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).

God’s Will Scale

The One Slide: End of Life Questions
The One Slide: End of Life Questions (Photo credit: stevegarfield)

It’s official: they have a research scale for everything, including God’s Will. In dealing with my elderly father’s illness and end-of-life (EOL) decision-making/interface with the health care system, I kept remembering research I’d read about religiosity and EOL choices. Higher religiosity is associated with preference for life-prolonging medical treatments. This may seem counterintuitive at first, but perhaps people with higher religiosity are less likely to doubt the limits of medical science and our health care system. Researchers developed the Gods’ Will Scale to measure degree of religiosity (Winter, et al, 2009, Preferences for life-prolonging medical treatments and deference to the Will of God, J. Relig Health. 48: 418-430) The New York Times today has an interesting Opinion piece related to this topic: Why Do Americans Balk at Euthanasia Laws?  Contributors to this article point to the fact that the US population scores much higher on religiosity scales than do our peer nations. I should mention again that my father is a retired Presbyterian minister living in the conservative and highly religious state of Virginia.

I praise God and every other possible Higher Being that I live in a relatively enlightened state—that state being Washington State, which joined Oregon in the Death with Dignity Act. We also have a relatively active and from what I hear effective POLST Paradigm program: Physician Orders for Life-Sustaining Treatment Paradigm. POLST Paradigm program is designed to improve the quality of care people receive at the end of life. As they describe the program “It is based on effective communication of patient wishes, documentation of medical orders on a brightly colored form and a promise by health care professionals to honor these wishes.” From what I understand, POLST was started in response to complaints from patients that their EOL wishes as declared on Living Wills/Advance Directives were not being honored within the health care system. There have been cases of patients tattooing “DNR” (Do Not Resuscitate) on their chests in an attempt to have their wishes honored. Supposedly this works as long as rescue personnel bother to read their tattoo.

On the POLST website they describe patient-centered end-of-life care as, “Effective communication between the patient or legally designated decision-maker and health care professionals ensures decisions are sound and based on the patient’s understanding their medical condition, their prognosis, the benefits and burdens of the life-sustaining treatment and their personal goals for care.”

All people over the age of 18 are advised to have a Living Will/Advance Directives. In addition, people with a life-limiting illness should have a POLST. In Washington State POLST forms can be signed by physicians, nurse practitioners or physician assistants–that, of course, varies state to state according to their scope of practice regulations. Virginia has not yet adopted the POLST Paradigm.

In my opinion, my father has not received patient-centered end-of-life care. Instead, he received costly life-sustaining medical treatment and remains hospitalized in ICU. But at the same time, he is up and walking with help, complaining about the hospital food, and ready to get back to his work of taking communion to people in nursing homes. So, maybe it’s God’s will?

In (Nurses) We Trust

An oil lamp, the symbol of nursing in many cou...
Image via Wikipedia

Nurses did it again: topped Gallop’s annual Honesty and Ethics of professions survey for the twelfth straight year. In fact, nursing has topped the Gallop survey every year except one since nursing was added to the list in 1999. Nursing was eclipsed by firefighters in the 2001 poll, which was conducted two months after 911. It is interesting to note that Gallop started the Honesty and Ethics survey in 1976, and nursing wasn’t included until 1999. Prior to 1999 pharmacists or clergy were rated #1.

The 2011 Gallop Honesty and Ethics poll was based on a telephone (landline and cell) survey conducted November 28-December 1st from a random sample of 1,012 adults representing all 50 states and Washington, DC. The survey question was, “Please tell me how you would rate the honesty and ethical standards of people in these different fields—very high, high, average, low, or very low?” Rankings of the professions by overall results are done based on the percentage of respondents answering either ‘very high’ or ‘high.’ This year 84% of those surveyed rated nurses as very high/high (and only 1% rated nurses ‘very low/low). Pharmacists were the next highest medical profession in the ranking, 73%, very high/high, followed by medical doctors at 70%. Military officers and high school teachers rank higher than doctors.

