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.
”Three decades of evidence have shown that nurse practitioners with full practice authority play a vital role in improving health outcomes, especially in underserved communities, Ramos observed in his remarks. Focusing on the connections between FPA, access to care, and health outcomes, the Dean presented his case to the state’s Joint Legislative Committee on Access to Healthcare and Medicaid Expansion at the North Carolina General Assembly and urged them to pass the SAVE Act to grant full practice authority for NPs providing primary care. Ramos, who is also the vice-chancellor of nursing affairs for Duke, was among eight experts presenting varied views on full practice authority.
“Full practice authority isn’t new. This isn’t innovative. We have 30 years of evidence from 24 states, D.C., and several US territories about the benefit of granting full practice authority to NPs.”
In speaking to the joint committee presided over by Sen. Joyce Krawiec, Ramos addressed the role that nurse practitioners have in transforming health care access and outcomes in North Carolina, including the opportunity to expand care in rural areas that face health care shortages. The joint committee is hearing from experts as they consider passing the SAVE Act, which was first introduced in 2021 to expand full practice authority for primary care NPs in North Carolina. A similar version of the SAVE Act has been introduced in previous legislative sessions, but no action was taken on the legislation.
Role of FPA in Access to Care and Health Outcomes
“Nurse practitioners should be able to practice at the highest level of their competencies, education, and licensing,” Ramos said. “Full practice authority isn’t new. This isn’t innovative. We have 30 years of evidence from 24 states, D.C., and several US territories about the benefit of granting full practice authority to NPs. This improves health outcomes and expands health care to underserved populations and will benefit the people of North Carolina.”
Across the state, 97 of 100 counties face a health professional shortage.
Ramos reflected on his role as dean of the top school of nursing in the state and the second-ranked school in the U.S., and the intense pride he has seeing Duke graduates strengthen their career opportunities with the education they gain at Duke. “The nurse practitioner workforce growth is faster in states with full practice laws than in states with restricted practice,” said Ramos, who is interested in attracting NPs to practice in the state.
Ramos observed that the first states to authorize full NP practice authority began doing so in 1994 — nearly three decades ago — and that, once passed, full NP practice authority has never been repealed. “Full practice authority for primary care NPs improves care access, improves care outcomes, and improves workforce supply,” said Ramos, who also addressed a systematic review of 33 studies that showed no evidence for better NP care outcomes in states with more practice restrictions.
NPs with FPA Increase Efficacy of a State’s Health Workforce
In addressing the critical nursing workforce shortages across the U.S., Ramos notes that NP workforce growth is faster in states with full practice laws compared to states with restricted practice. Across the U.S., during the COVID-19 pandemic, states issued temporary waivers of NP practice restrictions. “This enabled more time-responsive NP practice and care provision as well as a streamlined process for NP orders in the absence of physician signature requirements and an increased capacity of the health care workforce to respond to COVID-19,” Ramos said.
Ramos observes that the reliance of nurses in this manner during a pandemic and health care crisis demonstrates the clinical, scientific, and relational expertise that support nurse influence in improving health outcomes, and it demonstrates the confidence that the health care systems and public have in nurses, who have been considered the most trusted and most ethical profession for more than 20 years.
In conclusion, Ramos pointed out to the committee that:
NP practice restrictions contribute to inadequate care access and primary care workforce shortages, particularly in rural areas.
NP practice restrictions can be a barrier to improving health outcomes and reducing health outcomes and reducing health-related economic costs.
NP practice restrictions requirements can lead to an unsafe and fragile care model, including risks such as the possibility of immediate NP loss of ability to care for patients if a physician can no longer provide supervision for any reason, including moving, retiring, and so on.
NP practice restrictions weaken health workforce responsiveness to emergencies.
Physician supervision agreements can contribute to unnecessary and excessive costs.
The SAVE Act (House Bill 277/Senate Bill 249) did not receive a committee hearing during the 2021 legislative long session. However, following the conclusion of the committee’s work later this spring, the bill could move forward when the legislature returns for the 2022 short session on May 18, 2022.
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
New Programs
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.
