Got Medicaid (Expansion) Virginia?

DSC00367_2My hometown of Richmond, Virginia is fond of putting large statues of white men on horses in the middle of its streets. Richmond is also the setting for a political and health care drama of Southern Gothic proportions. Virginia is an ACA non-Medicaid expansion state, but the state’s leaders have been debating Medicaid expansion over the past year. Earlier this month Phillip P. Puckett, a Virginia Democratic state senator, suddenly resigned to take a job on the Virginia tobacco commission. Curious circumstances surrounding his resignation have led to an investigation by the U.S. Department of Justice and the FBI, as reported in this recent Richmond Times Dispatch article. His resignation flipped control of the Virginia State Senate to Republicans intent on blocking Medicaid expansion efforts. Today Virginia Governor Terry McAuliffe announced his plan to bypass the recalcitrant Republican General Assembly and expand Medicaid to 400,000 low-income Virginia residents. (see: Modern Healthcare Va. Governor to Bypass Lawmakers, Expand Medicaid, 6-20-14). Governor McAuliffe also plans to block funding a $300 million facelift of the Capitol complex where many of the lawmakers have their offices. The bright and shiny Virginia State Capitol is shown in this photo I took about a year ago.

Medicaid plays vital roles in people’s lives and in our health care system. Medicaid improves access to basic health care services for millions of our children, low-income adults, the elderly (long-term care services), and people with disabilities. Medicaid saves lives. Medicaid funds large portions of our public hospitals, health centers, and nursing homes. Without Medicaid, most of our children’s hospitals would be forced to close.

Several of my struggling small business owner nieces and nephews who live in Virginia would benefit from Virginia’s Medicaid expansion. My elderly father who lives in Richmond would benefit from Medicaid expansion for long-term care services not covered by Medicare. My own son who lives in our Medicaid expansion state of Washington is about to get Apple Health, our version of Medicaid because the University of Washington has ended their student health insurance plan–or at least what was masquerading as a health insurance plan (see my previous post, “My Young Invincible, His Lost and Found Toe, and University Health Insurance that ‘Technically Isn’t'” 4-23-14).

Virginia and other Southern states have high ratios of physicians to the general population, yet have the worst poverty and shortest life spans of any region in the U.S. Virginia has the second highest number of free clinics in the country. North Carolina has the most and Georgia is close to Virginia’s number. Most of the free clinics are faith-based and pride themselves on not accepting any ‘government handouts.’ This generally includes the clinics not accepting Medicaid or Medicare reimbursements. These Southern states are part of the Black Belt of entrenched poverty and severe health inequities. Are free health clinics part of the solution or part of the problem?

The deeply entrenched American notion of charity care as the way to provide safety net services engenders stigma, shame, dependency, and resentment among recipients. Charity care is especially pronounced in the Bible Belt South. People do not want to have to depend on the kindness of strangers. Charity care further fragments an already fragmented, disorganized health care system. Charity care clinics have to compete for donations, grants, staff, and patients. Charity care further fragments and separates us as members of society—sorts us into the haves and the have nots, into worthy and unworthy citizens. Charity care perpetuates poverty. Despite compassionate staff and health care providers, charity care is always leftover care, afterthought care, second-rate care. Charity care gets discouraging, both to give and to receive. I know this first-hand, having been on both the giving and receiving ends of charity health care.

Medicaid and Medicare are both basic entitlements; they are not charity care. So Virginians, come down off your high horses and get Medicaid expansion.

New Zealand Postcards/ Disaster Preparedness: Lions and Tigers and Zombies and Earthquakes, Oh My!

DSC01509There are many things to worry about in this world. For instance, right now in my hometown of Seattle, the Alaskan Way Viaduct is sagging a bit due to the large-scale drilling going on in the downtown area. The Alaskan Way Viaduct is built on ‘reclaimed land’ from Puget Sound that would most likely turn to liquefaction in our next earthquake (similar to what happened in the Christchurch earthquakes). But OK—state officials say it’s nothing to worry about.

As I write this post I am sitting on a ‘somewhat active’ series of volcanoes, on land that was covered in a hot mud eruption only ten years ago. Rotorua, on the North Island of New Zealand is a hot mess. The youth hostel we are staying in has fire action directions in each bedroom, but no information about what to do in case of an earthquake–or a volcanic eruption.

