Insights from a Bedside Nurse

Hazel Torres, MN, RN is Assistant Director for SPCMG Regional Professional Development and Research in Pasadena, CA.

I am married to a bedside nurse and he is the biggest critic of the work of NPD Specialists.  From his world view, the “educators” (his term) walk around the units with clip boards (he must have had several of these in his career as a nurse), critiquing what the staff are doing, coming up with new acronyms and talking about concepts that reside in the theoretical, ideal and even magical world (did I mention that he’s the biggest critic?).

I actually think that there are more nurses out there who think like him than we care to acknowledge.  He is more open and frank about his opinions with me because he is also the biggest supporter for my success in my role as an NPD specialist. He’s always more than happy to share with me how HE thinks I could be successful in what I do.  I’m sharing these insights in case you need a source for candid, not-quite-so-nice feedback that’s deeply rooted in love and the desire for improvement. Here are some of the things that he’s shared with me over time:

1. Be credible.  If you have not walked a shift in the nurses’ clogs, it would be very difficult for you to engage them for any education you have to do.   As an NPD specialist, you would be hard pressed to deliver your message or your education across if you can’t relate to the woes of a bedside nurse.  It would be important for you to understand good vs. bad times during the shift, bedside lingo vs. theoretical terms, etc.  He is more likely to be engaged with someone who he knows to have gotten “their hands dirty” at one point in their career.  This concept becomes even more critical when you are assigned to a specialty department such as L&D or ED or ambulatory.  He further suggests that being current doesn’t just mean reading the latest professional journals and attending conferences; he thinks that this would be enhanced by the NPD specialist coming to a unit or department to be immersed in physician, patient and staff interactions and learning about its culture and unspoken language.  This immersion also would provide the NPD specialist valuable insight for conducting needs assessment and the opportunity to reinforce previously taught concepts.
2.  Don’t leave out structure, process and outcomes.  When teaching theoretical concepts or “niceties”, always relay how this is actually supported by the department’s structure, processes, and workflows.  Giving real life examples on how to do it right and how to do it despite having to overcome perceived barriers or frustrations give the nurses the ability to translate it into their practice a lot quicker.  He admits that despite the desire to have evidence-based practice, there has to be a conscious effort from the NPD specialist to go against practice-based practice.  Educating the nurses on the structures, processes and workflows associated with the concept being taught lessens this burden for the nurses.  It’s also important to address some questions in their heads – “How will this be measured?”  “How will it be sustained?” “What’s in it for me?” According to him, one of the first thoughts that cross a staff nurse’s mind during an in-service is that this is yet another “flavor of the month”.  There should be an emphasis on what initiative this is replacing or enhancing (if any) and how this will be sustained in what time frame.  An NPD specialist who goes to teach a new concept without knowledge of its application will not only be ineffective and wasting everyone’s time, they will also lose credibility with their audience.
3. Listen.  Some of the staff could have ideas on how improvements could be made in their department.  Some of these ideas are not necessarily related to clinical education, however, the staff might look to the NPD specialist as a resource or an advocate for their concerns.  They might have suggestions on how the trays could be delivered to the patients’ rooms while you’re giving a class on improving HCAHP scores.  Discuss the suggestion after the class but don’t dismiss it.  Even after you bring this up to the appropriate person or committee, you might not be able to influence the workflow of the dietary department but you would have gained the staff’s trust and respect for advocating for their cause and moving their ideas forward.
4. Be an advocate.  As nurses, we have a very keen sense of reading into other people’s intentions.  The staff nurses often respond to the intentions that they perceive the NPD specialist has in delivering the education.  In other words, your primary goal as a NPD specialist is not to teach, it is to affect change; the idea is not to tell people how it should be done but rather to influence their thinking to want to do the right thing.  Use reward and recognition as often as you would coaching and counseling.  Be an advocate for the staff nurses and the nursing profession itself as much as they, the staff nurses, are advocates for their patients.
5. Practice what you preach.  Nobody wants to hear “do as I say not as I do” especially as adults.  He says that he learns from the NPD specialists not just by attending their classes but more so by observing how they conduct themselves outside of the classroom.  Remember his observation about walking around with a clipboard?  That might not have been a detail his previous NPD specialists paid attention to but he definitely did.  He says that it’s important for the NPD specialist to acknowledge that they’re always being observed.  It’s important to give the staff something more meaningful to learn from such as communication skills, leadership styles and even de-escalation techniques; the staff might still notice what you’re wearing or carrying but this way, they actually learn from what you’re doing.

At the end of the day, he acknowledges that professional development is a calling requiring different skill sets than what we have learned in nursing school and in practice.  He ends with this witty remark – “If you’re teaching 5 year olds, you don’t have to act like a five year old. You just have to understand what motivates them and know how to communicate with them”.  . To become successful nurses, we learn the skill of constantly assessing and evaluating the needs of the patients we serve.  To become successful NPD Specialists, we must also learn the skill of constantly assessing and evaluating the needs of the nurses that we serve.  After all, we have to effect change in the nurses’ skills, knowledge and behavior in order to meet our ultimate nursing calling of improving the health and welfare of the communities we serve.  What feedback have you received (good, bad, or ugly) that has changed the way you perform your responsibilities as NPD specialists?