A new study published in the Journal of the American Medical Association Internal Medicine (JAMA IM) found several factors – including staff assumptions about minoritized groups – may play a role in the variability in the quality of care provided to U.S. nursing home residents with advanced dementia
The study, “Nursing Home Organizational Culture and Staff Perspectives Influencing Variability in Advanced Dementia Care: The ADVANCE Study,” identified organizational factors and staff perceptions at nursing homes that may drive known variability in the type of care provided nursing home residents with advanced dementia, especially in the use of more aggressive interventions like tube-feeding or hospitalizations. These aggressive interventions are considered by many to be markers of poor quality of care, as they often do not promote clinical benefits or comfort among persons with advanced dementia.
Prior research has shown Black residents (versus white residents and those in facilities in the southeastern part of the United States) get more aggressive care, including greater use of feeding tubes and hospital transfers.
“The study identified several factors that nursing homes could target to improve delivery of goal-directed care to all residents. One is to improve provider knowledge and communication skills that less aggressive interventions may be more in line with the residents’ wishes and best evidence,” said Dr. Lopez. “For example, many nurses may believe that feeding tubes prolong the life of advanced dementia patients, but this is not borne out by existing studies. Nursing homes need to make sure their staff is aware that hand feeding is better for residents. Based on prior research, aggressive interventions can be less effective compared to less-intensive interventions, like feeding residents manually, while requiring more time of the nursing staff provides better care to their patients.”
The most concerning finding was that staff in nursing homes had preconceptions that families of Black residents did not want to engage in advance care planning and preferred more aggressive care.
“Staff preconceptions that Blacks are less willing to engage in advance care planning and want more aggressive care speaks to the need to address systemic racial biases in nursing homes,” said Dr. Mitchell, noting that nursing homes in the United States tend to be racially segregated and low-resource homes tend to have more Black residents. “Achieving health equity for all nursing home residents with advanced dementia must be the driving force behind all efforts aimed at reducing disparities in their care.”
Researchers conducted 169 staff interviews at 14 nursing homes in four states. They identified factors that were typical of nursing homes that provided less intensity of care including: the quality of the physical environment (e.g., good repair, non-malodorous), the availability of standardized advance care planning, greater staff engagement in shared decision-making, and staff understanding that feeding tubes do not prolong life. Aggressive intervention was considered suboptimal.
More equitable advanced dementia care, the study concluded, may be achieved by addressing several factors, including staff biases towards Black residents. Other solutions include increasing support and funding for low-resourced facilities, standardizing advance-care planning, and educating staff, patients, and their families about evidenced-based care and goal-directed decision-making in advanced dementia.
Other researchers collaborating in this study work at Beth Israel Deaconess Medical Center, Harvard Medical School, Meyers Primary Care Institute, University of Massachusetts Medical School, Oregon Health & Science University School of Nursing, the University of Tennessee at Martin, Emory Center for Health in Aging and the Nell Hodgson Woodruff School of Nursing at Emory University, the Center for the Study of Aging and Human Development at Duke University School of Medicine, and the Geriatrics Research Education and Clinical Center at Veteran Affairs Medicine Center.
According to the findings of a new national survey of nurses by the National Commission to Address Racism in Nursing (the Commission), nearly half reported that there is widespread racism in nursing, demonstrating a substantial problem within the profession. Comprised of leading nursing organizations, the Commission examines the issue of racism within nursing nationwide and describes the impact on nurses, patients, communities, and health care systems to motivate all nurses to confront systemic racism. Integrity calls on the profession and nurses to reflect on two realities, one as the most trusted profession while also being a product of our environment and culture. It is necessary to work toward connecting these two realities.
“My colleagues and I braced ourselves for these findings. Still, we are disturbed, triggered, and unsettled by the glaring data and heartbroken by the personal accounts of nurses,” said Commission Co-Lead and American Nurses Association (ANA) President Ernest J. Grant, PhD, RN, FAAN. “We are even more motivated and committed to doing this important work justice. Racism and those individuals who do not commit to changing their ways but continue to commit racist acts have absolutely no place in the nursing profession.”
According to more than 5,600 survey respondents, racist acts are principally perpetrated by colleagues and those in positions of power. 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%).
Superiority continues to surface as a primary driver from nurses representing predominantly white groups along with nurses who are advantaged and privileged by unfair structural and systemic practices. These survey findings move beyond the rhetoric to the reality and should serve as a call-to-action for all nurses to confront racism in the profession.
