In early 2016, Mt. Sinai Hospital* approached the Visiting Nurse Service of New York (VNSNY) to propose that VNSNY offer home care services to post-operative transgender patients. This was the genesis of VNSNY’s Gender Affirmation Program (known as GAP), which to date has provided home care to over 400 transgender patients. *a strategic partner of VNSNY
DailyNurse recently interviewed Shannon Whittington, RN MSN PCC C-LGBT Health, the Clinical Director of GAP at VNSNY. We asked her about the nature of gender affirmation treatment, the home nursing care that VNSNY provides, and the outstanding LGBT-friendly services that VNSNY offers to patients across the Tri-State New York area.
What is gender affirmation surgery (GAS)?
A surgical procedure that creates or removes body
parts that align with the patients’ gender expression. E.g. vaginoplasty,
phalloplasty, metoidioplasty, facial feminization, breast
Is this the same thing as “sex-change surgery?”
SW: It is the same thing but we don’t use the terms “sex-change
Gender Affirmation or Gender Confirming surgeries are the correct terms now. Understanding that this is a linguistically fluid language, words and meanings are always changing and we need to be mindful of correct terminology.
What are the components of the VNSNY Gender Affirmation Program?
The program emphasizes home care following surgery from other providers. I train clinicians (nurses, social workers, physical
therapists, home health aides, speech and occupational therapists) in cultural
sensitivity as it particularly relates to transgender patients. The training is extensive and they are also
educated in how to teach the patients to care for their new or altered body
parts (i.e. penis, vagina, breast, face)
DN: How did you come to specialize in the treatment of Gender Affirmation surgery patients?
SW: Fortunately, I was chosen for this project by my
manager. I had no idea what I was saying
yes to but this has literally changed the trajectory of my career path. I discovered a passion that I did not know I
What sorts of clinical training do nurses in the program need to take care of
GAS post-surgery patients?
They need to know what to assess for and what is
normal and what is not. They learn about
vaginal dilation because the patients who undergo vaginoplasty must do this on
a regular basis. Patients come home with VACs, JP drains, foleys and supra
pubic catheters. Although the nurses are already familiar with these devices,
they need to teach the patients how to manage them. The clinicians are also
trained in social determinants of health for this cohort.
DN: What sorts of cultural issues do nurses need to learn about before tending to a GAS patient?
SW: We really need to understand that these patients, like all
of our patients, are patients first who happen to be transgender. We must
respect their chosen names, their pronouns and their gender expression. We
focus on getting them better and integrated back into society. It’s a beautiful
thing to witness and an honor to be associated in such a transitional journey.
DN: How does the Gender Affirmation Program reflect the larger VNSNY commitment to LGBT patients?
It reflects our commitment to this population on an
agency wide basis. What is great is that
we are now getting non-operative transgender patients who are seeking home care
services for reasons other than gender affirming surgeries. They feel safe here and seek care outside of
gender affirming surgeries.
We are initiating various ways to continue to be inclusive along
the binary spectrum by hiring gender non-confirming and non-binary individuals.
These individuals have a lot to offer and need to be the best expressions of
themselves in their work environment just like the heteronormative society we
all live in.
And can you tell us something about the SAGE training in your organization?
All divisions of the Visiting Nurse Service of New York have been awarded Platinum
certification (the highest level possible) from SAGE, the world’s largest and oldest organization dedicated to
improving the lives of LGBT older people.
than 80 percent or more of VNSNY’s clinical and other staff have received SAGE Care LGBT cultural competency
training, further establishing VNSNY as a
preferred health care provider for New York City’s LGBT residents.
SAGE training is designed to increase awareness among VNSNY clinical and
administrative staff of cultural issues and sensitivities around sexual
orientation and gender identification, so as to ensure a welcoming and
respectful health care environment for all individuals within the LGBTQ
Among other things, the training stresses the importance of approaching each patient in a non-judgmental fashion and never making assumptions about anyone’s sexual orientation or family structure. We want every patient to feel they can be totally open about who they are with every member of our GAP team who walks through their door.
Coming in March 2020!
