About

Nevada Cultural Competence in Nursing (DEI Requirement)

Pre-Evaluation

Please complete the evaluation below prior to reading any of the course material.

Introduction   

There is no doubt that modern medicine has made many technological advancements over the last few decades, forging the way for highly intricate diagnostic and treatment methods and improving the quality and longevity of many lives.  

In order to truly keep up with changing times, healthcare professionals must consider much more than the technical aspects of healthcare delivery. They must take a closer look and a more conscientious approach to the way in which care is delivered, particularly across a wide variety of demographics and characteristics. Ensuring care is delivered with empathy, respect, and equity, as well as noting and honoring a patient’s differences, is how care transforms from good to truly great.  

Practicing diversity, equity, and inclusion (DEI), as well as cultural competence in nursing professions must become a standard.   

Health Disparities 

When covering cultural competence in nursing, it is vital that a provider knows that each patient is a unique individual. However, there are some characteristics such as race, gender, age, sexual orientation, or disability that can create gaps in the availability, distribution, and quality of healthcare delivered.  

These gaps can create lasting negative impacts on patients mentally, physically, spiritually, and emotionally and even lead to poorer outcomes than patients not within a special population. Modern healthcare professionals have a responsibility to learn to identify risks, provide sensitive and inclusive care, and advocate for equity in much the same way that they have a responsibility to learn how the human body, medications, or hospital equipment works.   

Epidemiology 

In order to understand the importance of cultural competence in nursing as well as the best practices for DEI in healthcare, let’s turn to data.   

Healthy People 2020 provides a myriad of data that includes countless implications for changes that need to occur in healthcare settings for equitable care of all populations.  

The data includes statistics such as:  

• 12.6% of Black/African American children have a diagnosis of asthma, compared to 7.7% of white children (16).   
• The rate of depression in women ages 65+ is 5% higher than that of men of the same age, across all races (16).  
• Teenagers and young adults who are part of the LGBTQ community are 4.5 times more likely to attempt suicide than straight, cis-gender peers (16).  
• 16.1% of Hispanics report not having health insurance, compared to 5.9% of white populations (16) .  
• The national average of infant deaths per 1,000 live births is 5.8. The rate for Black/African American infants is nearly double at 11 deaths per 1,000 births (16).  

• 12.5% of veterans are homeless, compared to 6.5% of the general U.S. population (16).   

Additional disparities are seemingly endless and point unquestionably to the fact that cultural competence and DEI awareness are no longer things that healthcare professionals can be uninformed about. The purpose of this course is to outline and explore the most common or serious healthcare disparities, address ways in which healthcare delivery needs to be adjusted, and start the conversations needed to create a new generation of healthcare professionals that will close these gaps.   

The importance of understanding DEI best practices in the health setting, as well as possessing cultural competence in nursing, is vital in making positive changes for all populations. 

Implicit Bias 

Before even diving into the characteristics and unique circumstances of various client demographics, it is important to understand and acknowledge implicit bias. Learning information about different cultures is not enough and implicit biases held by clinicians may impede their ability to apply that knowledge in culturally competent ways and lead to care that violates the ethics of nursing.  

Implicit bias is a subconscious opinion or view that can impact attitudes and behaviors. Everyone has implicit bias; it is created through a combination of the attitudes a person was raised with and around, their lived experiences, and their effort to understand the experiences of those around them; all of which influence the lens through which we view the world. This differs from explicit bias which involves conscious behaviors such as slurs, harassment, or inappropriate comments.  Having implicit bias is not inherently bad, but it is important to be aware of those biases and that they may be influencing the way a healthcare professional cares for their clients (29).  

An easy-to-understand example is caring for a client who comes in wearing a hat with the logo of a baseball team you like. This common ground may make you feel more connected to this client, a conversation may be easygoing and familiar, and you may feel more inclined to make sure they are having a good experience. This does not mean you dislike your clients who do not share this commonality with you, but simply that the connection with this client shapes your thoughts and behaviors in a positive manner.  

More often, though, we hear about implicit bias in a negative connotation as it has the capacity to impact the way clinicians feel about their clients which spills over into the way they listen to, assess, believe, and provide care for them. Implicit bias is subtle and insidious and may go unnoticed by both the clinician and the client, but the effects are cumulative and lead to gaps in health outcomes over time. Failing to address biases may actually impact the ethics of nursing care; autonomy, justice, beneficence, nonmaleficence, and veracity (36).  

Autonomy  

Autonomy is the principle that clients should be respected as individuals and allowed to make their own choices about their health, bodies, and treatment plans, free from outside influence or bias. Clients will often look to healthcare professionals for guidance on what to do for their health or how to proceed with treatment. Options should be offered with information about the risks and benefits of potential treatment plans in an unbiased, nonjudgmental way so that clients can make the best and most informed decision for themselves.  

Unaddressed biases could lead nurses to give nonverbal or verbal cues to what they think or expect a client to do. It could lead to subtle changes in the way care options are presented to clients or may lead to clinicians omitting certain choices altogether, ultimately reducing the autonomy clients have over their own health.  

Justice  

Justice is the principle that all clients deserve fair and equitable care regardless of individual circumstances or differences. The care needed by clients from certain socioeconomic backgrounds, education levels, abilities, languages, cultures, or other unique circumstances will differ from other clients and those needs should be considered and accommodated when planning care. Biases may lead healthcare professionals to feel that disadvantaged clients should not receive individualized care because it is a “handout” or they may feel pity or judgment for those clients, as a result providing unjust and inequitable care.  

A common example is incarcerated clients who are just as entitled to quality healthcare as their non-incarcerated peers but are much more likely to experience biased, uncompassionate, or judgmental care.  

Beneficence  

Beneficence is the moral obligation to do good. Nurses acting out of beneficence will strive to prevent harm, protect clients’ rights, and work towards the best possible outcomes to improve the healthcare experience for clients. An example of a way in which implicit bias can contradict beneficence is for transgender or nonbinary clients who have a different name or pronouns than what is legally listed in their chart. Nurses with bias against these clients may not put effort into utilizing the proper pronouns of name, causing distress and emotional harm to clients, and negatively impacting their experience during an already stressful time of illness or injury.  

Nonmaleficence  

Nonmaleficence is often associated with the Hippocratic oath and is the principle that healthcare professionals will do no harm to their clients. This principle is often understood to be of more importance than all the rest and all other actions or principles should be conducted in such a way that they do no harm. Differences in behaviors and attitudes towards clients, including stereotyping and microaggressions can negatively impact the client experience and the principle of nonmaleficence. Often, these types of issues will lead clients to delay or stop seeking care or will cause diagnoses, possible treatments, or preventative health measures to be missed. Even if the health outcome is good, harm is still done if clients feel uncomfortable, unsafe, or disrespected during care.  

An example of how implicit bias can affect nonmaleficence is assuming an elderly client is cognitively impaired and directing questions and conversation to their caregiver. This not only is condescending and disrespectful but also increases the risk that important information needed for comprehensive care will be missed by not speaking with the client directly.   

