use them, success stories like this can happen.
Also Essential: Providing Support for Minority and Disadvantaged Students
Universities can take other helpful measures to provide their students with enough support, resources, and opportunities to experience success. At UWA, many steps are taken to give the diverse student body equal and exciting opportunities including scholarships and mentorships to empower students of color.
In summer 2020, the UWA Division of Nursing was awarded a $2.4 million grant from Health Resources and Services Administration (HRSA) for nursing scholarships over five years. With this grant, UWA created Project EARN (Educating Alabama Rural Nurses), which provides invaluable financial aid scholarships for students from disadvantaged backgrounds.
When students have financial support through aid and scholarships, they can spend more time focusing on their education and getting ready to take the licensing exam and less time worried about working to pay bills and support themselves or their families
Dr. Mary Hanks, RN, MSN, EdD, the Division of Nursing Chair; and Dr. Chineda Hill, EdD, MSN, CNL, an Associate Professor of nursing at UWA, have also recently developed a new program, Sustah2Sister, that focuses on empowering women of color to build professional relationships and nurture seeds for life-long success. This program is a series of seminars that includes guest speakers to inspire and support women of color at UWA, including nursing students.
The Widespread Impact of Students Passing Their NCLEX
One of UWA’s university-wide missions is to serve the surrounding community. This region in Alabama has a diverse population, with over 40% living in poverty. Just like many places all over the country, surrounding rural hospitals are also in desperate need of more nurses.
When a nursing student passes their NCLEX exam, many opportunities open up for them. The field of nursing is a life-changing career path that brings financial stability to many disadvantaged and minority students.
For UWA nursing students, passing the NCLEX opens up the opportunity for immediate job placement in an industry that has a constant need for more qualified workers. After passing their NCLEX, many UWA graduates decide to stay and work in Alabama, with some going to work in the rural areas that are experiencing a nursing shortage crisis. Since studies show that patients respond better to those that look like them, it’s valuable to the community as a whole that UWA’s diverse nursing students are now entering the workforce.
Increasing the NCLEX pass rate to 100% was an impressive feat, but it also has real-life outcomes that are widespread and optimistic. Ultimately, the UWA Division of Nursing’s success story can be attributed to many factors. With supportive department leaders, hardworking students, university-wide efforts, and the right test prep tools, nursing programs across the country can thrive.
Three Duke University School of Nursing researchers and their collaborators were recently awarded new funding for pilot projects — all centered around reducing health inequities and improving patient care.
This year’s pilot program required that faculty members submit proposals that incorporate at least one of the following racial justice themes:
Dismantling structures that perpetuate racism;
Advancing solutions that ensure health equity in marginalized populations;
Multilevel approaches to addressing social contributors to health;
Methods that improve the participant experience and address racial equity in data collection, analysis, and reporting.
The School’s Center for Nursing Research (CNR) is pleased to announce this year’s grants address the clinical context of sickle cell disease (SCD) management and associated health disparities for adults in Sierra Leone; improve our understanding of the pediatric urobiome, particularly in underserved populations; and acquire large datasets that will allow Duke researchers access to variables needed to improve understanding of health disparities.
Since 2017, the pilot program has encouraged researchers to investigate relevant and innovative ideas that promote health equity and address the School’s Research Areas of Excellence: data science, health innovation, population health and precision health. The goal of the program is to encourage team science and endorse scientific inquiry that positions investigators to be competitive for extramural research funding. The program is administered by the CNR and funded through a generous award from A. Eugene Washington, M.D., M.P.H., M.Sc., chancellor for health affairs, Duke University, and president and CEO, Duke University Health System.
“It was important for the CNR to invest in pilot research that addresses health equity and racial justice so that we are well-positioned to contribute to the future of nursing science,” said Christin Daniels, assistant dean for research development. “This year’s topics tackle a wide variety of pressing challenges – locally and globally, and we’re thrilled to support our researchers’ endeavors toward solving big problems. This pilot program is made possible by our volunteer reviewers, and we’d like to thank them for their collegiality and service. We’d also like to thank Chancellor Washington for the generous award that allows us to offer this program.”