Disaster preparedness and effective disaster messaging are important components of public health. In the U.S., disaster preparedness communications specialists came up with the  Zombie Disaster Preparedness Campaign. Supposedly this campaign started out as a joke by a CDC communications specialist frustrated over the lack of public interest in their traditional disaster preparation information. But then the Zombie Campaign became so effective they’ve continued to use and expand upon it. This shows that with the ‘Chicken Little’ dire warnings of impending doom, a little levity can help.

Last week in Wellington, we talked with Sara McBride, a PhD candidate at Massey University at the Joint Center for Disaster Research. (The photo here is of the inside of their Emergency Operations Center where they coordinate disaster response for the university and conduct trainings). Her area of expertise is as a risk communicator, work which she was doing in Christchurch before the earthquakes. She told us that disaster communication is tricky because too much emphasis on doom and gloom results in people becoming fatalistic. Ms. McBride is currently doing research and work on earthquake/disaster preparedness and messaging in Washington State (where she grew up). As Professor Timothy Melbourne writes in his guest editorial in today’s Seattle Times, the Seattle area is at high risk for major earthquakes and tsunamis on the scale of those in Japan three years ago (“What Our Region Has Not Learned from the Japan Earthquake and Tsunami, 2-25-14). He points out that Washington State needs an honest and transparent assessment of building safety (and other structures such as our dams and bridges). This is an excellent ‘health in all policies’ topic for nurses to get involved with.

When I Used Food Stamps

English: Logo of the .
English: Logo of the . (Photo credit: Wikipedia)

Just in time for Thanksgiving come the huge additional cuts to Food Stamps being considered by the U.S. House-Senate Farm Bill Conference. Many of my colleagues are joining the “Food Stamp Challenge,” attempting to limit their spending on food to the current food stamp daily allotment for an individual (in my home state of Washington this is $4.20/day). Many of my health reporter colleagues on various list-servs and social media sites are debating how to cover the issue of food stamps and food security. There’s a dismaying amount of whining from the health reporters about how much junk food people buy with food stamps. As if people with food stamps should only be able to shop for kale and arugula at Whole Foods…

This is my food stamp story:

When I was twenty I worked for a home health agency in Boston.  I worked as a home health aide for minimum wage–$3 an hour at the time with no health benefits. I had dropped out of school and was living on uncooked Ramen noodles and peanut butter.

One of my clients was a 29-year-old African-American woman who was homeless, or rather had been homeless until she was hit by a car and ended up in the hospital. When I worked with her she was recovering from a broken leg and she stayed at her aunt’s small apartment in Roxbury. It was my first experience using food stamps. She would give me her food stamps and a grocery list and I’d go down to the small corner market and trade the scrip for food. People in the store looked at me funny and seemed to wonder why a clean-cut white girl in khaki pants and a polo shirt was using food stamps. Sometimes things were so turbulent in her apartment I couldn’t get in to see her.

Food security is not just a basic human need; it is also basic human dignity. If you have an elected official who is a conferee on the House-Senate Farm Bill Conference, please send them a strong nudge to not slash Food Stamps in favor of lining the pockets of large agribusinesses. Representative Suzan DelBene of Washington state ((Legislative District 1: Apple and tulip and grape (wine) grower and Microsoft country))–please protect Food Stamps.

See: Cut in Food Stamps Forces Hard Choices for Poor by Kim Severson and Winnie Hu (NYT 11-7-13).

Devilsih Dealings in Hospital Mergers

devilish latte
devilish latte (Photo credit: strikeseason)

Hospital mergers between faith-based (mainly Catholic) and secular healthcare systems are picking up speed and setting off more alarm bells across the country. Here in my home state of Washington–one of our nation’s most secular and socially progressive states–we are quickly becoming the state with the largest percentage of Catholic hospitals. If all of the pending hospital mergers go through, more than half of all hospital beds in Washington State will be in Catholic hospitals. How can this be?

In my previous blog post “God and Mary and Jesus are back….and Coming to a Hospital Near You” (February 27, 2012) I wrote about the concerns raised by the merger of Seattle-based secular Swedish Hospital with Seattle-based (Catholic) Providence Health and Services. As part of the merger deal Swedish Hospital dropped its abortion services. Since the merger, employees have reported they are not allowed to talk with or refer patients for pregnancy termination or give patients resources about our state’s Death with Dignity Act. There are also concerns voiced about the merger’s effect on access to and quality of health care for LGBTQ individuals.