Veracity  

Veracity or truthfulness is the obligation to communicate openly and truthfully with clients in a respectful, objective, and timely manner. Veracity is a key component in building trust between clinician and client. When implicit bias is present, clients may sense this, and the trust relationship is broken down. Clients may have poor compliance with treatment or not ask questions if they feel mistrustful of clinicians. Lack of veracity also increases risks for clients who may not have a full understanding of their care if information is omitted due to bias.  

For example, a clinician may minimize a discussion about side effects from a particular form of birth control because they feel their client is young or already has enough children and needs to take birth control regardless. Their bias does not increase the risks of the method of birth control, but the client being uninformed does increase the risk of serious complications (36). 

One of the first steps in addressing implicit bias is to identify it. Biases may present in many different forms and may impact client care in obvious or more subtle ways. If this is your first time exploring your own implicit biases, it can feel overwhelming or intimidating. It can be helpful to understand some of the different types of implicit bias and examples of what they might look like in order to identify biases you may be harboring or including in your nursing care.  

• Halo Effect– Halo effect bias is assuming beliefs or opinions about someone based on one aspect of their appearance that is flattering or desirable. An example in healthcare would be not asking a teenage client if they vape, drink alcohol, or use drugs because they are an attractive and put-together student. Assuming someone does or does not participate in certain behaviors based on their appearance may lead to missed opportunities to gather accurate information and may create an inaccurate assessment of the client.  
• Horns Effect– Similar to the halo effect, horn effect bias is assigning beliefs or opinions about someone based on one aspect of their appearance that is deemed undesirable. In healthcare, this could be viewing overweight clients as lazy, irresponsible, or less worthy of treatment. It could also be seeing clients with a lot of tattoos as being involved in criminal activity.  
• Confirmation Bias– Confirmation bias is seeking or paying more attention to information that confirms an opinion or belief rather than seeking information that disproves it. This is equivalent to “seeing what you want to see.” In healthcare, this could look like accepting a previously given diagnosis even when additional data contradicts it, or a client doesn’t quite meet criteria.  
• Affinity Bias– Affinity bias is the unconscious preference for people who look or behave similarly to oneself. There is a natural tendency to feel more comfortable around people of similar backgrounds, appearances, or ways of speaking and to feel less comfortable around those who are different in these areas. This bias can lead nurses to provide care that is more compassionate or with more attention to detail for clients who are like themselves. However, they also risk providing care that is of lower quality care or less empathetic to clients who are very different from themselves.  
• Attribution- Attribution bias is the tendency to explain a person’s behavior as being part of their character rather than evaluating any situational factors. This could be assuming a client who is late to an appointment is lazy or does not care about their health, when in reality they may have some very stressful external factors affecting them. Attribution bias may also be assuming clients who are noncompliant with medication are passive about their health, when in reality they may not be taking the medication because of an undesirable side effect they are afraid to mention.  

• Gender Bias- Gender bias is assuming a person’s abilities, intelligence, role, or symptom severity based purely on their gender. Nurses may have gender bias against clients by assuming a female client is “chatty” or “dramatic” if she is describing multiple symptoms or issues during a visit. Nurses can hold gender bias against other healthcare professionals, assuming a woman in scrubs is a nurse and a man in scrubs is a doctor, when in reality either role may be occupied by either gender.  
• Contrast Bias– Contrast bias is the effect of comparing 2 separate things against each other rather than judging them as individual circumstances. This is commonly seen through the hiring process when 2 candidates may be compared to each other and one is deemed less qualified in comparison, even though they both may be well-qualified candidates. In healthcare, this can occur when comparing clients’ responses to procedures or pain. One client in labor may be stoic and quiet while another is vocal and higher energy. Both are normal responses to pain, but the more vocal client may be seen as difficult or dramatic when compared to the quiet client.  
• Anchoring Bias– Anchoring bias is being “anchored” or only focusing on one initial piece of information about a situation, which then influences a person’s decision-making ability for the rest of the situation. An example in healthcare is a client with a history of congestive heart failure (CHF) presenting to the emergency department with a complaint of shortness of breath (SOB). Since SOB is a common symptom of progressing CHF, clinicians may be initially inclined to think this is the source of the symptom. This may lead to a delay in testing or diagnosis for other potential causes of SOB, such as a pulmonary embolism. By being anchored to the initial thoughts about this client’s case, a provider risks a missed diagnosis or poor outcome.  
• Conformity Bias– Conformity bias is acting similar to those around you, despite your own views or other information about a topic. In healthcare, an example of conformity bias is a nurse working in an office where many staff members have a negative or judgmental view of clients with Medicaid insurance. The nurse may not have any experience with insurance or have noticed a difference in clients based on their insurance type, however the exposure to frequent negative comments about Medicaid eventually rubs off on the nurse who now shares a negative view of these clients. 
• Name Bias- Name bias is an assumption about a person’s gender, race, or ability to fluently speak English prior to even meeting them. In healthcare, name bias can be related to clients whenever their name is viewed in the chart or can also be related to the hiring of healthcare professionals when recruiters are reviewing job applications. Assumptions from a person’s name are often baseless and others may change their opinion once they meet a person, but this bias could lead to missed opportunities for those without the “preferred” sounding name; usually Western or European, white, or even male.  (37,38) 

Implicit biases in healthcare may not just be about nurses’ behavior towards clients but can also exist within healthcare itself. Nurses may have certain biases against other nurses who are a different age, experience level, gender, race/ethnicity, or sexual orientation than themselves and may assume those nurses are less capable, intelligent, efficient, or have a lower work ethic. This may lead to resentment and tension among a department which hurts the unit’s teamwork and cohesiveness. A department with staff tension and a lack of teamwork will indirectly hurt client care as well, as staff are more likely to be stressed, burned out, or distracted.  

On a systemic level, implicit bias from those in positions of power has led to; 1) largely underrepresented minority races as healthcare providers (in 2018 56.2% of physicians were white, while only 5% were Black and 5.8% Hispanic)(30), 2) lack of support, acceptance, and resources for LGTBQ individuals in the home, workplace, school, and community, 3) varied assessment of disability and inconsistent reporting throughout the population (reports range from 12% to 30%)(31), 4) difficulty obtaining health insurance or utilizing health resources for already at-risk groups.  

Race and Ethnicity 

One of the most significant disparities in healthcare, and the one garnering the most attention and campaigns for change in recent years, is race and ethnicity. However, when covering the best practices for cultural competence in nursing, it is essential that we go over this topic. Studies in recent years have revealed that minority groups, particularly Black Americans, are sicker and die younger than white Americans. Examples include:   

Current data shows that Black men are more likely to be diagnosed with prostate cancer and 2.5 times more likely to die from it than their white peers. A 2019 study through the University of Michigan Rogel Cancer Center explored prostate cancer outcomes when factors such as access to care and standardized treatment plans were controlled. They found that outcomes were comparable and Black men experienced similar mortality to the white men in the study, implying that they did not “intrinsically and biologically harbor a more aggressive disease simply by being Black” (11). 