Extending SCD Management: Adapting Management Recommendations to Sierra Leonean Context
Ibemere serves as the principal investigator for her study entitled “Extending Sickle Cell Disease (SCD) Management: Adapting Management Recommendations to Sierra Leonean Context.” She is collaborating with Paula Tanabe, PhD, MSN, MPH, RN, FAEN, FAAN, vice dean, research, and Laurel Chadwick Professor of Nursing, Nirmish Shah, MD, associate professor of medicine, and Cheedy Jaja, PhD, assistant dean for global engagement, University of South Florida.
Evidence-based guidelines exist for sickle cell management, but they do not currently account for the unique perspectives of sub-Saharan populations, who have the greatest prevalence of SCD. Approximately 75 percent of those born with SCD are born in sub-Saharan Africa, and 50 to 90 percent will die before the age of 5. The estimated life expectancy for adults with SCD in Sierra Leone is 20 to 30 years shorter than in high-resourced settings. To reduce the inequitable access to a clinical model for SCD management, the project team will assess clinician and community member knowledge of the National Heart, Lung, and Blood Institute SCD recommendations and evaluate existing SCD management algorithms (e.g. SCD toolbox) for the clinical context in Sierra Leone.
The chasms between SCD outcomes in low-income settings contrasted with those in high-resource settings are linked to systematic decisions and structural barriers which impede workforce development and patient access to care. If left unaddressed, researchers expect continued poor health outcomes for individuals living with SCD in sub-Saharan Africa. Guided by the culture-centered approach, this study will engage Sierra Leonean colleagues, elevating the voices of historically marginalized and minoritized populations while investing in the clinical improvement of SCD disease management within this specific cultural context.
These findings will inform the development of a SCD care management model rooted in evidence-based practice for providers, and the preliminary data will help inform the development of a future NIH R21 submission.
Stability of the Pediatric Urinary Microbiome
Principal investigator Kelly will lead the study entitled “Stability of the Pediatric Urinary Microbiome” along with her collaborators Lisa Karstens, PhD, assistant professor, Oregon Health and Science University, and Tatyana Sysoeva, PhD, assistant professor of microbiology, The University of Alabama in Huntsville.
Urinary tract infections (UTIs) are the most common outpatient infections in the U.S. and are among the most serious bacterial infections encountered by pediatricians. In children, UTIs can result in life-long health consequences including renal scarring, hypertension, renal insufficiency, and pregnancy complications, such as preeclampsia and preterm birth. Antimicrobial resistance of urinary pathogens that cause UTIs is increasing, yet antibiotics remain the standard treatment for UTIs in children. Antibiotic use increases resistance and may change the child’s microbiome. There is a pressing need to develop non-antibiotic therapeutics for UTI treatment, especially in children.
UTIs are more common in Latinx and white children. Inability to make frequent trips to a clinic for urine collection presents a barrier to care that is exacerbated in marginalized populations. At-home urine collection and storage would improve adherence and enhance the quality of the urobiome data.
This pilot study will utilize urine samples in children taken over the course of two months to determine the stability of the urinary microbiome in children and determine if at-home collection is viable, particularly in the Latinx population. The team will translate their study materials into Spanish and work with a community advisory board to ensure the Latinx community helps guide the research. The long-term goal of this study is to develop a predictive test that can identify children at increased risk of UTIs as well as a non-antibiotic intervention strategy. Kelly and team anticipate using the study data towards a future R01 grant submission.
National Representative Databases for Clinical Research
Myers will serve as the principal investigator of the study entitled “National Representative Databases for Clinical Research.” The research team includes Michael Cary, PhD, RN, Elizabeth C. Clipp Term Chair in Nursing and associate professor and Nancy Crego, PhD, RN, CCRN, CHSE, assistant professor, and Michael J. Smith, MD, professor of pediatrics, Bradley Hammill, DrPH, associate professor, and Gina-Maria Pomann, PhD, assistant professor, with the School of Medicine.
National administrative databases are rich sources of clinical information that may serve as the basis for a multitude of research projects. The School of Nursing and overall Duke community have limited access to such databases. In addition, the databases are not in formats that allow untrained analysts to perform appropriate analyses. This pilot project seeks to purchase the following data sources and convert data into user-friendly formats for Duke research utilization:
Kid’s Inpatient Database from Healthcare Cost and Utilization Project (HCUP)
National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Surveys
National Immunization Survey
National Inpatient Survey
National Emergency Department Sample Census Data and Area Health Resources Files
Myers and team will use this data to build the School of Nursing’s first data warehouse, Health e-Data. The data contained within the warehouse will significantly enhance our ability to access and study large-scale, national clinical data.