The phrase, “nursing is the most trusted profession in the US” is inserted into many public speeches—by nursing leaders ,of course—but also by politicians pandering to the nursing vote. It is almost taken for granted that nurses are trusted. But why are we so trusted?

First, you can’t trust nursing leaders for the full answer to this question. They have a vested interest in positive spin, such as this recent statement by ANA’s President Karen Daley: “The public’s continued trust in nurses is well-placed, and reflects appreciation for the many ways nurses provide expert care and advocacy.” Well, yes, but isn’t there more to it than that?

If you dig into analysis by the Gallop researchers, they point out that the medical professions as a whole are generally highly trusted in our society, and that stability is the norm in American’s rating of professions. However, American’s opinions do shift in response to real-world events (e.g.: 911 and firefighters), and mostly to large scandals that reflect poorly on a profession. For instance, the clergy took a tumble in ratings in the wake of the Catholic priest sex abuse scandals (as well as the Evangelical sex scandals such as Jim Bakker/closets, etc). For whatever reason (relative low-profile/low power and prestige perhaps?) nurses and pharmacists have been able to avoid widespread scandals.

Sandy Summers (a nurse) on her The Truth About Nursing website states, “The reason the ‘most trusted’ poll results don’t do too much for us is that this public view often goes hand in hand with the prevailing vision of nurses as devoted, angelic handmaidens.” And Suzanne Gordon (a journalist/not a nurse, but rather a die-hard nurse advocate) goes even further, writing on her blog last year, “I am getting tired of these polls that try to assuage nurses and stroke them and make them feel better.” Both Sally and Suzanne point out that trust does not equal respect, and that many people may trust nurses but have little idea what they really do. But I’m not convinced that you have to understand what someone does to be able to trust them.

I find it intriguing that the four most highly trusted professions (listed in order) are nurses, military officers, pharmacists, and grade school teachers. All four have strict codes of ethics and standards of practice, and all—for the most part—work within rigid hierarchies for ‘the man’ or ‘the woman.’ They don’t typically work on their own as physicians can and often do. They all, in various ways, take orders. And they aren’t exactly the highest paid professions around—although the average pharmacist salary now tops six figures. So—taking orders within a rigid hierarchy and not profiting in a huge way would seem to be related to high public trust. The lowest ranked professions on the trust survey are members of congress, car salespeople, telemarketers, and lobbyists. The lesson here for our country? Perhaps more nurses should become members of congress?

Violence at Work

ER (TV series)
Image via Wikipedia

This past week our local public radio station, KUOW, ran a series on workplace safety in Washington state. For those of you not familiar with Pacific NW-specific high-risk jobs, these include loggers and commercial fishermen, including scuba-diver harvesters of geoducks (world’s largest clams/highly priced aphrodisiac in China and Japan—when you see a photograph of one you’ll understand why). Then there are the non region-specific high-risk jobs of police officers, corrections officers and security guards.

But the highest risk job category of all in Washington state is that of nurses’s aid, followed closely by RN. The highest risk place to work is Western State Hospital. Nurse’s aids, nurses, and other frontline workers at Western State Hospital are assaulted on the job 60 times more than the average worker in Washington state. Western State is the largest psychiatric facility west of the Mississippi and houses criminal defendants when they are found mentally incompetent to stand trial.  So it is in effect a combination correctional and psychiatric facility with highly volatile and violence-prone patients.

Nationwide, nurses working in Emergency Departments (EDs) are at high risk for workplace violence, generally in the form of physical violence from patients, family members or other visitors. EDs and urgent care centers are where people go for violence-related injuries stemming from domestic violence or gang violence. EDs and urgent care centers are where people go who are intoxicated or having acute psychiatric emergencies—usually accompanied by police. Waiting room overcrowding, long wait times to be seen by a provider, lack of visible security systems, lack of staff training on de-escalation techniques, and understaffing, all contribute to increased risk of violence. Reports from around the country indicate a steady increase in ED violence, most likely stemming from weakening primary care safety net services, forcing more desperate and frustrated patients into EDs for basic health care needs.