A 2020 study found that Black individuals over age 56 experience a decline in memory, executive function, and global cognition at a rate much faster than their white peers, often as much as 4 years ahead in terms of cognitive decline. Data in this study attribute the difference to the cumulative effects of chronically high blood pressure, more likely to be experienced by Black Americans (20). 

Black women experience twice the infant mortality rate and nearly four times the maternal mortality rate of non-Hispanic white women during childbirth. One in five Black and Hispanic women report poor treatment during pregnancy and childbirth by healthcare staff. Studies indicate that in addition to biases within the healthcare system, some of these poor outcomes may also be attributed to cumulative effects of lifelong inferior healthcare (1). 

Lack of health insurance keeps many minority patients from seeking care at all. 25% of Hispanic people are uninsured and 14% of Black people, compared to just 8.5% of white people. This leads to a lack of preventative care and screenings, a lack of management of chronic conditions, delayed or no treatment for acute conditions, and later diagnosis and poorer outcomes of life-threatening conditions (4). 

Emerging data indicates that hospitalizations and deaths from COVID-19 are disproportionately affecting Black and Hispanic Americans, with Black people being 153% more likely to be hospitalized and 105% to die from the disease than white people. Hispanic people are 51% more likely to be hospitalized and 15% more likely to die from COVID-19 than white people (21). 

The potential reasons are many, from genetics to environmental factors such as socioeconomic status, but data repeatedly shows that these factors are not enough to account for the disproportionate health outcomes when you correct for age, socioeconomic status, and other demographics; it eventually comes down to inequity in the structure of the healthcare systems in which we all live.  

For example:  

• Medical training and textbooks are mostly commonly centered around white patients, even though many rashes and conditions may look very different in patients with darker skin or different hair textures (13). 
• There is also a lack of diversity in physicians; in 2018, 56.2% were white, while only 5% were Black and 5.8% Hispanic. More often than not, patients will see a physician who is a different race than they are, which can mean their particular experiences as a minority person, and how that relates to their health, are not well understood by their physician (2). 

• While the Affordable Care Act increased the number of people who have access to health insurance, minority patients are still disproportionately uninsured, which leads to delayed or no care when necessary (4). 
• Minority patients are also often those living in poverty, which goes hand in hand with crowded living conditions and food deserts due to outdated zoning laws created during times of segregation. This means less access to nutritious foods, fresh air, or clean water which has overall negative effects on health (21).  
• Much of the issues with modern healthcare come from a history of racism as the healthcare system was being built. There is a long history of mistreatment, lack of consent, and lack of representation of Black clients which has shaped some modern attitudes about care delivery as well as being passed down as generational trauma that affects the way Black clients seek out and participate in care. It is important as clinicians to understand where some of this mistrust or skepticism comes from and not misinterpret hesitancy as passivity.  

Examples of historic racism include:  

• One of the most infamous examples is the Tuskegee Syphilis Study which took place in 1932 and included 600 Black men, about two-thirds of whom had syphilis. During the study, the men were told that they were being treated for syphilis and they were periodically monitored for symptom progression and blood collection. In exchange, they were given free medical exams and meals. Informed consent was not collected, and participants were given no information about the study other than that they were being “treated for bad blood”, even though no treatment was actually administered. By 1943, syphilis was routinely and effectively treated with penicillin, however the men involved in the study were not offered treatment and their progressively worsening symptoms continued to be monitored and studied until 1972 when it was deemed unethical. Once the study was stopped, participants were given reparations in the form of free medical benefits for the participants and their families. The last participant of the study lived until 2004 (33).  
• The “father of modern gynecology,” Dr. J. Marion Sims, is another example steeped in a complicated and racially unethical past. Though he did groundbreaking work on curing many gynecological complications of childbirth, most notably vesicovaginal fistulas, he did so by practicing on unconsenting, unanesthetized, Black enslaved women. The majority of his work was done between 1845 and 1849 when slavery was legal and these women were likely unable to refuse treatment, sometimes undergoing 20-30 surgeries while positioned on all fours and not given anything for pain. Historically his work has been criticized because he achieved so much recognition and fame through an uneven power dynamic with women who have largely remained unknown and unrecognized for their contributions to medical advancement (39).  
• Another example is the story of Henrietta Lacks, a young Black mother who died of cervical cancer in 1951. During the course of her treatment, a sample of cells was collected from her cervix by Dr. Gey, a prominent cancer researcher at the time. Up until this point, cells being utilized in Dr. Gey’s lab died after just a few weeks, and new cells needed to be collected from other patients. Henrietta Lacks’ cells were unique and groundbreaking in that they were thriving and multiplying in the lab, growing new cells (nearly double) every 24 hours. These highly prolific cells were nicknamed HeLa Cells and have been used for decades in the development of many medical breakthroughs, including studies involving viruses, toxins, hormones, and other treatments on cancer cells and even playing a prominent role in vaccine development. All of this may sound wonderful, but it is important to understand that Henrietta Lacks never gave permission for these cells to be collected or studied and her family did not even know they existed or were the foundation for so much medical research until 20 years after her death. There have since been lawsuits to give family members control over what the cells are used for, as well as requiring recognition of Henrietta in published studies and financial payments from companies who profited off of the use of her cells (34).  
• Breastfeeding trauma, wherein Black enslaved women were used as wetnurses, forced to separate from their own babies so they could feed the infants of their owners. This is passed down as generational trauma and lower breastfeeding initiation and continuation rates among Black clients (35).  

When considering all of the above scenarios, the common theme is a lack of informed consent for Black patients and the lack of recognition for their invaluable role in society’s advancement to modern medicine. It only makes sense that these stories, and the many others that exist, have left many Black patients mistrustful of modern medicine, medical professionals, or treatments offered to them, particularly if the provider caring for them doesn’t look like them or seems dismissive or unknowledgeable about their unique concerns. Awareness that these types of events occurred and left a lasting impact on many generations of Black families is incredibly important in order for medical professionals to provide empathetic and racially sensitive care. 

Potential solutions to these problems are in the works across many fronts, but the breaking down and resetting of old institutions will likely require change on a broader, political level.  

Medical school admission committees could adopt a more inclusive approach during the admission process. For example, they pay more attention to the background and perspectives of their applicants and the circumstances/scenarios in which they came from as opposed to their involvement in extracurriculars (or lack of) and former education. Incentivizing minority students to choose careers in healthcare as well as investing in their retention and success should become a priority in the admissions process (13). This is one of the main drivers and only possible paths to having minority representation in healthcare systems nationwide.  

Properly training and integrating professionals like midwives and doulas into routine antenatal care and investing in practices like group visits and home births will give power back to minority women while still giving them safe choices during pregnancy (1).  

