Being a Whole Person, Healing the Whole Community

•February 22, 2012 • 1 Comment

Our experiences with patients or populations, and the communities in which they live, ought to be the impetus for making our primary responsibility the practice and research that enables healthy policy change and identifies innovative strategies for addressing the social determinants of health.          -Betty Bekemeier

From:Upstreamnursing practice and research
Betty Bekemeier

Research increasingly suggests that when nursing and other health-related sciences focus their attentions on the social determinants of health, we will achieve improved health status and greater health equity in the populations we serve.  This focus requires an upstreamapproach. Upstream approaches refer to an analogy used in the United States for describing efforts focused on primary prevention and addressing root causes of disease and disability. This upstream analogy addresses the underlying issues that cause downstreamproblems rather than going to great lengths to address fully developed and ongoing crises downstream. Many of us in nursing are in downstream positions, researching questions and working with programs that relate to caring for acutely at-risk, vulnerable families or communities and without a focus on activities that would drive a movement from downstream work to upstream measures that change harmful systems instead of responding to their negative outcomes. Our present emphasis on downstream approaches occurs, in part, because of the complexity of addressing social conditions that impact health from upstream and, in part, because of our traditional conceptions of care.

Nurses can be natural leaders in addressing the social conditions that impact health, given our holistic perspective on health, our intimate experiences with individuals and communities that provide a unique view of the outcome of social forces such as poverty and failed policies, and our skills in fostering health protection at the individual and collective level (Butterfield, 2002). Focusing our research and practice pursuits on the underlying causes of poor health status and health disparities requires an upstream perspective that brings nursing (back) into the realm of policy analysis, social reform, environmental health, sociology, and international health.

Nursing education and research reinforce traditional caring models of service and have dissuaded us from acting to create and support policies that assure healthy conditions, from researching root causes of poor health, and from changing the systems that overspend health dollars on illness rather than prevention. Nurses tend to be educated in theoretical models of service (not advocacy), thereby focusing practice on caring for individuals in need. A study conducted by Rains and Barton-Kriese (2001) of baccalaureate nursing students nearing graduation found that nursing students did not see connections between the personal, professional, and political. Nursing seemed grounded in application and service.”  Similarly, nursing research generally works to substantiate what is done rather than what could be different and, as a result, reinforces a distance between the tasks of service-oriented nursing work and the complexities of social change. Instead, nursing research could focus on that which challenges political structures that oppress, employing a critical paradigm that is more interested in how data can be used for social change than the extent to which it is scientifically compelling (Ford-Gilboe & Campbell, 1995, p. 22).

Nursing scholarship around the analysis of care cannot be apolitical when contrasted with the politicized systems in which nurses practice today. Thankfully, opportunities do exist to participate in an emerging critical discourse on caring that expands the notion of caring as the coreof nursing and envisions a more emancipatory practice in which nurses participate in communities in a caring paradigm different from that in which we were taught (Stevens 1992). In exercising a practice of caring that joins with vulnerable populations and with each other, we can respond to the complex problems of social inequities through the collective action and participatory research, which these problems require (Beauchamp 1975, p. 276). This future could be ours with a collective commitment to social change, political participation, and expanded notions of caring.

While improving the health of the few, we may serve as individuals, as nurses we are complicit in the illness and death of many. Alternatively, our experiences with patients or populations, and the communities in which they live, ought to be the impetus for making our primary responsibility the practice and research that enables healthy policy change and identifies innovative strategies for addressing the social determinants of health. Surely, barriers exist in nursing theory, education, and research that have inhibited support for this expectation of ourselves. For us to be effective, however, in assuring healthy conditions for all populations, the caring practice of nursing necessitates participation in the political process and challenging imbedded social systems and powerful interests (Beauchamp 1975, p. 278). The public should (and perhaps does) expect this of us. We should also expect this of one another.

Source: Bekemeier, B. (2008). “Upstream” nursing practice and research. Applied Nursing Research, 21(1), 50-52.


Poll Finds Wide Gap Between the Care Patients Want and Receive at End of Life

•February 16, 2012 • 1 Comment

New research shows most Californians would prefer a natural death at home without becoming a burden on family. But few document their wishes, leaving their loved ones in the dark.