Annals of LGBTQ Public and Population Health
The mission of Annals of LGBTQ Public and Population Health is to bring together state-of-the-art cross-disciplinary scholarship which seeks to enhance the health and well-being of sexual and gender minority (SGM) individuals at the population level with an eye to the intersectional identities that SGM people possess.
We are interested in papers that advance education, policies, laws, and approaches to enhance SGM care and SGM health.
Helping patients to navigate what comes after a difficult diagnosis is a necessary part of our profession. In my many years working with patients facing progressive diseases, like chronic obstructive pulmonary disease (COPD), I have found that they often have questions, namely:
do I do now?
That’s where we, as
nurses and other health care providers, can offer answers. COPD is not
currently curable; however, there is still hope for these patients. Lifestyle
changes and medical advancements make it possible for patients to improve their
ability to breathe and overall quality of life. The objective of treatment is
to slow the progression of the disease and assist with managing its symptoms. As
patients with COPD come to terms with their disease, here’s what I would
recommend to guide them through the next steps of their journey, from diagnosis
With Them to Create a Plan
After giving a
diagnosis of COPD, educating patients on the disease and working with them on a
personalized plan to start addressing their symptoms is an important first
step. In fact, there are many lifestyle changes that patients can make every
day to not only accommodate their new medical needs but also to help improve
lung function. Committing to a diet of anti-inflammatory foods — like fatty
fish or dark leafy greens — participating in regular low-impact physical
activities and other techniques can help to reduce inflammation in the lungs
that can exacerbate symptoms.
Them Take the Steps to Quit Smoking
Smoking can cause
significant damage in the lungs which only increases over time. One of the best
things that patients can do if they’ve been diagnosed with chronic lung disease
is to quit smoking if they currently smoke. It’s important to arm them with information
and tools they need to successfully do so — whether it’s helping them to
identify smoking triggers, create an exercise and diet regimen or connect to
support groups or other resources. For example, at Lung Health Institute, we
offer our patients access to programs like American Lung Association’s Freedom
From Smoking® Plus, a flexible online smoking
cessation program that can be completed in six weeks.
Have an Honest
Conversation About What Treatment Is Right for Them
patient is different, and treatments will vary for each patient with COPD — depending
on the severity of the disease and other factors, including age, fitness level or
medical history. That’s why it’s critical to create an environment where patients
are comfortable being completely honest about how they’re feeling both
physically and mentally. That will ensure that we can provide them with the
best course of action when it comes to their treatment.
Melissa Rubio, Ph.D., APRN, is a nurse practitioner and principal investigator for research at the Lung Health Institute, based at its Dallas clinic. Rubio also currently serves as a visiting professor at DeVry University’s Chamberlain College of Nursing in Downers Grove, Illinois. Prior to joining Lung Health Institute, Rubio worked at Pleasant Ridge Internal Medicine in Arlington, Texas, as a family nurse practitioner. Rubio holds a doctorate in philosophy from the University of Wisconsin-Milwaukee College of Nursing. She also earned a bachelor’s degree in nursing from the same school. She is a board-certified family nurse practitioner and a certified principal investigator. Rubio is also a member of the North Texas Nurse Practitioners and the Southern Nursing Research Society.
It was no great leap for Austin Regional Clinic to embrace the
concept of population health, an approach that aims to improve the health of groups
of people, particularly those with more medically complex conditions. Our
medical group was founded on those principles back in 1980, when no one ever
heard of the term. Over time, we became very good at population health and now we
are often asked to present our “best practices.”
What’s the secret to
our success? The
long answer often includes a description of our IT investments. No doubt the
advent of electronic medical records has made us better — instead of reacting
to illness, we are beginning to use the data to predict illness, allowing us to
shift resources to the sickest patients.
But it is the human
element — the way each provider engages with the patient — that takes us from
simply identifying the high-risk to making a difference in their lives. The
technique we’ve honed is motivational interviewing.
Listen Versus Fix
The “front line” of
our population health program is our nurse navigation team. Ten years ago, it
consisted of four trained nurse navigators who primarily guided our Medical
Home patients — individuals living with chronic conditions who rely on frequent
care from various specialists. Today, this team has grown to 25 and now
includes in-hospital nurse navigation as well as a Home Health Navigator.
While the roles within
our team have expanded, our approach to patient interaction has not. Instead of
telling our patients, we ask questions. We hire listeners, not fixers.