Universal health insurance, basic housing regulations, access to grocery stores, and many other socio-political changes could also work towards closing the gaps in accessibility to quality healthcare and may vary by geographic location.  

LGBTQ 

Another highly at-risk group for healthcare inequity are members of the Lesbian, Gay, Bisexual, Transexual, and Queer (LGBTQ) community. When practicing cultural competence in nursing, the provider must become aware of how vulnerable this population is, especially in healthcare settings. Risks and examples of disparities within the LGBTQ community include:   

• Youth are 2-3 times more likely to attempt suicide.  
• More likely to be homeless. 
• Women are less likely to get preventative screenings for cancer. 
• Women are more likely to be overweight or obese. 
• Men are more likely to contract HIV, particularly in communities of color.  

• Highest rates of alcohol, tobacco, and drug usage 
• Increased risk of victimization and violence 
• Transgender individuals are at an increased risk for mental health disorders, substance abuse, and suicide, and are more likely to be uninsured than any other LGB individuals (17) 

Current data suggests that most of the health disparities faced by this group of people are due to social stigma, discrimination, lack of access or referral to community programs, and implicit bias from providers leading to missed screenings or care opportunities.   

Support systems and social acceptance are strongly linked to the mental health and safety of these individuals. Lack of support and acceptance in the home, workplace, or school leads to negative outcomes. Also, a lack of social programs to connect LBGTQ individuals to each other and build a community of safety and acceptance creates further gaps.   

There is currently still discrimination in access to health insurance and employment for this population which can affect accessibility of quality health care as well as affordable coverage.  

Following this, a compilation of recent data showcases that there are significant issues with the quality and delivery of care provided to those in the LGBTQ community.  

This data includes: 

• In a 2018 survey of LGBTQ youth, 80% reported their provider assumed they were straight and did not ask (18).  
• In 2014, over half of gay men (56%) who had been to a doctor said they had never been recommended for HIV screening (14).  
• A 2017 survey of primary care providers revealed that only 51% felt they were properly trained in LGBTQ care (25).  

Although it is unclear as to whether this data stems from a lack of education or social awareness from the provider, it is evident that change needs to be made. At the root of many of the biases regarding LGBTQ clients is a lack of understanding when caring for people in this community. It is important for healthcare professionals to familiarize themselves with the definitions and differences in sexuality, gender identity, and the many terms within those categories to have a better understanding of how these factors affect the health and safety of clients. A glossary for reference and better understanding has been included at the end of this course.  

In order to improve these conditions and close the gap for LGBTQ individuals, much can be done on the community level and in medical training: 

• Community programs should be available to create safe spaces for connection and acceptance. 
• Laws and school policies can focus on how to prevent and react to bullying and violence against LGBTQ individuals. 
• Cultural competence training in medical professions needs to include LGBTQ issues. 

• Data collection regarding this population needs to increase and be recognized as a medical necessity, as it is largely ignored currently. 

It is essential for providers to stay up to date on changes and health trends among the LGBTQ population, as healthcare delivery methods may require adjustments over time; this is critical when learning about cultural competence in nursing. 

Case Study:  

Justin is a 44-year-old male who presents to the family practice office for an annual physical. He indicates some mild depression since a recent breakup with his long-term girlfriend but otherwise denies complaints today.  

His exam is normal, and he had routine lab work at his physical last year, so none is ordered today. His PCP refers him for psychotherapy and indicates that if his depressive symptoms have not improved within 6-8 weeks, starting an SSRI may be beneficial.  

Justin leaves the appointment with a referral and scheduled follow-up and nothing else. What the PCP failed to realize was that Justin ended his recent relationship to come out as gay and he has been dating men for about 4 months now. He was not asked to update any demographic information at check-in and was embarrassed to bring up the topic on his own.  

Discussion 

In this case, the PCP did not have a full picture of the client’s health history and risk factors. By assuming that Justin was still heterosexual because his last partner was a woman, the opportunity to educate about risks and screen for STIs, particularly HIV, was missed. Justin also may be a good candidate for medications like PREP and could benefit from the reduced risk of contracting HIV. A discussion about this medication and if it is a good fit for the client did not take place.  

Gender and Sex 

Gender and sex play a significant role in health risks, conditions, and outcomes due to a combination of factors, including biological, social, and economic elements.  

Among the differences in health data related to gender are:  

• Women are twice as likely to experience depression than men across all adult age groups (7).  
• About 12.9% of school-aged boys are diagnosed and treated for ADHD, compared to 5.6% of girls, though the actual rate of girls with the disorder is believed to be much higher (9).  

• A 2010 study showed men and women over age 65 were about equally likely to have visits with a primary care provider, but women were less likely to receive preventative care such as flu vaccines (75.4%) and cholesterol screening (87.3%) compared to men (77.3% and 88.8% respectively) (5).  
• In the same study, 14% of elderly women were unable to walk one block, as opposed to only 9.6% of men at the same age (5).  
• Heart disease is the leading cause of death in women, yet women are shown to have lower treatment rates for heart failure and post-heart attack care, as well as lower prevalence but higher death rates from hypertension than men (6).  

It is also important to differentiate the difference between gender and sex when practicing cultural competence in nursing.   

Sex is the biological and genetic differentiation between male and female, whereas gender is a social construct of difference in societal norms or expectations surrounding men and women. For someone looking to better practice cultural competence in nursing and provide both equitable and inclusive care, it is essential that you know this differentiation.   

Some health conditions are undeniably attributable to the anatomical and hormonal differences of biological sex; for example, uterine cancer can only be experienced by those who are biologically female. Many of the inequalities listed above disproportionately burden women due to the social and economic differences they experience in society; for example, 1 in 4 women experience intimate partner violence as compared to 1 in 9 men (22).   

What are the reasons for this? A lot of it has to do with how women are perceived in society, how their symptoms may present differently than male counterparts, or how their symptoms are presented to and received by medical professionals.   

For centuries, any symptoms or behaviors that women displayed (largely mental health related) that male doctors could not diagnose fell under the umbrella of hysteria. The recommended treatment for this condition was anything from herbs, isolation, sex, or abstinence and it is only in the last one hundred years or so that more accurate medical diagnoses began to be given to women. Hysteria was not deleted from the DSM until 1980 (27). 

The Cameron study found that women were more verbose in their encounters with physicians and may not be able to fit all their complaints into the designated appointment time, leading to a less accurate understanding of their symptoms by their doctor (5).  

The same study also indicated that women tend to have more caregiver responsibilities and feel less able to take time off for hospitalizations or treatments (5).  

Symptoms of mental health disorders like ADHD may look different in girls than in boys. Girls who are having difficulty focusing may be categorized as “chatty” or a “daydreamer” by teachers, whereas boys are more likely to draw attention for being hyperactive or disruptive when both are experiencing symptoms of ADHD and could benefit from treatment (10).  