When it comes to how they want to spend their final days, Californians would prefer to die a natural death at home without being a burden, financially or emotionally, on their families. Yet according to a new poll released today by the California HealthCare Foundation, a disparity exists between what people say they want at the end of life and what actually occurs.

The survey, Final Chapter: Californians’ Attitudes and Experiences with Death and Dying, finds nearly 8 in 10 Californians say that if seriously ill, they would want to speak with their doctor about end-of-life care, but fewer than 1 in 10 report having had a conversation, including just 13% of those age 65 or older.

Additionally, while 82% say that it is important to put their wishes in writing, less than one quarter have actually done so. More than half say they have not talked with a loved one about the kind of care they want at the end of life.

The survey explores differences in attitudes toward death and dying among major ethnic groups in California. For example, Latinos rate “living as long as possible” much more highly than other groups.

“With end-of-life treatment, there is a clear gap between wishes and actions,” said Mark D. Smith, MD, MBA, president and CEO of the California HealthCare Foundation, which commissioned the survey. “People consistently stress they want to die comfortably and without pain. If so, the single most important thing they can do is to talk to their loved ones and physicians, and put their wishes in writing, something most Californians aren’t doing.”

Preferences Not Being Followed

The survey finds patients’ wishes regarding treatment are not always honored. Only 44% of Californians who have lost a loved one in the last 12 months say their loved one’s end-of-life preferences were completely followed and honored by medical providers. These numbers drop to 26% for those whose loved ones experienced a language barrier and 25% for those who were uninsured at the time of death.

Similarly, most Californians would prefer to die at home, but that is not typical. Seventy percent of those surveyed say their home is their preferred place of death, but only 32% passed away in their homes, according to death records data from the California Department of Public Health.

Paying for the Conversation

A major barrier to effective end-of-life planning is the lack of frank discussion between patients and health care providers. The average 15-minute office visit does not leave time to explore the natural progression of illness and the preferred treatment options for those nearing death.

As part of its original package to expand health coverage, the Obama Administration proposed requiring public and private insurance to cover voluntary conversations about end-of-life planning between patients and providers. After the issue became politicized, the idea was dropped from the final bill.

The new poll finds broad support among Californians, regardless of political affiliation, for reimbursing doctors to talk about end-of-life options. Eighty-four percent of Democrats, 72% of Republicans, and 80% of Independents say it would be a good idea to pay for the conversation.

Putting a Plan in Place

To help patients have their say if they are unable to speak, CHCF promotes the use of Physician Orders for Life-Sustaining Treatment (POLST). Developed in Oregon two decades ago, POLST is a standardized medical order form (in California it is printed on bright pink paper) that indicates the specific types of treatment a seriously ill patient does or does not want. The voluntary form is signed by the doctor and the patient and is designed to travel with a patient across medical settings.

POLST complements, but does not replace, the Advance Health Care Directive. An advance directive, which should be filled out by any adult regardless of one’s health status, provides a broad outline of a person’s wishes relating to end-of-life care, and allows an individual to appoint a “health care proxy” — the person they want to speak on their behalf. Only POLST, however, carries the power of a physician order.

According to the survey, nearly two-thirds of Californians say they would want to complete a POLST form if they became seriously ill, including 77% of those who are 65 or older. Seventy-one percent say they would want a seriously ill loved one to complete the form so they could understand their wishes.

The State of Palliative Care

In 2009, nearly 100,000 Californians with serious illness died in hospitals, according to public health records. Palliative care treats pain and other symptoms, provides psychosocial and spiritual support, and ensures that medical treatments align with patient and family wishes. Increasingly, hospitals are recognizing the enormous value of palliative care to patients who are seriously ill.

CHCF is releasing an accompanying report on palliative care: When Compassion Is the Cure: Progress and Promise in Hospital-Based Palliative Care. Produced by the National Health Foundation and the University of California, San Francisco Palliative Care Program, it profiles the state of palliative care in California’s acute care hospitals.