My own physician is part of Swedish and I’ve had conversations with her about whether or not my end-of-life wishes/Advance Directives would be honored if I ended up in a Providence/Swedish hospital. I considered switching health care providers, but now most all in the Seattle area are affiliated with Catholic hospital systems. Even the University of Washington Medical Center is merging/affiliating with PeaceHealth, a large Catholic healthcare system. You have to wonder about these names. Who can argue (especially all of us Pacific Northwest hippies) with a name like PeaceHealth?

As I stated in my previous post– I am all for religious freedom. But I also believe that the separation of church and state goes both ways—not only protecting the
church/religion from the bully-power of the state, but also the state
(government and civil society) from the bully-power of the church.

The ACLU of Washington has taken up the issue of hospital mergers and hosted an excellent panel discussion last week on this topic at Town Hall, Seattle. You can hear a full recording of it here. The audience Q&A session was the most interesting part of it for me. Someone asked why no hospital administrators were on the panel. The answer from the organizers was that they wanted an educational forum and not a public debate–and that hospital administrators had ample resources and platforms already for voicing ‘their side’ of the issue. A woman asked what the ramifications will be for health science student education at University of Washington with the merger/affiliation with PeaceHealth. Two of the panelists were UW faculty members and one replied, laughingly, that they weren’t authorized to answer that question. How sad and how telling and oh how political health care is in our country.

Nurse Nancy Sells Pot In My Backyard

IMG_1089She doesn’t look like a pot-pusher, does she? Neither does she look like the Little Golden Book (1952) Nurse Nancy. And I doubt she looks much like the porn film’s Nurse Nancy.

Her nurse mug started showing up all over my neighborhood this summer, mainly stapled to every other utility pole as shown here. I knew we had a thriving medical marijuana market in Seattle since many of my young adult patients asked me for prescriptions (which I informed them they didn’t qualify for). I also knew that Washington State voters had approved I-502 legalizing marijuana in November 2012, and that our state officials were drafting rules/regulations for the legal production and sale of recreational marijuana. But that was all largely invisible and intangible to me before the Nurse Nancy signs appeared in my neighborhood.

Full disclosure: Although I am a firm believer in harm reduction, I voted against I-502 largely because I didn’t think it was a well-crafted voter initiative. Last fall they acknowledged that state officials would have to build the ‘seed-to-store pot system’ from the ground up within just one year. Admirably, state officials are on target to complete that work by December of this year. They have capped total pot production in our state next year at 40 metric tons. In our super environmentally-conscious region, there’s hot debate about sun-grown vs. greenhouse-grown pot. The carbon footprint of greenhouse grown pot is supposedly quite substantial. Governor Inslee nixed their plans to have the Washington State seal attached to all recreational marijuana sold in our state. We are the Evergreen State, but he decided that was taking it too far.

It turns out that the Seattle-based medical marijuana Nurse Nancy is a real nurse, with, as she states on her website, over thirty years experience as a nurse. She also touts hers as a family-owned and operated business that she runs with her two young adult sons (one who says he has celiac’s disease treated with medical marijuana). Mom-Nurse Nancy (if that is even her real name) supposedly is the one who packages the medical marijuana (in mason jars oh so reminiscent of the good ole’ moonshine days!). They currently carry four different varieties of medical cannabis with wonderful names: Purple Diesel, Purple Snapple, Emerald City (aka Seattle), and huh, Cheese?  I find it curious that her sons are the official ‘public face’ of Nurse Nancy. Her business appears to be legal and well-run and I don’t know of any state nurse licensing issues with what she is doing.

I am intrigued. Not by marijuana but by Nurse Nancy and this great social, political, and public health state-wide experiment that is our initiative to legalize marijuana. Recreational marijuana is due out next spring, at $10-12/gram, in 334 state-licensed pot stores. Medical marijuana will continue to be allowed to be distributed though home-delivery services such as Nurse Nancy.

Quick Toes in Stinky Shoes

The Old Running Shoes
The Old Running Shoes (Photo credit: Mike Spray)

Way to go to Heather Boyle, RN who just had her wonderful Narrative Matters essay included in the latest edition of the health policy journal Health Affairs. Her essay is entitled “As Sports Fees Rise, A Young Athlete Learns That If You Can’t Pay, You Can’t Play.” Heather is a nurse at the Center for Change, an inpatient treatment center for adolescents with eating disorders in Orem, Utah. I had the pleasure of teaching Heather for two of her nursing courses at the University of Washington, where she graduated in 2012.