To close these gaps and ensure equitable care for men and women, the way that teachers, doctors, and nurses view and respond to girls and women must be adjusted.  

• Children who are struggling in school should be looked at more comprehensively and the differences in learning styles widely understood.  

• Screening questionnaires and standard preventive care used when caring for clients in primary care.  
• Social services should be utilized to help determine if women are pushing aside their own healthcare needs due to responsibilities at home.  
• Medical professionals must be trained in the history of inequality among women, particularly regarding mental health, and proper, modern diagnostics must be used.  
• The differences in communication styles of men and women should be understood when caring for patients.  

Religion 

Religion can impact when patients seek care, which treatments they will participate in, and how they perceive their care. Even advanced technology in healthcare can be perceived as unsatisfactory if it violates religious preferences for patients, so it is very important for healthcare professionals to be aware of certain religious preferences to provide the most competent and sensitive care possible.  

Consequences of culturally incompetent care include:   

• Negative health outcomes due to not participating in care that violates their religious beliefs.  

• Patient relationships with healthcare professionals can suffer if they feel disrespected or misunderstood, causing patients to delay or avoid seeking care altogether.   
• Dissatisfaction with care which can even lead to long-term trauma surrounding major events like birth, death, or chronic disease if a patient felt uninvolved or disrespected in their care (26).   

There are many religions with different practices and ordinances, but we will cover some of the more major and common implications regarding health practices here. Typically, views on pregnancy/birth, death, diet, modesty, and treatment for illness are the most important areas for healthcare professionals to understand. Providers must continue to educate themselves on the practices and preferences of various religions; it is essential to practicing cultural competence in nursing. 

Disclaimer: Please note that each religion has many variations and that not all practices may be the same. The following information has been sourced from “Cultural Religion Competency in Clinical Practice,” written by Drs. Diana Swihart, Siva Naga S. Yarrarapu, and Romaine L. Martin (26). 

Buddhism 

Study and meditate on life, cause and effect, and karma, working towards personal enlightenment and wisdom. They believe the state of mind at death determines their rebirth and prefer a calm and peaceful environment without sedating drugs. Have ceremonies around birth and death. Their diet is usually vegetarian (26).  

Christian Science 

Based on the belief that illness can only be healed through prayer. They typically choose spiritual healing for disease or illness prevention and treatment. Often refuse vaccines and delay treatment for acute illnesses. They avoid tobacco and alcohol but have no other dietary restrictions (26). 

The Church of Jesus Christ of Latter-Day Saints/Mormon 

Heavily family-oriented, involvement of family in major health/life events is important. Strict abstinence outside of heterosexual marriage. Fasting is required monthly, exempt during illness. Blood or blood products are accepted. Abortion is prohibited unless it is a result of rape or the mother’s life is in danger. Two elders present for the blessing of those ill or dying (26). 

Hinduism 

Centers on leading a life that allows you to reunite with God after death. Believes in reincarnation and so the environment around dying people must be peaceful. The presence of family and a priest during end of life is preferable. After death, the body is washed and not left alone until cremated. Euthanasia is forbidden. The right hand is used for eating (26). 

Islam 

Belief in God and the prophet Abraham. Prayer is required five times daily. Observe Ramadan, a month of fasting and abstinence during daylight (children and pregnant women are exempt from fasting). Autopsies should only be performed if legally necessary. Must eat clean, halal, food and excludes pork, shellfish, and alcohol. Female patients require female healthcare providers. Abortion is prohibited (26). 

Jehovah’s Witness 

Believe the destruction of the present world is coming and true followers of God will be resurrected. Do not celebrate birthdays or holidays. Believe death is a state of unconscious waiting. Euthanasia prohibited. Refuse blood and blood products. Abortion is prohibited. Pregnancy through artificial means (IUI, IVF) is prohibited (26). 

Judaism 

Belief in an all-powerful God and varying levels of interpretation/observance of laws and traditions. Cremation is discouraged or prohibited. Prayer is important for the sick and dying, after death the body is not left alone. Must eat kosher foods, which excludes pork. Amputated limbs must be saved and buried where the person will one day be buried. Abortion is allowed in certain circumstances (26). 

Protestant  

Christian faith formed in resistance to Roman Catholicism. Autopsy and organ donation are acceptable. Euthanasia is not acceptable. No restrictions on diet or traditional western medicine treatments (26). 

Roman Catholicism 

Christian faith is steeped in tradition and observance of sacraments. Clergy is present at end of life for the sacrament of Last Rites. Avoid meat on Fridays during Lent. Mass and Communion on Sundays is an obligation, and they may require a clergy member to visit during hospitalization. Abortion and birth control (other than natural family planning) are prohibited. Artificial conception is discouraged. Newborns with a grave prognosis need to be baptized (26). 

To better practice cultural competence in nursing and improve the quality of care given that respects a patient’s faith and religious boundaries, one should focus on:  

• Understanding basic differences and preferences with various religions and providing training for staff.  
• Encouraging family to participate in health decision-making where appropriate.  
• Providing interpreters where needed. 
• Promoting an environment that allows for clergy, healers, or other religious figures of comfort to visit and participate in care if desired.  
• Providing dietary choices that are considerate of religious dietary preferences.  

• Recruiting staff that are minorities or of various religions.  
• Respecting a client’s views on controversial topics such as pregnancy/birth, death, and acceptance or declining of treatments even if it conflicts with staff members’ own beliefs (26). 

Case Study 

The nurse is caring for a terminally ill 78-year-old woman, Patricia. Several weeks ago, the client and her family decided that when the disease progressed, she would like to be placed on hospice and die at home without extraordinary measures or resuscitative efforts.  The family is Roman Catholic and has also requested a priest be present to administer Last Rites.  

Patricia was placed on hospice earlier this week and her condition has worsened to the point where death is near, and the priest has been called in. The nurse assists with clearing and tidying the space around Patricia’s bed and has brought in additional seating for family members. The priest performs the sacrament of Last Rites and then the family sits around the bed and prays together. The nurse administers pain medication on occasion, but for the most part, allows space for the family’s religious needs. After a few hours, Patricia dies, and the family continues to sit with her. They are sad, but overall, there is a sense of peace.  

The nurse checks on the family a few weeks later as part of a follow-up program for grieving families. Patricia’s husband and children all agree that while they are grieving her loss, they feel a sense of spiritual peace with the time surrounding her death and they know it is what she wanted.  

Discussion 

This is an example of how attention to the beliefs and wishes of clients plays an important role in client and family perception of care received compared to the overall health outcomes. This client was terminally ill, so the health outcome was never going to be recovery or disease treatment. The client’s comfort level surrounding the end of life and the grieving process for the family afterward were both facilitated by making space for religious and spiritual needs in addition to medical care.  