Among the findings:

  • Palliative care consultation services have experienced a great deal of growth in recent years: Between 2007 and 2011, pediatric services increased by 128%, while adult services increased by 24%.
  • Most palliative care services have modest budgets, with 60% operating on less than $300,000 annually.
  • Every major metropolitan area in California except Los Angeles increased the number of hospital-based palliative care programs between 2007 and 2011. The percentage of Los Angeles hospitals with such programs actually decreased.
Source: California Healthcare Foundation

Free Kit to Help Patients Quit Smoking

•February 15, 2012 • Leave a Comment

Until a few years ago, providers treating people with mental illness or substance use disorders did not typically encourage their clients to quit tobacco. Smokers with behavioral health conditions have only recently been identified by tobacco control and cessation professionals as a priority population (defined by high prevalence rates and/or targeting by the tobacco industry), even though their smoking rates are 2-4 times higher than in the general population.

Morbidity and Mortality in People with Serious Mental Illness, a report issued by the National Association of State Mental Health Program Directors in 2006, found that persons with serious mental illness die, on average, 25 years earlier and suffer increased medical co-morbidity. Often they die from tobacco related diseases and are more likely to die from these diseases than from alcohol use.

The need to help this clientele quit tobacco is clear. Some strongly held myths have stood in the way of progress in this area. Fortunately a growing body of research is debunking these myths, making way for new interventions.


** Myth: Persons with mental illness and substance use disorders don’t want to quit.

*** Fact: The majority of persons with mental illness and substance use disorders want to quit smoking and want information on cessation services and resources.

One study examined depressed smokers’ readiness to quit and the applicability of the Stages of Change framework to a psychiatric sample. The majority (79 percent) reported intention to quit smoking with 24 percent ready to take action in the next 30 days. This study is one of the first to examine the smoking behaviors of currently depressed psychiatric outpatients.

Another study found that 79 percent of hospitalized psychiatric patients who smoke were not only interested in quitting, but agreed to participate in a clinical study to help them quit.

In a review of clinical trials, 50 – 77 percent of smokers in substance use facilities were interested in quitting.

** Myth: Persons with mental illness and substance use disorders are unable to quit smoking.

*** Fact: Persons with mental illness and substance use disorders can successfully quit using tobacco

In a review of 24 studies, most of which combined medications and psychoeducation and/or cognitive behavioral therapy, the recorded quit rates of patients with mental illness or addictive disorders were similar to those of the general population. The studies were not uniform enough to allow a meta-analysis.

** Myth: Smoking cessation worsens psychiatric symptoms.

*** Fact: Smoking cessation does not worsen psychiatric symptoms, and can actually improve them.

A randomized trial found that actively depressed smokers who quit reported a significant decline in depression symptoms and a reduction in alcohol use, compared with participants who continued smoking.

In a study with smokers with schizophrenia who quit, there was no worsening of attention, verbal learning or memory, working memory, executive function or inhibition, or clinical symptoms of schizophrenia.

** Myth: Smoking cessation threatens recovery for persons with substance use disorders.

*** Fact: Smoking cessation can enhance long-term recovery for persons with substance use disorders.

A systematic review of 17 studies found that concurrent tobacco cessation treatment with individuals in addictions treatment was associated with 25 percent increased abstinence from alcohol and illicit drugs six months or longer after treatment.

• Caveat – in one well done study looking at concurrent vs. delayed tobacco cessation treatment there were comparable quit rates at 18 months, but there were lower prolonged alcohol abstinence rates for the concurrent treatment group at 6 months.


Meet with county mental health and alcohol and drug programs and make the case for including tobacco dependence treatment in their programs and facilities. Contact CTC for technical assistance.