The KUOW episode “Violence in the ER” and the accompanying Seattle Times article “Most violent job in Washington? Nurse’s Aid” highlight ED workplace violence in Tacoma General Hospital in Tacoma, and Harborview Hospital in Seattle—the state’s two biggest hospital EDs. Tacoma General Hospital ED uses a metal detector at all times to screen patients and visitors. Harborview Hospital only uses a metal detector in the ED at night, and at other times security guards use a hand-held metal detector on patients and visitors they deem high risk.  Harborview Hospital administrators, like many for hospitals across the country, have chosen not to install permanent metal detectors for fear of slowing down emergency care. According to the KUOW report, on a recent Saturday night a man got into the Harborview ED with a backpack containing a large knife, two cans of pepper spray, a cap gun, and bullets.

Third behind ED and psychiatric hospital settings for workplace violence for nurses is home care/home hospice. Work in these settings is usually done solo, with possible exposure to domestic violence or drug activity.

The Occupational Safety and Health Administration (OSHA), the federal agency charged with ensuring safe and healthful working environments for US workers, has failed to issue federal standards on workplace violence in health care settings. So far, they have only published voluntary guidelines on this topic. California, Washington, Florida, Illinois, New Jersey, Tennessee, and Nevada have passed state laws requiring further protection for health care workers. For instance, in Washington state, all health care settings are required to develop and implement plans to protect employees from violence. State law now makes it a felony for anyone to attack a health care provider—including verbal threat of assault. Washington state law requires all health care settings to keep records of any violent act (including verbal threats) against an employee, patient or visitor.

According to Jeaux Rinehardt, president of the Washington State Emergency Nurses Association, the felony assault charge is mainly enforced for attacks on doctors—rarely for attacks on nurses or other health care providers. He also echoes many nurses around the country in stating that nurses are actively discouraged from reporting and documenting workplace violence by managers or hospital administrators. (KUOW News: Violence in the ER, 7-13-11)

I worked in home health in Richmond and Baltimore for seven years during the height of the crack cocaine epidemic of the late 1980’s/early 1990’s. I worked in a large downtown Baltimore hospital urgent care center for six years. If you have watched any episodes of “The Wire” that’s what it was like to work and live in Baltimore at that time. The worst thing that happened to me during those years was that an intoxicated patient peed on me during a pelvic examination right when we had a power outage. She got scared she said, so it’s not like she meant any harm. The urgent care center I worked for was well staffed, had excellent relations with the community it served, and had a visible, well-functioning security system. We had panic buttons we carried in our pockets at all times, but I never had to use it. All staff received regular training in violence prevention techniques.

By contrast, working at various community health centers in and around Seattle for 15 years, there were at least ten times when patients seeking narcotics verbally or physically threatened me. These clinics were usually poorly staffed, served large numbers of impoverished people, had no security systems in place, and did not have clear protocols or “pain contracts” for use of narcotics. I remember front desk staff calling for police in several of the cases, but I think in only one case was I encouraged to complete an Incident Report.

An aspect of workplace violence in health care settings I had not even thought of appeared as a spin-off of a KevinMD.com guest blog. In 2007 Patricia Allen, RN wrote “Violence in the Emergency Department and how to promote ER safety.” It is a short blog post, mainly advertising her book. What I found more interesting was a reader’s comment. Steve Parker, MD: “Here in Arizona, hospitals are gun-free zones. Most physician and healthcare providers will not carry their guns into the hospital. Risk of getting caught is too high.” I had to read his comment twice before I understood it, because it never occurred to me that health care providers would carry concealed weapons to work. I thought that was confined to really bad TV shows.