Age 

As the Baby Boomer generation ages, there is a growing number of older adults in the U.S. In 2016, there 73.6 million adults over age 65, a number which is expected to grow to 77 million by 2034. As of 2016, 1 in 5 older adults reported experiencing ageism in the healthcare setting (24). As the number of older adults needing healthcare expands, the issue of ageism must be addressed. For providers looking to improve cultural competence in nursing practices, it is vital that ageism is addressed, as it flies under the radar. Ageism is defined as stereotyping or discrimination against people simply because they are old. 

Ways in which ageism is present in healthcare include:   

• Dismissing a treatable condition as part of aging. 
• Overtreating natural parts of aging as though they are a disease. 
• Stereotyping or assuming the physical and cognitive abilities of a patient purely based on age. 
• Providers being less patient, responsive, and empathetic to a patient’s concerns or even talking down to patients or not explaining things because they believe them to be cognitively impaired. 

• Elderly patients may internalize these attitudes and seek care less often, forgo primary or preventative screenings, and have untreated fatigue, pain, depression, or anxiety  
• Signs of elder abuse may be ignored or brushed off as easy bruising from medication of being clumsy (24). 

There are many reasons why ageist attitudes in healthcare may occur, including:  

• Misconceptions and biases among staff members, particularly those that have worked with a frail older population and assume all elderly people are frail.  

• Lack of training in geriatrics and the needs and abilities of this population. 
• Standardizing screenings and treatments by age may help streamline the treatment process but can lead to stereotyping. 
• Changing this process and encouraging an individual approach may be resisted by staff and viewed as less efficient. 

In order to combat ageism and make sure healthcare is appropriately informed to provide respectful, equitable care:  

• Healthcare professionals can adopt a person-centered approach rather than categorizing care into groups based on age. 
• Facilities can adopt practices that are standardized regardless of age. 
• Facilities can include anti-ageism and geriatric-focused training, including training about elder abuse. 
• Healthcare providers can work with their elderly patients to combat ageist attitudes, including internalized ones about their own abilities (24). 

On the opposite end of the lifespan, children are vulnerable to gaps in care due to assumptions about their cognitive capacity to participate in their care. Healthcare professionals may ignore or minimize communication from young clients, dismissing their concerns as trivial or something to be handled by adults.  

This is partly because most medical decision making does require parental consent for anyone under the age of 18, with some exceptions for sensitive issues like STIs depending on your state. However, just because the final decision-making authority lies with the parents doesn’t mean that children and teens have no opinions or desire to be a part of their care (32).   

Children also may exhibit behaviors that are less cooperative than adults due to pain, fear, or illness. This is developmentally appropriate and should not be labeled as “difficult” or “bratty,” but approached with empathy and an understanding of different developmental levels.  

Different approaches include:   

• Distractions such as toys, songs, videos, and comforts like hugs or breastfeeding should be used for babies and toddlers who are too young to understand what is happening. 
• Play can be used for preschoolers to help demonstrate wearing hospital gowns/shoes/caps, giving medicine, or changing bandages. Preschoolers can be given simple explanations and use play to eliminate some of the unknown and prepare for hospital or clinic experiences.  
• School age children can be given more detailed information and may enjoy picture books or stories. They should be given the opportunity to ask questions that should be answered honestly and not dismissed with responses like “You don’t need to worry.”  
• Teenagers should be included in a full discussion of the risks versus benefits of treatment plans and more advanced information or even pamphlets and reading materials can be given about the disease process or treatment. This age group is striving for autonomy and should be treated respectfully, allowed to be a part of the decision-making process, and given privacy when possible and appropriate. Responsibility for their health should be shifted to them while still under the supervision of an adult. Teenagers who are taken seriously and given respect as an individual are more likely to form a trusting rapport with healthcare professionals, which is in turn necessary for their cooperation and compliance with treatment plans (32). 

• It should also never be assumed that teenagers are “too young” be engaging in risky behaviors such as smoking, drugs, alcohol, or sexual activity. Making assumptions opens the door for missed screenings and preventative care (32). 

Child Life specialists are a wonderful resource that should be utilized whenever available; these professionals are licensed in child development and assist with coping and education for children and adolescents in the hospital or clinic setting. They can be present for situations ranging from a simple blood draw to disclosing a terminal diagnosis (32). 

Age specific treatment requirements change across the lifespan, and an important part of cultural competence is familiarity with the unique needs, strengths, and challenges of each age group. Familiarity with Erikson’s stages of development with help clinicians better understand their clients’ needs and customize care accordingly.  

A brief review of Erikson’s stages of development is included below.  

1. Trust vs Mistrust, birth to 2 years: Infants and young toddlers in this stage are completely dependent on others to meet their needs. Their communication is very limited (crying) and, if cared for, they quickly learn that their needs will be met, and they are safe. If infants in this stage receive poor care, they may be fearful and struggle to trust their needs will be met.  
2. Autonomy vs Shame and Doubt, 2-3 years: At this stage, toddlers are seeking more control over choices and their bodies (and may even have tantrums when they want control). Skills, such as feeding themselves, getting dressed, communicating more effectively, helping with small tasks, and potty training provide a sense of confidence. If toddlers are not given some control over their own choices and bodies, they may doubt their abilities or feel shame.   
3. Initiative vs Guilt, 3-5 years: In this stage, children learn to explore, make decisions, and assert themselves in social interactions. If allowed freedom to explore the effect of their choices and interactions, children will develop a sense of initiative. If they are repressed through control or criticism, they will develop a sense of guilt.  
4. Industry vs Inferiority, 6-11 years: In this stage, children work to improve their abilities and seek recognition of their competence. If encouraged and praised, children will develop a sense of confidence. If ridiculed or discouraged, they will doubt their abilities.  
5. Identity vs Confusion, ages 12-18 years: This is the period of adolescence which is famously tumultuous. At this stage, individuals work to better understand their values, interests, and sense of self separate from the family unit. They seek independence and control over their appearance and how they spend their time and their acceptance in a peer group is important. Adolescents who receive positive reinforcement for their individuality will develop a strong sense of self. Those who do not receive positive reinforcement will lack confidence and feel insecure.  
6. Intimacy vs Isolation, 19-40 years: In this stage, adults work to form deeper and more intimate relationships, through both romantic partners and friendships. Success during this stage depends on how successfully a person achieved the previous stages. Those who are able to form strong relationships with others feel a sense of intimacy and contentment, whereas those with poor or unstable relationships will feel isolated and lonely.  
7. Generativity vs Stagnation, 40-65 years: During this stage, adults work to create and solidify a good and productive life, contributing to the world through careers, family, and community engagement. Those who are successful will feel a sense of connection and motivation, those who are unsuccessful may feel disconnected or stagnant.  
8. Integrity vs Despair, 65+: In this stage, older adults begin to look back on their lives and evaluate the impact or goals they have accomplished or failed to accomplish. Adults who feel proud or accomplished with all they have done will have a sense of integrity and satisfaction, whereas those with many regrets or lack of pride will feel despair or bitterness.  (41) 

Case Study 

Sydney is a 17-year-old client who presents to the pediatric office alone with a complaint of dysuria. She has been coming to this office for years but has never spoken with her nurse practitioner alone, so she is feeling nervous, particularly given the nature of her symptoms.  