Review and implement strategies from the following tool kits:

• Smoking Cessation for Persons with Mental Health Illness – A Toolkit for Mental Health Providers 

• Tobacco Treatment for Persons with Substance Use Disorders – A Toolkit for Substance Abuse Treatment Providers

Train health care providers on treating tobacco use and dependence. CTC offers FREE in-person and webinar trainings. All trainings can be tailored to the audience. Visit the CTC website to view a list of trainings offered: 

Refer smokers with mental illness or substance use disorders to the California Smokers’ Helpline for FREE help with quitting. Visit the Helpline’s website for more information and to order free promotional materials:


What About You? A workbook for those who work with others

•January 31, 2012 • Leave a Comment

This workbook was developed by The National Center on Family Homelessness to help those who work with others assess and plan their own self care.  It uses many tools to help you take your stress temperature and assess your personal, professional, and relational self care.  I am also including a link to the Professional Quality of Life assessment (ProQOL). “The ProQOL is the most commonly used measure of the negative and positive affects of helping others who experience suffering and trauma. The ProQOL has sub-scales for compassion satisfaction, burnout and compassion fatigue.”

“ To put the world in order we must first put the nation in order;
to put the nation in order; we must first put the family in order;
to put the family in order, we must first cultivate our personal life;
we must first set our hearts right.” —Confucius

Why get up in the morning to continue doing the work you do? What motivates you? One of the many things which motivates us is that people who have experienced homelessness and other traumas can and do heal. We know that this healing happens with the support of case managers, housing search workers, outreach teams, social workers, health care providers, and many others. We also know that if we are to “put the world in order,” we must take care of ourselves, our families, and our organizations. We must remember to breathe.

We have developed this guide as a tool to help you along the way. It is divided into three sections:

YOU: Taking care of yourself has to do with, well, yourself. This is the starting place. We can’t expect our families, friends, colleagues, or organizations to place a value on self-care if we don’t do so ourselves.

YOU & OTHERS: Our relationships with others are a key piece of taking care of ourselves. Sometimes these relationships help; sometimes they distract. No matter what, we know that taking care of ourselves cannot happen in isolation.

YOU, OTHERS, & WORK: Our workplace plays a large role in our lives. It is where we spend much of our waking time and energy. For many of us who work with those experiencing homelessness, our work is more of a vocation or a calling than it is a 9-to-5 job. The people we serve have complicated, often overwhelming problems. To help them through their journey, we must create team and organizational cultures that value care of the self, the team, and the organization.

No one thing works for everyone. There is no self-care cookie cutter. So we have sprinkled a little bit of everything throughout this guide. We hope that it will make you think, make you laugh, and occasionally make you remember to breathe.

Download: What About You? A workbook for those who work with others

Copyright 2008: The National Center on Family Homelessness


Why the pain?

•January 24, 2012 • 1 Comment

Embraced by the Needle
by Dr. Gabor Mate

Addictions always originate in unhappiness, even if hidden.

They are emotional anesthetics; they numb pain.  The first question — always — is not “Why the addiction?” but “Why the pain?” The answer, ever the same, is scrawled with crude eloquence on the wall of my patient Anna’s room at the Portland Hotel in the heart of Vancouver’s Downtown Eastside: “Any place I went to, I wasn’t wanted. And that bites large.”

The Downtown Eastside is considered to be Canada’s drug capital, with an addict population of 3,000 to 5,000 individuals.  I am staff physician at the Portland, a non-profit, harm-reduction facility where most of the clients are addicted to cocaine, to alcohol, to opiates like heroin, or to tranquilizers — or to any combination of these things.

Many also suffer from mental illness.

Like Anna, a 32-year-old poet, many are HIV positive or have full-blown AIDS.  The methadone I prescribe for their opiate dependence does little for the emotional anguish compressed in every heartbeat of these driven souls.

Methadone staves off the torment of opiate withdrawal, but, unlike heroin, it does not create a “high” for regular users.

The essence of that high was best expressed by a 27-year-old sex-trade worker.  “The first time I did heroin,” she said, “it felt like a warm, soft hug.” In a phrase, she summed up the psychological and chemical cravings that make some people vulnerable to substance dependence.

No drug is, in itself, addictive.

Only about 8 per cent to 15 per cent of people who try, say alcohol or marijuana, go on to addictive use.  What makes them vulnerable? Neither physiological predispositions nor individual moral failures explain drug addictions.  Chemical and emotional vulnerability are the products of life experience, according to current brain research and developmental psychology.

Most human-brain growth occurs following birth; physical and emotional interactions determine much of our brain development.  Each brain’s circuitry and chemistry reflects individual life experiences as much as inherited tendencies.