As she mentions in her essay, Heather grew up in rural Washington State, near the Olympic rainforest. She took up running in elementary school by helping her family members deliver newspapers. A star high-school runner, Heather encountered financial barriers to participation in her school’s track team. Heather advocates for elimination of the “pay for play” rules in order to increase access to school sports. For my health policy course, Heather wrote a health policy essay/personal narrative on school sports, using the format of Narrative Matters. She now has her essay published, plus there is a link to her reading her essay. “Quick Toes in Stinky Shoes” was her original title for the essay, and in the published piece the editors retained it as a subheading. Heather I am so proud of you!

Elliott Bay Book Company ‘Becoming a Nurse’ Event/June 11th, 7pm

The following is from the Elliott Bay Book Company (Seattle) Events page for June. I believe I have Karen Maeda Allman, bookseller and director of Author Events at EBB to thank for the kind description. As a writer who uses their bookstore as a gathering space, she is referring to the fact that I am part of Waverly Fitzgerald’s monthly Shipping Group at the EBB cafe. Thank you Waverly and all my fella’ Shippers for all the support over the years!

I want to add that we may (hopefully) be joined on June 11th by Nina Gaby, psych nurse practitioner, visual artist, and writer from the Boston area. Her essay “Careening Toward Reunion” in the Becoming a Nurse anthology is quite dogeared in my personal copy. I seriously want to meet her… If you are in the Seattle area on June 11th, please come join us for some nurse power time at Elliott Bay.


Start: 06/11/2013 7:00 pm

It’s a particular pleasure for us when writers who use our bookstore as a gathering space have new work to celebrate, as will happen a few times this spring and summer. Tonight, Josephine Ensign, who has contributed so much to our community as a nurse and teacher of the next generation of nurses, appears with colleague Eddie Lueken and Karla Thellen for a group reading from their new anthology, I Wasn’t Strong Like This When I Started Out: True Stories of Becoming a Nurse (edited by Lee Gutkind, InFact Books). Nurses are the backbone of the healthcare system and these stories reveal something of the experiences of nurses at all stages of their careers. Here is illuminating reading for those aspiring to join the profession as well as for those who benefit from their work.


ISBN-13: 9781937163129
Availability: On Our Shelves Now
Published: In Fact Books, 3/2013

The Elliott Bay Book Company
1521 Tenth Avenue
Seattle, WA 98122
United States

Nursing Out of the Closet

Today at 12:01a.m., the government of my hometown of Seattle began to issue IMG_0672same-sex marriage licenses. Last month Washington Referendum 74 for marriage equality passed with 54% of the state vote (and 82% of the vote in Seattle). The Seattle couple given the honor of being the first same-sex couple in Washington State to receive a marriage license was Pete-e Petersen (age 85) and her partner of 35 years, Abbott Lightly (age 77). They are both retired nurses. Ms. (Captain) Petersen was a Korean War Air Force nurse who ran a M*A*S*H-type hospital and then went into public health nursing. She became California’s first nursing home ombudsman for the State Department of Health under then Governor Ronald Reagan.

In interviews with Petersen and Lightly, they talk about the prejudice, stigma, and threat of losing their nursing jobs if they didn’t ‘pass’ as being straight women. It wasn’t until they moved to Seattle after they both retired that they felt safe enough to come out of the closet and live openly as a lesbian couple. In a televised interview with the couple early this morning, they both said they didn’t think they’d live to see the day when they could get an official marriage license and get married.

I’ve been reflecting on nursing, and especially nursing education, in terms of LGBTQ issues. I remember my very closeted lesbian nursing instructors from the 1980’s, and the still closeted lesbian nursing professors I know. In nursing school I got absolutely no educational content on LGBTQ issues, except being told that gay men were vectors of HIV/AIDS. Most nursing education today is not much better, although hopefully we teach that HIV/AIDS comes from a virus and not from gay men.