To a psychologist, motivational interviewing is a fundamental technique. It is less well known in most doctor and nurse cultures. Providers are taught to fix. Yet, we’ve found, that without first understanding the patients’ goals and then uncovering the obstacles that stand in the way of their goals, our sickest patients don’t feel compelled to change.
How does it work? Instead of telling
patients to change, we guide them to express their own commitment out loud,
which has been shown to improve patients’ ability to actually make a change.
‘Fishing with My
When I asked one of my
patients with a chronic breathing disorder about his goal, he replied, “I’d
like to be able to fish with my grandson.” Later, at his appointment and
others, I asked questions about what might be getting in the way of his goal.
“I can’t breathe outside” or “I can’t leave the house without my breathing
device.” We discussed the obstacles and set forth reasonable small goals to
progress him forward. Each time he achieved a goal, he was motivated to set another.
My patient was aware
of his barriers. With motivational interviewing, he became empowered to learn
how to overcome them.
population health program is an investment in time and money, but the effort pays
off. As last year showed, Austin Regional Clinic’s success has the numbers
to back it up:
than $3 million in 2018 shared savings, bringing the total to almost $25
million in the past eight years
80% screening rate for depression and fall risk, up from 38% just two years
of diabetic patients moved to “good controlled” from “poor controlled”
of our Medicare population is up to date on their colorectal screenings, up
from 65% a few years before
Every year we set new
population health goals, raising the bar just a bit. Admittedly, improving
population health is a marathon, and we are only in the first leg of the race. Enhanced
predictive analysis using artificial intelligence and machine learning will guide
us to the patients for whom we can make the greatest impact on their health.
Our philosophy concerning our patients is unwavering — to not just consider each patient’s illness, but to see the person. To understand their values, their lives, and their support. To listen and to empower.
The most accurate
predictive analysis cannot compel a patient to change — a patient’s will
does that … and the dream to fish with a grandson.
In honor of “Nephrology Nurses Week,” September 8-14, 2019, Daily Nurse is highlighting two very special dialysis nurses.
At 25 years old, Jackson, KY resident Bridgette Chandler was living with her husband and raising two young children while enjoying a satisfying career as a nursing tech.
Bridgette’s life changed forever after she rushed to the emergency room with what she thought was a case of the flu. Instead of flu, doctors informed her, she was actually suffering from kidney failure. During the long wait for a transplant she underwent arduous four-hour dialysis treatments three times a week.
Despite finding that dialysis made her “a completely
different kind of tired that sleep doesn’t fix,” in her determination to remain
actively involved with her young family, Bridgette opted for at-home dialysis at
the Fresenius Kidney Care clinic in Kentucky. With her home treatments, Bridgette
managed to experience all of the special events that happen in a family, from
games and recitals to the hubbub of birthdays and holiday seasons. She remarks,
“For me, being able to take part in special moments with my family was most
important and that’s why I chose home therapy. It gave me the opportunity to
take back some of the control of my health.”
Five years later Bridgette found a donor and had her kidney transplant surgery. Even before the hospital had discharged her, she asked her doctor how long she had to wait before she could start school and become an RN. Now, Bridgette is working alongside her former nurses, treating home dialysis patients at the same clinic that treated her. “Because of my personal experience, my intention had always been to become a nephrology nurse” she says. “I stayed in touch with my nurses and doctors who made such a difference in my life. When a position became available in the clinic with those nurses and doctors, I jumped on it.”
Bridgette’s experience also creates a special bond with her
patients: “helping patients find ways to make dialysis work for them has
definitely been beneficial. I’ve had so many patients tell me they respected me
so much more because I understand what they are going through. Many of my patients
have even told me that I give them hope. That is just as important to me
as it is to them. That’s why I wanted to be a nurse.”
Anne Diroll was also destined to become a nephrology nurse.
A year after losing her father to a sudden heart attack, 15-year-old
Anne was hospitalized for a week after being struck by a car.
During her time in the hospital, unable to walk, and suffering from a “huge hematoma,” she had plenty of time to think and look around. She saw—and deeply admired—the nurses who cared for her, and was inspired by fellow patients stories, learning of “tragedies and hardships in others’ lives that I had never experienced or been aware of at a young age, and [I] thought ‘this is a part of life that needs healing.’”