For any drug to work in the brain, the nerve cells have to have receptors – — sites where the drug can bind.  We have opiate receptors because our brain has natural opiate-like substances, called endorphins, chemicals that participate in many functions, including the regulation of pain and mood.  Similarly, tranquilizers of the benzodiazepine class, such as Valium, exert their effect at the brain’s natural benzodiazepine receptors.

Infant rats who get less grooming from their mothers have fewer natural benzo receptors in the part of the brain that controls anxiety.

Brains of infant monkeys separated from their mothers for only a few days are measurably deficient in the key neurochemical, dopamine.

It is the same with human beings.

Endorphins are released in the infant’s brain when there are warm, non-stressed, calm interactions with the parenting figures.

Endorphins, in turn, promote the growth of receptors and nerve cells, and the discharge of other important brain chemicals.  The fewer endorphin-enhancing experiences in infancy and early childhood, the greater the need for external sources.

Hence, the greater vulnerability to addictions.

Distinguishing skid row addicts is the extreme degree of stress they had to endure early in life.  Almost all women now inhabiting Canada’s addiction capital suffered sexual assaults in childhood, as did many of the males.

Childhood memories of serial abandonment or severe physical and psychological abuse are common.  The histories of my Portland patients tell of pain upon pain.

Carl, a 36-year-old native, was banished from one foster home after another, had dishwashing liquid poured down his throat for using foul language at age 5, and was tied to a chair in a dark room to control his hyperactivity.  When angry at himself — as he was recently, for using cocaine — he gouges his foot with a knife as punishment.  His facial expression was that of a terrorized urchin who had just broken some family law and feared draconian retribution.  I reassured him I wasn’t his foster parent, and that he didn’t owe it to me not to screw up.

But what of families where there was not abuse, but love, where parents did their best to provide their children with a secure, nurturing home? One also sees addictions arising in such families.  The unseen factor here is the stress the parents themselves lived under, even if they did not recognize it.  That stress could come from relationship problems, or from outside circumstances such as economic pressure or political disruption.  The most frequent source of hidden stress is the parents’ own childhood histories that saddled them with emotional baggage they had never become conscious of.  What we are not aware of in ourselves, we pass on to our children.

Stressed, anxious, or depressed parents have great difficulty initiating enough of those emotionally rewarding, endorphin-liberating interactions with their children.

Later in life such children may experience a hit of heroin as the “warm, soft hug” my patient described: What they didn’t get enough of before, they can now inject.

Feeling alone, feeling there has never been anyone with whom to share their deepest emotions, is universal among drug addicts.

That is what Anna had lamented on her wall.  No matter how much love a parent has, the child does not experience being wanted unless he or she is made absolutely safe to express exactly how unhappy, or angry, or hate-filled he or she may at times feel.  The sense of unconditional love, of being fully accepted even when most ornery, is what no addict ever experienced in childhood — often not because the parents did not have it to give, simply because they did not know how to transmit it to the child.

Addicts rarely make the connection between troubled childhood experiences and self-harming habits.

They blame themselves — and that is the greatest wound of all, being cut off from their natural self-compassion.  “I was hit a lot,” 40-year-old Wayne says, “but I asked for it.  Then I made some stupid decisions.” And would he hit a child, no matter how much that child “asked for it”? Would he blame that child for “stupid decisions”?

Wayne looks away.  “I don’t want to talk about that crap,” says this tough man, who has worked on oil rigs and construction sites and served 15 years in jail for robbery.

He looks away and wipes tears from his eyes.


LGBT Homeless Youth

•January 20, 2012 • Leave a Comment

Across the United States, lesbian, gay, bisexual, and transgender (LGBT) youth are grossly over-represented in the homeless youth population. These youth are at an increased risk of being victims of violence in homeless youth housing facilities. Homelessness takes a toll on both physical and mental health.