I think back to a time in the 1990’s when I was running the women’s clinic at a Baltimore LGBTQ community clinic (the photo here is of me with friends, at the March on Washington for Lesbian, Gay and Bi Equal Rights and Liberation/April 1993). I was advised by colleagues to not publish a paper I’d written based on my experience providing health care at the clinic(co-authored with my wonderful Johns Hopkins professor/expert on women’s health, Elizabeth Fee). This wasn’t based on their concerns for patient confidentiality, but was based on their firm belief that publishing the paper would label me as deviant and could negatively impact my future career in academic nursing. Since I was a single mother, I needed a job, so I ditched the paper.

Carla Randall and Mickey Eliason, both present or former nurse educators, write about similar experiences in their recent article “Out Lesbians in Nursing: What Would Florence Say? (Journal of Lesbian Studies, 16:65-75, 2012). They point to the fact that historically nursing was dominated by “lesbians, nuns, and spinsters.” They contend that lesbians currently constitute the largest minority group within nursing. (I would add that is only likely for the older cohort of nurses. The largest ‘minority’ group for the younger cohort of nurses is men/ a healthy addition to our profession). Randall and Eliason state that none of the national or international nursing organizations include sexual orientation or gender identity in their nondiscrimination policies. Most other health professions organizations—including the American Medical Association—have issued statements specifically addressing non-discrimination for LGTBQ patients and health care professionals. They also point to results of a study they published in 2010 in Advances in Nursing Science where they reviewed all articles in the top 10 nursing journals between 2005-2009. They found that only 0.16% of the articles included LTGBTQ issues. Longtime nursing educator and activist Peggy Chinn has also published about her experiences of homophobia within nursing education. Her 2008 article “Lesbian Nurses: What’s the Big Deal?” was published in the journal Issues in Mental Health Nursing. Interesting choice.

Turning to the younger—and thankfully more open-minded/supportive of LGBTQ human rights—generation, I am inspired by the young nurse activists who are helping to bring positive change to nursing education and nursing practice. Some are my own students (one of whom contributed to my ‘resources’ list below). Two others are Fidelindo Lim and Nathan Levitt, who both work and teach in NYC. They co-authored a thoughtful “Viewpoint” essay in the American Journal of Nursing (Nov 2011) “Lesbian, gay, Bisexual, and Transgender Health: Is Nursing in the Closet?” In their essay they conclude:

“Homophobia, stigma, and discrimination lead to health disparities and reduced access to care. If we are to remain faithful to our profession’s mission and the public’s trust, we must take a proactive approach to addressing the health needs and safety of LGBT patients, some of whom are nurses themselves.”

There’s a wonderful interview clip of Nathan Levitt, a transgender male, talking about his own experience with health care when he sought breast surgery. His surgeon required him to first see a mental health therapist to “see what’s wrong with you.” When he got to the therapist’s office, she told him she’d just completed one of his cultural competency trainings on LGBTQ health, and that obviously he was the expert on this, not her (video-clip interview available on The American Nurse Project site.) Education and enlightenment can have a boomerang effect.

Additional recommended readings/resources:

Ethnomed Local/Global Resource

Harborview Hospital on First Hill seen from Pi...
Harborview Hospital on First Hill seen from Pioneer Square neighborhood, Seattle, Washington, USA. (Photo credit: Wikipedia)

Harborview is the large King County hospital located on “Pill Hill” in the middle of Seattle. It is the only Level 1 Trauma Center for all of Washington, Alaska, Montana and Idaho. Harborview’s specific mission is to care for the county’s most vulnerable patients. As such, it forms the most visible part of the health care safety net for the Seattle area. I am always a bit awed by the scope of what they do, and have been able to see some of that firsthand this summer—from the high-tech trauma ICU to the low-tech/high touch Daryel /Somali Women’s Wellness Project.

A useful Harborview resource I highly recommend is Ethnomed. Ethnomed is Harborview Medical Center‘s ethnic medicine website. The main purpose of Ethnomed is to help busy health care providers integrate cultural information into their clinical practice. While Ethnomed’s focus is on the main refugee and immigrant population groups currently coming to and residing in Seattle/King County, there is also general cross-cultural information that would be useful in any area. There are links to specific cultures, to different clinical topics, and links to printable patient education handouts in different languages including Spanish. On the main page there’s a link to sign-up for Ethnomed’s electronic newsletter.