Anne began her nursing studies almost as soon as she was
discharged from the hospital. Initially working as a pulmonary nurse, when she sought
a new job, she “didn’t know anything about kidneys, except that they made urine.
In my interview for a dialysis nurse position, my interviewer explained that the
reason dialysis nurses exist is because [failing] kidneys don’t make urine, so
I was able to understand that dialysis is to kidneys as ventilators are to
lungs. I got the job and have been a nephrology nurse ever since.”
Today Anne manages a Fresenius Kidney Care clinic in
California, overseeing the care of 50 patients.
The American Nephrology Nurses
Association (ANNA) launched Nephrology Nurses Week in 2005 to give employers,
patients and others the opportunity to thank nephrology nurses for their
life-saving work. In addition, ANNA seeks to interest other nurses in the career
opportunities available in nephrology.
About 30 million adults in the
United States suffer from chronic kidney disease. The nephrology nurses who
treat them make a positive difference in the lives of patients and their
families every day. Caring for kidney patients requires nurses to be highly
skilled, well educated, and motivated, and nephrology nurses cite the variety
and challenges of the specialty as fueling their ongoing passion.
For more information nephrology
nursing, the Nephrology Nurses Week celebration, and more, visit www.annanurse.org/
You are seeing a newly booked
patient in your jail medical clinic. He states that the last time he was in
jail, he was given a second mattress because he had surgery on his back many
years ago. You note that the patient has not seen a doctor on the outside for
many years, that the patient walks and moves normally, and that he has a normal
neurological examination. You tell the patient that medical does not give out
passes for extra mattresses. The patient angrily erupts in a blaze of
obscenities and threatens a lawsuit.
Manipulation happens when a patient
wants something that they should not have (like an extra mattress and pillow)
and will not accept “NO” for an answer. There are several strategies
patients may employ in an attempt to force practitioners to change a
“No” to a “Yes.” This patient started with the “other
doctors gave me what I want” strategy and when that didn’t work, he
employed the “threatening” strategy. (I covered this in more detail in a post last month.)
Verbal Jiu-Jitsu is what I call the
technique of deflecting and defusing such manipulative confrontations. The
first and most important rule of Verbal Jiu-Jitsu is to remember that this is
not a war or a contest! There should be no “battle of wills” between
you and your patient. There is no winner or loser. Instead, you and your
patient are having a conversation. The whole goal of Verbal Jiu-Jitsu is to
avoid any kind of verbal battle.
I know that it is tempting to think
of an unpleasant verbal exchange as a debate-style contest, with a winner and a
loser at the end. But even if you “win” a verbal battle, you’ve
actually really lost because you have not accomplished your goal of getting
your patient to understand and accept your treatment plan! Your patient is
still not happy and will simply renew the verbal battle at another time in
another way — and maybe more effectively next time.
The second rule of Verbal Jiu-Jitsu
is to have compassionate understanding of your patient. That person in front of
you is not an opponent to be defeated. He is your patient. Like everybody else,
inmates are just trying to get by as well as they can in a very tough
environment — they’re in jail! It’s just that many inmates (and people on the
outside, for that matter) have poor interpersonal skills and resort to
pathological social habits. This is what they know and what works for them. If
a patient has successfully gotten his way throughout his life by bullying and
threatening others, that is how he is going to interact with you, too.
You don’t have control over this —
but you do have control over your reaction. When patients confront you with
threats, they will expect you to respond the way that most other people would
— which is either to fight back or to give in. You should do neither.
Take, for example, the case of this
patient in your clinic who has angrily threatened to sue you plus has lobbed in
a few F-bombs for good measure. There he is, red faced, fists clenched, and
LOUD. Nurses, deputies, and other inmates are watching. How are you going to
handle this? How will you accomplish your goal of defusing the situation and
facilitating reasonable communication with your patient?
The single worst thing you could do
would be to respond to anger with anger: “You can’t talk to me like that!
Get the hell out! Who do you think you are?” First of all, the patient is
accustomed to this type of response and will be far more comfortable and
effective with a loud confrontation than you.