Video: Feels like home: Helping homeless LGBT youth
Need to Know correspondent Mona Iskander traveled to Minneapolis recently. There she met one young man who made it up from the streets thanks to a small innovative program now drawing attention across the country. (external link)

Eighteen-year-old Kelly R. was homeless. At the age of sixteen, her parents kicked her out of her home because she is transgender. Subsequently, she ran away from the group home in which she had been placed by the Administration for Children’s Services. When the weather got too cold for her to sleep outside and she could not earn enough money from prostitution to rent a hotel room, she stayed at a large emergency youth housing facility in lower Manhattan. The staff regularly forced her to bathe in an open showering facility with the shelter’s male occupants. One day in the shower, a group of these males attacked her. They beat her against the cement floor until her entire body was inflamed with contusions. They did not stop until her jaw was ripped from her face. This all occurred with staff present. This actually happened to a transgender girl in 2002. Sadly, similar acts of violence against lesbian, gay, bisexual, and transgender (LGBT) youth in emergency and transitional housing programs for homeless youth are very common.

A large segment of the homeless youth population is composed of LGBT youth. Those who occupy homeless youth housing facilities are at a great risk of being assaulted and otherwise harassed. In order to better protect LGBT youth in these housing programs from violence, social service agencies must adopt regulations aimed at curbing all violence in homeless youth housing programs as well as regulations addressing the particular problems faced by LGBT youth. These regulations should require, among other things, that all showering facilities in youth housing programs be private; that housing programs have low occupancy limits; that housing programs be prohibited from discriminating on the basis of sexual orientation or gender expression in providing any service; and that these programs provide LGBT nondiscrimination and sensitivity training to all staff. These training and nondiscrimination requirements should apply to all programs regardless of whether they are operated by religious organizations, which may believe that homosexuality and transgenderism are immoral. These agencies should also promulgate regulations to ensure that there are housing programs created specifically to serve the needs of homeless LGBT youth.

This [article] will discuss these proposed policies and the problems faced by homeless LGBT youth with reference to homeless youth housing programs in New York City, San Francisco, and Houston and the laws governing programs operated in those jurisdictions. This discussion is intended to provide an examination of the interplay among the laws, organization policies, and care of homeless LGBT youth in these jurisdictions, in order to formulate policy solutions to improve the homeless youth systems’ responsiveness to LGBT youth nationwide. Thus, this [article] advocates that these solutions be adopted in all jurisdictions. As used in this [article], the term “homeless youth housing program” includes the following: shelters housing youth between the ages of sixteen and twenty-one on an emergency basis for short periods of time, transitional living facilities providing housing for youth within the same age range for longer periods of time, and services to help youth transition to independent living.

The first part of this [article] presents an overview of the prevalence of LGBT youth in the homeless youth population, examines why they are overrepresented in this population, and describes the violence many of these youth face in homeless youth housing programs. The next part introduces the agencies that are empowered to regulate homeless youth housing programs in New York City, San Francisco, and Houston. The next part proposes regulations to reduce violence against all youth, both LGBT and non-LGBT, in homeless youth housing programs. The final part recommends regulations aimed at reducing violence against LGBT youth specifically and creating LGBT-affirming living environments.

(Download the full [article] here)

Source: Hunter, E. (2008). What’s good for the gays is good for the gander: Making homeless youth housing safer for lesbian, gay, bisexual, and transgender youth. Family Court Review46(3), 543-557. doi:10.1111/j.1744-1617.2008.00220.x

Culturally Competent Disaster Nursing

•January 16, 2012 • Leave a Comment

Lessons learned from Hurricane Katrina underscore the need for post-disaster nursing care that is more sensitive to the cultural needs of communities of color

by Luis Clemens

Natural disasters are colorblind in terms of whom and how they strike. “When a disaster hits, it doesn’t hit by race, color or creed. It hits people who are humans and bleed,” says Marilyn Pattillo, PhD, GNP, CNS, deputy team commander of the Federal Emergency Management Agency (FEMA)’s National Nurse Response Team. Yet, how disaster victims react to displacement, illness and stress is very much culture-based.

“Cultural competence is an integral part of any disaster behavioral health intervention,” says Nadine Mescia, MHS, associate director of the Florida Center for Public Health Preparedness at the University of South Florida College of Public Health in Tampa. “In order to be effective, [health workers responding to disasters] must be aware of cultural differences among survivors and patients.”