The Journey Toward LGBT Cultural Proficiency

Tim Rodden, MDiv, MA, BCC, FACHE, is the Director of Pastoral Services at Christiana Care Health Systems and is Co-chair of the United Way of Delaware PRIDE Council LGBTQ Health Equity Task Force.

There is growing attention to providing culturally competent health care to our patients/families who are lesbian, gay, bisexual or transgender (LGBT). This raises a few questions: Why is this needed? What does LGBT culturally competent health care mean? How do we go about achieving this? I hope to offer some insight into these basic questions in this blog and to whet your appetite to learn more in a Train-the-Trainer webinar that will occur in June 2016.

Let’s begin with a working definition of cultural competence. There are several definitions that have been offered over the years. One of the seminal works in the field of “cultural competence” dates to 1989 when Terry L. Cross, et al wrote Towards a Culturally Competent System of Care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed [Cross, Bazron, Dennis, and Isaacs (1989)].  In it they describe cultural competence as a “set of congruent behaviors, attitudes, and policies that come together in a system, agency, or amongst professionals to work effectively in cross-cultural situations.” In practice, “a culturally competent system of care acknowledges and incorporates, at all levels, the importance of culture, the assessment of cross-cultural relations, vigilance towards the dynamics that result  from cultural differences, the expansion of cultural knowledge, and the adaptation of services to meet culturally unique needs”.

Why should we address LGBT cultural competence in health care? It has been difficult to get a completely accurate picture of the health disparities facing the LGBT communities because we don’t regularly collect sexual orientation and gender identity data like we do for other demographic groupings e.g., race, ethnicity and language. There have been a few relevant studies conducted that help us understand the need for addressing this today in the health care arena. In the 2007 California Health Interview Survey we see the disparities between LGB populations and the heterosexual population in seeking preventive care and in divergent use of emergency services:

% adults delaying/not seeking health care

           - Heterosexual – 17%

           - LGB – 29%

% adults receiving emergency health care

           - Heterosexual – 18%

           - LGB – 24%

In the study When Healthcare Isn’t Caring (2010, Lambda Legal’s Survey on Discrimination Against LGBT People and People Living with HIV) we get a picture of the “perception of care” from the perspective of these groups. 7.7% of LGB and 26.7% of Transgender respondents report they were refused medical care because of sexual orientation or gender identity. Given this it is not unsurprising to see that some LGBT people have the perception that they will be refused future health care for the same reason: nearly 10% of LGB and 52% of Transgender respondents believe they will be refused health care.

Our work is to reduce health disparities and to encourage people to get the health care needed in spite of cultural differences whether sexual orientation, gender identity, or any other cultural factor.

What does LGBT culturally competent health care mean? One of the leaders in advocacy for LGBT people in receiving equality in health care is the Human Rights Campaign Foundation which publishes the Healthcare Equality Index (HEI) each year. The HEI provides a road map for healthcare systems in measuring best practices for LGBT patient – and- family centered care and for LGBT workforce inclusion. 

The Core Four Requirements of the HEI address the following four broad policy and procedure areas for health care facilities:

In addition the self-reported survey assesses best practices and gives concrete examples for practices in the following areas:

• LGBT Patient Services & Support
• Transgender Patient Services & Support
• Patient Self Identification
• Medical Decision Making
• Employee Benefits and Policies
• Community Engagement

LGBT patients and families are looking to this published index more and more to seek out health care facilities and by extension their providers who can provide LGBT culturally competent care. Facilities that rank the highest receive the designation of Leader in LGBT Healthcare Equality which sets them apart from other facilities/providers.

How do we go about achieving LGBT cultural competence? Better yet the question might be asked, how do we go about striving for LGBT Cultural Proficiency? Cross, et al describes cultural proficiency: when cultural differences are highly regarded and the need for research on cultural differences and the development of new approaches to enhance culturally competent practices are recognized. This level of achievement goes beyond cultural competence:  when cultural differences are accepted and respected; continuous expansion of cultural knowledge and resources and continuous adaptation of services occur; continuous self-assessment about culture and vigilance toward the dynamics of cultural differences exist.

Achieving cultural competence and perhaps cultural proficiency is a developmental process. First you have to recognize the need for doing things differently, that you may not have all the answers. Secondly, you need to determine who the key stakeholders are in making needed changes to policies and procedures. Thirdly, you need the buy-in and active engagement of leadership so that there is impetus behind the transformation. Lastly I would say you need to actively involve the LGBT community in assessing current state, what needs to change, what can change and to provide the motivation for making the changes. 

Delaware’s largest private employer, Christiana Care Health System, has been participating in the Healthcare Equality Index since 2011 and since 2012 the system’s two hospitals: Christiana Care Wilmington Hospital and Christiana Care Christiana Hospital have received the designation of Leader in LGBT Healthcare Equality. All new nurses hired by the system receive comprehensive orientation. During the orientation day titled “Exceptional Experience” they participate in an education module called Your LGBTQ Patient: Providing Culturally Competent Care. 

The strategies employed in this education module with additional resources will be presented in the Train-the-Trainer Webinar that Tim Rodden, MDiv, MA, BCC, FACHE and Bret Herb, LCSW will conduct on June 16, 2016 for the Association for Nursing Professional Development. (Tim coordinates LGBT health for Christiana Care and Brett is a gender therapist and mental health consultant for Christiana Care.)