Second, the patient (and everyone
watching) have now learned that a verbal confrontation is an effective way of
getting under your skin — very useful information! Also, since you (hopefully)
are not practiced and adept at angry shouting, your heart will be jack-hammering
and you’ll develop a monster headache — at least that’s what would happen with
me. You will have ruined your own mood for the rest of the day. How effective
are you then going to be with the rest of your clinic schedule?
Finally, the fight is not over! The
patient can (and will) renew the attack at another time.
Another wrong response is to
compromise: “There is no reason to be angry! Calm down and we can work
something out.” This is a mistake! If you compromise, you have established
the precedent that becoming angry is an effective strategy with you. Other
inmates will learn this and you will inevitably have to endure many more
confrontations like this.
Instead, defuse and deflect. One way
would be to say: “I see that you are angry, so we are done for now.
Security will take you back to your dorm. We’ll talk again later after you’ve
calmed down.” It’s important to say this without raising your voice and,
if possible, to betray no emotion on your face or body language. The lack of
any reaction goes a long way to defusing such situations. No compromise, no
bargaining, no reaction.
The next day — or even in an hour
or two — you can call the patient back to medical and confidently expect a
more productive conversation. It is important at this second interaction not to
upbraid or belittle the patient. You should act as if the last incident is
It takes training, practice, and
time to master verbal defense skills. The best way to learn is through
role-playing scenarios. The response to angry outbursts happens to be one of
the easiest Verbal Jiu-Jitsu skills to learn. The principles are: betray no
reaction or emotion, end the session (if the patient will not calm down
immediately), but make sure that such patients know that they are welcome back
as soon as they calm down. Bring them back later and act as if the incident is
Thousands of hospitalized patients die every year and the cause is directly attributed to nurses and their “failure to rescue” the patients within their care. We’ve all heard about that one patient that came in with one issue and died of another. Those of us who have reviewed charts for malpractice cases refer to it as the “snowball effect”—reading the progress notes of a patient who died due to failure to rescue will make you cringe at the glaring errors.
Patients may have one clinical issue, however minor, that if overlooked by the nurse, cascades into a huge mess of concurrent errors and oversights that often leads to the injury or needless death of a patient. Did you ever wonder why this occurs? Short staffing? Maybe. Nurse burnout? Could be. The main contributing factor, though, is that unfortunately there are many nurses who don’t think creatively or innovatively. They don’t act on their assessment findings nor do they follow up on a change in patient condition. They fail to act as advocates for their patient. Nurses who fail to rescue use “traditional thinking” rather than critical thinking.
Failure to rescue always includes four key elements: (1) Omission of care; (2) a failure to recognize a change in patient condition; (3) a failure to communicate a change in patient condition to medical or other staff; and (4) poor or lack of clinical decision making.
Preceptors and nursing instructors, no matter the level of nursing taught (RN, BSN, MSN, NP, or DNP), should review the below list. It contains elements of traditional thinking. Promoting traditional thinking stifles critical thinking.
who don’t think critically:
Don’t learn from their mistakes or the
mistakes of other nurses.
Demand that nothing changes and have a
“but we’ve always done it this way” attitude.
Treat each patient interaction in
Fail to “connect the dots” from one
interaction to another.
Fail to learn about cause and effect.
Do not connect new events with prior
Do not see what is possible in the future.
Solve problems in isolation.
Demand that all things be done their way
and not any other.
Allow personal dislikes and prejudices to
Have poor verbal and written communication
skills and do not interact well with others.
Do not further their education or promote education
Force others to make decisions quickly or
set time limits on when decisions can be made.
The behavior and clinical actions of nursing preceptors and instructors affect a student or new nurse long after their clinical rotation or orientation has ended. In fact, the actions of a preceptor or instructor will influence the new nurse far into their nursing careers.
The following statements, said by a preceptor or any nurse to another nurse, will stifle critical thinking:
“That’s a dumb idea.”
“I can’t believe your school didn’t teach
“Your idea is good, but it won’t work here.”
“It’s too complicated so I’ll just do it
and you can watch.”
“You spend too much time talking with your
“We tried that here on our unit and it
How do you teach critical thinking to your preceptees and students? Let us know in the comments!