The warehouse will also advance our ability to address racial equity in data collection, analysis, and reporting. Incomplete race data is a serious and persistent problem that hampers progress. Fortunately, the HCUP databases have created multiple procedures to address this issue. They have identified standardized categories for race and ethnicity, developed novel imputation methods to reduce the impact of existing missing data on disparities research, and linked zip code-level information (e.g., racial distribution, income, education, and poverty level) from the U.S. Census to address socioeconomic status data. They now also include data examining social determinants of health . As such, the creation of the Health e-Data warehouse will allow researchers to examine racial disparities more robustly and rigorously.
For Daniela Vargas, MSN, MPH, MA-Bioethics, RN, PHN, a nursing school textbook presented an early rude awakening to racism in nursing. Vargas, who identifies as an indigenous brown woman and whose family came from Mexico, was shocked by the generalized depictions of people of color in the NCLEX prep book. “It was in a way a precursor to what I started to not only experience myself, but also with colleagues who are people of color, what their experiences were in the profession as I moved through nursing school and then post nursing school as well,” she says.
Vargas, a nurse since 2016, now serves as co-lead for the National Commission to Address Racism in Nursing. In January, the commission released an eye-opening survey on racism within nursing. The national study found that nearly half of the respondents reported widespread racism in the profession.
According to more than 5,600 respondents, racist acts are principally perpetrated by colleagues and those in positions of power, says a press release. Over half (63%) of nurses surveyed say that they have personally experienced an act of racism in the workplace with the transgressors being either a peer (66%) or a manager or supervisor (60%).
A subtler racism
Vargas says that the survey’s findings did not surprise her. Today’s racism, she says, may not be as obvious as the discrimination practiced in previous times. “I would say it’s less blatant and less in your face than it was perhaps in decades past.”
Healthcare institutions, notes Vargas, may come out with public statements against racism. “Yet the cultures that remain in many of the units where nurses work, that has not changed. It’s just they’ve evolved into being less in your face, and in a way people have gotten more sophisticated in how racism gets expressed.”
For instance, management or peers might make it harder for a nurse of color to obtain a promotion, she notes. Or staff nurses would refuse to work with student nurses of color during clinical instruction.
On top of nurse burnout and nurses leaving the profession because of the pandemic, “you have this compounded racism that faces many nurses already,” Vargas says. “And it’s built up over time. Especially for newer nurses, they go into nursing without the tools or the knowledge that this is occurring in the profession, and then once they’re in it, and they’re practicing, then they’re like, Whoa, what just happened? And I have not been taught how to address this, because it’s not something we learned in nursing school.”
“As I continued to go into the profession, I then finally was able to say, this is racism. I’m not just experiencing nurse bullying or incivility. It’s now become much more toxic and insidious than what I thought I was going into when I was in nursing school,” Vargas says.
In addressing racism in nursing, “the first thing that needs to be done is acknowledge that it exists,” Vargas says. Also, when onboarding a new nurse to an institution or unit, “there needs to be some built-in curriculum that has an antiracist standpoint to it, that comes with an expectation that this is not tolerated at this institution from the get-go.”
Serious accountability needs to be put into place, Vargas says. “There’s a piece of accountability that needs to be had in regard to what type of accountability measures an institution is doing, because saying that you want to be it is very different than the action.” For example, just as there are whistleblower hotlines for abuse or unethical behavior, hotlines could be established for racist behavior, she suggests.
Similarly, she says, licensing bodies can put in place mechanisms to report racism. “There has to be a real conversation in the nursing profession in regard to accountability of the individual nurse too” because racism affects not only patient care, the patient experience, and the community experiences but also affects colleagues as well. “I don’t think that we have enough measures currently in place that seek accountability on the side of nurses experiencing racism.”
“What this survey did was really allow nurses of color to be able to share their lived experiences,” says Vargas. “And that is important because the voices of nurses of color are now being heard.”
“What this survey is a launchpad for, is to say this is no longer tolerated in the profession. It does not coincide with our code of ethics and we will be the generation that moves the profession forward in not tolerating it and allowing future generations to go without accountability.”