She reports pelvic pain and dysuria for about 2 weeks, along with some foul smelling yellow vaginal discharge. She admits to being sexually active with 2 partners in the last year. She reports using condoms inconsistently. She does take hormonal birth control for acne, which is listed in her chart.  

On exam, she has pelvic tenderness and yellow vaginal discharge. Otherwise, her exam is normal. The NP discusses that based on her history and exam; a diagnosis of chlamydia is likely. A urine sample is collected, and the NP states it will take a day or two for results to come back but that she can be started on an antibiotic now while awaiting results.  

This NP has known Sydney for many years, knows her mother well, and knows that abstinence is the preferred method of sex education taught in Sydney’s home. The NP agrees that Sydney is too young to be sexually active and feels very concerned that she has contracted an STI and decides to contact Sydney’s mother to inform her of today’s visit.  

Sydney’s mother is furious at this information and prohibits Sydney from attending prom the following week. She restricts access to her phone and activities outside of school. Sydney is distraught over the conflict at home and over the following weeks develops depressive symptoms with suicidal thoughts. She has sports physical for summer camp the following month but does not disclose any of her depressive symptoms to the NP as she now feels a lack of trust and that the NP just views her as a child with no autonomy.  

Discussion  

Consider this case and how the NP’s own implicit biases affected the care Sydney received. Now that the trust is broken between Sydney and her provider, the chances that she will seek care for future problems is small. This could result in serious negative health outcomes, particularly since she is experiencing suicidal thoughts and is at risk for self harm.  

Now imagine this same case, but instead of the NP interjecting their own biases about the client, they follow Nevada law which allows minors to receive confidential treatment for STIs without parental consent. Sydney could be treated discreetly without her parent’s knowledge and the NP could utilize the opportunity to discuss safe sex and the importance of using condoms. This is much more likely to result in a positive outcome for Sydney, as she will be treated for the chief complaint, as well as be empowered to practice safer sex and hopefully avoid future STIs. She will also maintain a trusting relationship with this provider and feel comfortable making appointments for future concerns.  

Veterans 

Veterans are a unique population that faces many health concerns unique to the conditions of their time in service. Much of veteran health care is provided through the Veteran Affairs (VA) facilities, a nationalized form of healthcare involving government-owned hospitals and clinics and government-employed healthcare professionals. Again, the purpose of this course is to educate providers on how to practice cultural competence in nursing; however, let’s introduce the disparities found within this population by utilizing a few statistics. 

• 1 in 5 veterans experience persistent pain and 1 in 3 veterans have a diagnosis related to chronic pain (8).  
• Approximately 12% of veterans experience symptoms of PTSD in their lifetime, compared to 6% of the general population and 80% of those with PTSD also experience another mental health disorder such as anxiety or depression (8). 

• More than 1 out of every 10 veterans experiences some type of substance use disorder (alcohol, drugs), which is higher than the rate for non-veterans (8).  
• In 2019, around 9% of homeless adults were veterans (28).  
• Veterans account for 20% of all suicides in the U.S., despite only about 8% of the U.S. population serving in the military (8).  
• Disparities also exist within the veteran population and veterans who are a minority race or female experience these issues at an even higher rate 

• For example, veteran women are twice as likely to experience homelessness than veteran men (28).  

The causes of these troubling issues for veterans are multifaceted; some of them relate to the nature of work in the U.S. Military and increased exposure to trauma (particularly with those involved in combat), and some of them relate to the care of veterans, and their mental health during and after their service.  

• 87% of veterans are exposed to traumatic events at some point during their service (8). 
• Current data suggests fewer than half of eligible veterans utilize VA health benefits 

• For some this means they are receiving care at a non-VA facility and for others it means they are not receiving care at all. 

• Care at civilian facilities means healthcare professionals who may not have a full understanding of veteran issues (12).  

• Less than 50% of veterans returning from deployment receive any mental health services (23).  

All service members exiting the military are required to participate in the Transition Assistance Program (TAP), an information and training program designed to help veterans transition back to civilian life, either before leaving the military or retiring. The program is evaluated annually for effectiveness and currently includes components about skills and training for civilian jobs and individual counseling regarding plans after exit.  

• Adding or strengthening components of TAP surrounding mental health care and utilization of VA healthcare services would be beneficial and could help reduce disparities. 

• Changing the military culture surrounding mental health to strengthen and mandate training and usage of debriefing for active duty military could be beneficial as well. 
• Incentivizing usage of the VA healthcare system for routine preventative and mental health care would help reach more veterans who may be in need. 
• Additional training for healthcare professionals working within the VA with an emphasis on mental health disorders would ensure high-quality of care for veterans utilizing their services.

Mental Illness and Disability 

Disabilities are emerging as an under-recognized risk factor for health disparities in recent years, and this new recognition is a welcome change as more than 18% of the U.S (15) population is considered disabled. Disabilities can be congenital or acquired and include conditions that people are born with (such as Down Syndrome, limb differences, blindness, deafness), those presenting in early childhood (Autism, language delays), mental health disorders (bipolar, schizophrenia), acquired injuries (spinal cord injuries, limb amputations, change in hearing/vision), and age related issues (dementia, mobility impairment).   

Public health surveys vary from state to state, but most categorize a condition as a disability based on the following: 1) blindness or deafness in any capacity at any age, 2) serious difficulties with concentrating, remembering, and decision making, 3) difficulty walking or climbing stairs, 4) difficulty with self-care activities such as dressing or bathing, 5) and difficulty completing errands, such as going to an appointment, alone over the age of 15 (19).   

Health disparities affecting people with disabilities can include the way they are recognized, their access and use of care, and their engagement in unhealthy behaviors. In order to practice cultural competence in nursing, understanding the disparities that those with disabilities face is essential. 

• Due to variations in the way disabilities are assessed, the reported prevalence of disabilities ranges from 12% to 30% of the population (19). 
• People with disabilities are less likely to receive needed preventative care and screenings (15). 

• Only 78% of women with disabilities were up to date with their pap test, while over 82% of non-disabled women were up to date with this preventative screening (19). 

• People with disabilities are at an increased risk of chronic health conditions and have poorer outcomes (15). 

• 27% of people with disabilities did not see a doctor when needed, due to cost, as opposed to only 12% of non-disabled peers (19). 
• 21% of children with disabilities were obese, compared to 15% of children without disabilities (19). 

• People with disabilities are more likely to engage in unhealthy behaviors such as cigarette smoking and lack of physical exercise than people without disabilities (15). 

• During Hurricane Katrina, 38% of the people who did not evacuate were limited in their mobility or providing care to someone with a disability (19). 

Many of the health differences between those with and without disabilities come down to social factors like education, employment (finances), and transportation which significantly affect access to care.  