This issue has taken on additional urgency in the aftermath of the heavily criticized government response to the devastation wrought by Hurricane Katrina. The delayed and muddled relief efforts were perceived by many African Americans as the product of institutional racism.

Nurses responding to natural disasters have precious little control over how government resources are apportioned, but they do have control over how they treat patients. The consensus among many nurses who responded to Katrina is that cultural competence was the norm in the immediate wake of the hurricane. This was because the first wave of responders consisted of local nurses with first-hand knowledge of the affected communities’ cultural needs.

What Went Wrong

However, significant shortcomings in cultural competence arose in the following weeks and months, as new waves of disaster responders from across the nation–who lacked the local health professionals’ cultural familiarity with the affected communities of color–began to arrive.

Jennifer Field Brown, PhD, APRN, is the only white professor in the Nursing Department at historically black Norfolk State University in Virginia. When asked by the federal Substance Abuse and Mental Health Services Administration to work in a Louisiana shelter some six weeks after Katrina hit, Brown admits she was excited and jumped at the opportunity. But the racial and cultural tensions she observed during the two-week assignment have left her thinking for months.

“Many of the nurses were angry with the [largely African American] population that was still at the shelter,” she says. “There were many times when evacuees [said], ‘they don’t care about us.’”

Brown believes this perception was fueled by the cultural gap between the predominately poor and African American evacuees and the mostly middle class and white shelter staff. “[Some of] the response workers were appalled that some of the evacuees would not cash their checks because they had no family member with a checking account, [or] that they’d cash their checks and buy a TV. [The prevailing attitude among many of the shelter staff seemed to be] if you didn’t lose anything you are not entitled to anything.”

Deshotels, whose parents grew up in New Orleans, points out that strained race relations are not a new phenomenon in the Crescent City. “Because we have such a long history of racism and oppression [here], there is an always an air of tension and mistrust,” he says.

New Orleans used to have–and perhaps still has–a majority black population. Katrina scattered tens of thousands of the city’s African Americans throughout much of the country, so it is impossible to know for sure. But much of the city’s longstanding black middle class and working class have been displaced and have not returned. Cheryl L. Nicks, RN, CNNP, CGT, CLNC, CPLC, president of the New Orleans chapter of the NBNA, has been in touch with only three out of 65 members since the hurricane struck. She says, “Our chapter has basically been demolished.”

Caught Unprepared

Another shortfall in culturally competent health care that has worsened in New Orleans post-Katrina is the result of a dramatic and largely unforeseen population shift. In the place of many African American evacuees have come many thousands of Hispanic workers hired to help clean up and rebuild the city. Their arrival, a direct consequence of the hurricane, has amplified the difficulties the city’s public health system already faced in treating Hispanic patients.

The Roman Catholic Archdiocese of New Orleans created the Latino Health Access Network (LHAN) three years ago in response to the lack of sufficient health services for the Hispanic community. Shaula Lovera, director of LHAN, cites the absence of any evacuation information in Spanish as what she considers a typical example of the neglect faced by the Hispanic population before Katrina.

Now, the huge influx of Hispanic workers has dramatically increased the need for Spanish-speaking nurses and doctors. What used to be a small community of 14,000 in 2004 has grown to become a significant minority population whose access to health care is challenged by cultural, linguistic and economic barriers.

“These workers don’t make great salaries,” Lovera explains. “They have no access to Medicaid or Medicare. They don’t get health insurance from their employers.”
But often the biggest obstacle, she says, is simply navigating the hospital admissions process, with its personnel who don’t speak Spanish and its English-language forms that must be signed.

Before the hurricane, LHAN ran a Saturday clinic staffed by Spanish-speaking volunteer physicians and nurses. In 2002, before the clinic was established, only 2% of patients using LHAN’s services were Hispanic. But the number shot up to 17% after the clinic opened in 2003. This proves that Spanish-language medical attention was urgently needed, says Lovera.

The clinic, which was run by the Daughters of Charity, was badly damaged during the hurricane. Given the difficulties faced by Latino workers in getting treatment at local hospitals, LHAN has opted to bring bilingual nurses and doctors directly to the worksites. They give workers tetanus shots to guard against infections from accidents on the job and treat a series of common medical complaints. The lack of work boots, masks and gloves means that broken bones, sinusitis and cuts are a constant problem.