“Structural and systemic practices that allow the racist behaviors of leaders to continue to go unaddressed must be dismantled,” said Commission Co-lead and National Black Nurses Association (NBNA) President and CEO Martha A. Dawson, DNP, RN, FACHE. “As cliché as it sounds, it starts at the top. Leaders must be accountable for their own actions, set an example for their teams and create safe work environments where there is zero-tolerance for racists attitudes, actions, behaviors, and processes. Leaders must also create a climate that gives permission and support to dismantle institutional policies and procedures that underpin practice inequities and inequalities.”
Of those nurses who report that they have witnessed an act of racism in the workplace, 81% say it was directed towards a peer. Nurses say that they have challenged racist treatment in the workplace (57%), but over half (64%) said that their efforts resulted in no change.
“Nurses are ethically and professionally obligated to be allies and to speak up against racism, discrimination, and injustice for our patients and fellow nurses,” said Commission Co-Lead and National Coalition of Ethnic Minority Nurse Associations (NCEMNA) President Debra A. Toney, PhD, RN, FAAN. “Civil rights and social movements throughout history offer the blueprint, which demonstrates that diligent allyship is key to progress. To the nurses that challenge racism in the workplace, do not get dismayed by inaction, but continue to raise your voice and be a change agent for good.”
Many respondents across the Hispanic (69%) and Asian (73%) populations as well as other communities of color (74%) reported that they have personally experienced racism in the workplace. Overwhelmingly, the survey findings indicate that Black nurses are more likely to both personally experience and confront acts of racism. Most Black nurses who responded (72%) say that there is a lot of racism in nursing compared to 29% of white nurse respondents. The majority (92%) of Black respondents have personally experienced racism in the workplace from their leaders (70%), peers (66%) and the patients in their care (68%). Over three-fourths of Black nurses surveyed expressed that racism in the workplace has negatively impacted their professional well-being.
“The acts of exclusion, incivility, disrespect and denial of professional opportunities that our nurses have reported through this survey, especially our Black, Hispanic and Asian nurses, is unacceptable,” said Commission Co-lead and National Association of Hispanic Nurses (NAHN) President Adrianna Nava, PhD, MPA, MSN, RN. “Racism is a trauma that leaves a lasting impact on a person’s mental, spiritual, and physical health as well as their overall quality of life. As the largest health care workforce in the country, we must come together to address racism in nursing as the health of our nation depends on the health and well-being of our nurses.”
Since its inception in January of 2021, the Commission has been intentional and bold in leading a national discussion to address racism in nursing. The Commission has convened listening sessions with Black, Indigenous, and People of Color (BIPOC) nurses and hosted a virtual summit focused on activism with foremost subject matter experts. Collaborating with top scholars on the issue, the Commission developed a new definition of racism to establish a baseline for holding conversations, reflecting on individual or collective behaviors, and setting a foundation for the work ahead.
“The collective voices and experiences of BIPOC nurses nationally have provided a call for overdue accountability within the nursing profession to acknowledge and address the structural racism rooted within nursing, especially policies that have anti-Black and anti-Indigenous histories,” said Commission Co-lead and Member-at-Large Daniela Vargas, MSN, MPH, MA-Bioethics, RN, PHN. “The next generation of BIPOC nurses deserve more than performative activism and empty words that continue to yield no progress toward structural changes within the nursing profession or racial equity. The breadth of the nursing profession through the Code of Ethics for Nurses holds all nurses accountable for calling out racism and replacing racist policies rooted in white supremacy with ethical and just policies that promote and implement accountability, equity, and justice for nurses and the communities that we serve.”
Nursing’s challenges with the issue of racism are reflective of the larger society. As a profession, we need to confront these same challenges with racial inequities within the profession. As such, the Commission’s work is urgent to create safe and liberating environments for all nurses so that the profession exemplifies inclusivity, diversity, and equity. The Commission urges all nurses across every health care setting and environment to join us in boldly confronting systemic racism. We must address upstream sources of racism in order to build sustained safe and effective environments of optimal care delivery ideal for every nurse and every patient regardless of race, origin or background. Nurses can learn more and share a story of experiencing racism or being an ally for change today.
*Data was collected through a survey administered by the National Commission to Address Racism in Nursing Between October 7-31, 2021, 5,623 nurses completed this survey. *
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 