Nurses and Anti-Vaccination

Last week I wrote about the current pertussis epidemic in my home state of Washington, coincidentally the state with the highest percentage of parents opting out of vaccinating their children for all of the usual vaccine-preventable diseases such as polio, tetanus, diptheria, pertussis and hepatitis B. I concluded by hoping that my own pertussis booster would protect me against a planeload of Washington State coughers I recently had the pleasure of sharing a red-eye with on our way to NYC. Since the average incubation time from exposure to pertussis to symptoms is 7-10 days (and can be as long as 21 days), I’m not yet breathing a non-congested sigh of relief. But I’m hopeful.

I am a critical health care consumer and I teach my students to be critical health care providers.  On a personal basis I don’t accept all health care screening and prevention guidelines without first examining the evidence and deciding for myself what is best for my own health. For instance, I tend to agree with the conclusions about mammography screening written about (beautifully) by Veneta Masson, a nurse practitioner and poet living in Washington, D.C. in her essay “Why I Don’t Get Mammograms” (Health Affairs/Narrative Matters October 2010). I have used naturopathic, acupuncture and other ‘alternative’ medicine modalities for illnesses that are beyond the abilities of allopathic mainstream medicine to treat. But for most vaccinations, I am a discerning early adopter. Having been threatened with an attack by rabid dogs in Northern Thailand, I have even gotten my rabies vaccine series. Doing street outreach has extra hazards in a country like Thailand. I did get the rabies vaccine series in Bangkok since they cost significantly less there—Bangkok is one of the main WHO rabies centers in the world. (Thailand, a Buddhist country opposed to euthanasia of animals—even rabid ones—has one of the highest rates of rabies in the world).

As a health care provider I consider it my professional duty to stay current on recommended vaccinations, including the annual flu vaccine. I have the option of receiving it at my work site (limited times/places so not very convenient) or at my doctor’s office, or—as I usually opt for—at my local Safeway pharmacy. My annual flu shot comes between shopping for groceries, is immediately covered in full by my health insurance, and is administered by a very friendly and knowledgeable pharmacist within about five minutes of registering for it. (I fully realize all of these lack of barriers/facilitators do not exist for everyone). I have read the evidence on risks and benefits of the annual flu vaccine and am convinced on the side of getting the shot. I listen respectfully to my nurse colleagues who opt out of the flu vaccine, but I am dismayed by how many opt out for anything other than religious or valid medical reasons. I haven’t tried to convince them to change their minds because I never saw that as my job. But if any of them happen to be reading this, I hope they will at least reconsider their decision.

The evidence is fairly overwhelming in favor of nurses and other health care workers getting an annual flu vaccine, in terms of reducing the risk of transmission to their patients as well as co-workers. The flu vaccine has proven to be safe and effective, and the flu vaccine ‘industry’ is not exactly a huge profit making one. Since 1981 the CDC has recommended that all health care workers get the flu vaccine on an annual basis. (A good review from a nursing perspective is Paula Sullivan’s “Influenza Vaccination in Healthcare Workers: Should It be Mandatory? OJIN/available on ANA’s website). Most hospitals have relied on voluntary participation of health care workers, sometimes accompanied by vigorous (and I would suspect costly) education campaigns. While rates of flu vaccine compliance are high for most physicians’ groups (with the notable and not surprising exception of surgeons), the rates of flu vaccine compliance among nurses remain much lower. Why the difference?

A recent article in the journal Vaccine “What Lies Behind the Low Rates of Vaccinations Among Nurses Who Treat Infants?

English: Avian flu vaccine development by Reve...
English: Avian flu vaccine development by Reverse Genetics technique. Basa Sunda: Ngembangkeun vaksin flu unggas maké téhnik reverse genetics. (Photo credit: Wikipedia)

” (O. Baron-Epel, et al, 30(21), 5-12-12) explored this question (in this case for pertussis vaccination). Researchers in the UK conducted a series of focus groups with 25 public health nurses working at several Mother and Child Healthcare Centers, about their understanding and beliefs on vaccination. Common themes that emerged from the focus groups included the usual barriers to vaccination: fear of side effects, and a lack of perception of personal risk or risk of harming patients. Other barriers included lack of trust in health care authorities (and of health information), strong value of personal autonomy (being able to refuse vaccination), lack of respect of nurses by hospital administrators, and the fact that they did not view themselves as role models for patients. The researchers concluded “There is the need to increase the nurse’s awareness of the unethical aspect of not being immunized and increase the perception of themselves as transmitters of disease.” (p 3154).