While this approach has been helpful, LHAN is stretched thin and has had to rely on volunteer doctors and nurses from outside the region. In lieu of always being able to find Spanish-speaking clinicians, they provide qualified medical translators.

Closing Knowledge Gaps

Based on these lessons learned the hard way, Lovera feels strongly that the federal government must focus on enhancing the cultural competence of disaster response teams. And she’s not alone. How agencies such as FEMA will respond to these recommendations from health professionals, if at all, remains to be seen. But in the meantime, a growing number of nursing educators are beginning to look at ways to fill this crucial knowledge gap.

Laura Terriquez-Kasey, RN, MS, CEN, is a member of a New York-based Disaster Medical Assistance Team (DMAT) that was sent to Louisiana following Katrina. The Department of Homeland Security’s National Disaster Medical System relies, in part, on a number of DMATs stationed throughout the country. The DMATs consist of highly skilled medical professionals that can be quickly deployed following a natural or man-made disaster.

Terriquez-Kasey’s previous disaster experience includes 9/11 and Tropical Storm Allison. “When I went into Allison and the flooding in Texas in 2001, we were a large group of nurses and it was very helpful to have the capacity to speak Spanish,” she says. Too often, Terriquez-Kasey believes, in the rush to “get everyone treated right away” the “cultural piece” of disaster nursing is simply overlooked.

It is an oversight that she tries to correct as a clinical lecturer at SUNY-Binghamton’s Decker School of Nursing. “There is a tremendous knowledge deficit in our health care where we don’t necessarily take the time to understand where the [patient] is coming from,” Terriquez-Kasey contends. “You can’t help someone if you can’t assess them, and if the patient doesn’t open up to you then you are really not doing your job.”

Take a Free Online Course in Culturally Competent Disaster Response

In 2004, the Florida Center for Public Health Preparedness at the University of South Florida (USF) in Tampa began offering a short online course called “Assuring Cultural Competence in Disaster Response.” The 1.5-hour course was developed by Jennifer Baggerly, PhD, LMHC, RPT-S, a professor at USF who responded to Hurricane Katrina as well as the 2004 tsunami in south Asia.

According to the center’s Web site, the course is designed to prepare public health professionals to offer culturally competent disaster interventions to survivors, witnesses and responders to bioterrorism and other major public health threats and community disasters. The course helps build competencies in such areas as:

• Identifying the role of cultural factors in determining and delivering disaster intervention services.

• Identifying cultural barriers to offering disaster intervention services.

• Approaches, principles and strategies for developing cultural competency in assisting disaster survivors from diverse populations.

• Using appropriate methods for interacting sensitively, effectively and professionally with persons from diverse cultural, socioeconomic, racial and ethnic backgrounds, and persons of all ages and lifestyle preferences, when assisting disaster survivors, their family members, witnesses and disaster responders.

Baggerly says the purpose of the course is threefold. “The first reason is to prevent harm to the individual you are attempting to help. There are numerous examples of well-intentioned public health workers actually hurting [patients]. If you are not careful you can end up promoting harm. The second reason is for [health professionals] to be more effective and achieve faster results in recovery. Third, it protects the public health worker from harm. Sometimes [you can make] an unintentional faux pas that may anger some [patients].”

Anyone who signs up can take the online course for free, although you have to pay in order to receive continuing education credits. According to Baggerly, the course was envisioned as a convenient and immediate training option. “Especially in disaster response where [it is] very fast-paced, [health workers] are trying to respond quickly, so there is some anxiety that builds up.”

Nadine Mescia, MHS, associate director of the Florida Center for Public Health Preparedness, stresses the course’s importance by citing research that indicates “those who are at greatest risk for adverse outcomes following any disaster are. . .non-English-speaking [and] economically disadvantaged [persons].” The course, she says, helps bridge the cultural gap to those very groups.

For more information about the “Assuring Cultural Competence in Disaster Response” online course, visit

Source: Clemens, L. (2006). Culturally competent disaster nursing. Minority Nurse, 40-43.