• 13% of people with disabilities did not finish high school, compared to 9% of non-disabled peers. 
• Only 17% of people over the age of 16 with disabilities were employed, compared to nearly 64% of non-disabled peers. 

• Only 54% of people with disabilities had at-home access to the internet, compared to 85% of people without disabilities. 
• 34% of people with disabilities reported both an annual income <$15,000 and access to transportation, compared to 15% and 16% respectively for people without disabilities. 
• Fewer than 50% of people with disabilities have private insurance, while 75% of people without disabilities have private health insurance. 

• Even for those insured, 16% of people with disabilities have forgone care due to cost, compared to only 5.8% of insured people without disabilities (19). 

If access to necessary preventive and acute health care is to be increased for those with disabilities, much must be changed in regard to the social determinants affecting this population. Policy changes on a community, state, and federal level will be needed to provide the social and economic support these people need. Potential solutions include:  

• Streamline and standardize the process of identifying people with disabilities so they can be eligible for assistance as needed. 
• School programs to help people with disabilities graduate and find jobs within their ability level.  
• Community participation in making sure transportation, buildings, and facilities are accessible to all. 
• Make internet access a basic and affordable utility, like running water and electricity. 

• Address the inequities in health insurance accessibility and coverage. 
• Provide social and economic support programs for parents of children with disabilities and provide transitional support as those children become adults (15). 

LGBTQ Term Glossary  

• Sex: A label, typically of male or female, assigned at birth, based on the internal reproductive structures, external genitals, secondary sex characteristics, or chromosomes of a person. Sometimes the label “intersex” is used when the characteristics used to define sex do not fit into the typical categories of male and female. This is static throughout life, though surgery or medications can attempt to alter physical characteristics related to sex.  

• Gender: Gender is more nuanced than sex and is related to socially constructed expectations about appearance, behavior, and characteristics based on gender. Gender identity is how a person feels about themselves internally and how this matches (or doesn’t) the sex they were assigned at birth. Gender identity is not related to who a person finds physically or sexually attractive. Gender identity is on a spectrum and does not have to be purely feminine or masculine and can also be fluid and change throughout a person’s life.  

• Cis-gender: When a person identifies with the sex they were assigned at birth.  
• Transgender: When a person identifies with a different sex than the one they were assigned at birth. This can lead to gender dysphoria or feeling distressed and uncomfortable when conforming to expected gender appearances, roles, or behaviors.  
• Nonbinary: When a person does not identify as entirely male or female. A nonbinary person can identify with some aspects of both male and female genders, identify with certain characteristics at different times, or reject both entirely.  

• Sexual orientation: A person’s identity in relation to who they are attracted to romantically, physically, and/or sexually. This can be fluid and change over time, so do not assume a client has always or will always identify with the same sexual orientation throughout their life.  

• Heterosexual/Straight: Being attracted to the opposite sex or gender as your own. 
• Homosexual/Gay/Lesbian: Being attracted to the same sex or gender as your own.  
• Bisexual: Being attracted to people of many sexes, including your own. 
• Pansexual: Being attracted to people, regardless of sex or gender presentation.  

Conclusion

In short, cultural competence in nursing means that although a provider may not share the same beliefs, values, or experiences as their patients, they understand that in order to meet the patient’s needs, they must tailor their care delivery. Nurses are patient advocates, and it is on them to ensure that they are providing equitable and inclusive care to all populations.  

However, cultural competence in nursing is ever-changing and it is the responsibility of the provider to stay up-to-date in order to offer the best experience for all patients. 

Bioterrorism in Nursing

With advancements of science and developments in microbial genetics, there is heightened concern regarding the abuse of these discoveries for acts of terrorism and war. Effective preparedness is a crucial asset to have in the management of an attack.  Nurses and other healthcare practitioners play a vital role in this preparedness. It is essential that they have some knowledge of the prevention and control practices as well as knowledge of the various biological, chemical, nuclear, and radioactive agents that may be used in a potential intentional attack. Arming healthcare providers with expertise in preparedness, management, and treatment will allow for a smoother transition of action if a public health emergency ensues. It is vital for nurses to understand bioterrorism in nursing as nurses would play a major role in treatment of individuals affected by such an event. 

Introduction

The threat of biological warfare may seem like a farfetched idea, something only one may see in a movie. However, with the recent events of our world, it seems more and more likely. With advancements of science and developments in microbial genetics, there is heightened concern regarding the abuse of these discoveries for acts of terrorism and war. Although regulations and procedures are securing the exposure or release of such pathogens in research laboratories exist, there is still risk involved. 

Effective preparedness for bioterrorism in nursing staff is a crucial asset to have in the management of an attack.  Nurses and other healthcare practitioners play a vital role in this preparedness. It is essential that they have some knowledge of the prevention and control practices as well as knowledge of the various biological, chemical, nuclear, and radioactive agents that may be used in a potential intentional attack. Arming healthcare providers with expertise in preparedness, management, and treatment will allow for a smoother transition of action if a public health emergency ensues.  

“Bioterrorism is the intentional release or threat of release of biologic agents (i.e., viruses, bacteria, fungi, or their toxins) to cause disease or death among the human population or food crops and livestock to terrorize a civilian population or manipulate a government (1).” 

Preparedness for bioterrorism in nursing staff will improve the ability to detect and control other infectious diseases.  

“Weapons of mass destruction are atomic explosive weapons, radioactive material weapons, lethal chemical, and biological weapons, that are intended to harm a large number of people (2).” 

Characteristics of Bioterrorist attack (1): 

• The infectious agent used is likely to be uncommon and not prevalent to the region.  
• May be genetically modified to make it resistant to vaccines and medications.  
• It was produced in a way that enhances its transmission.  
• Has the characteristics of a mass casualty event. 
• Have a short and predictable incubation period. 
• The target population should have little or no immunity against the organism. 
• Little or no treatment should be available with the native population. 
• It can be either covert or announced and can be caused by any pathogenic microorganism.  

 Weapons of mass destruction have the potential to (2): 

• Produce a single moment of enormous destructive effect capable of killing millions of civilians, jeopardizing the natural environment, and altering the lives of future generations through their effects.  
• Cause death or serious injury of people through toxic or poisonous chemicals  
• Disseminate disease-causing organisms or toxins to harm or kill humans, animals or plants.  
• Deliver nuclear explosive devices, chemical, biological, or toxin agents to use them for hostile purposes or in armed conflict. 

Classification of Biological Weapons  

Several bioterrorist agents that are classified as the most dangerous include anthrax, botulism, plague, smallpox, tularemia, and viral hemorrhagic fevers. Bioterrorist attacks can also come in the form of food or waterborne agents (1). Biological weapons are classified into different categories by the Center for Disease Control (CDC). Agents of bioterrorism are classified into three groups Category A, Category B, and Category C. They are based on the agents’ priority to cause a risk to national security and how easily they can be disseminated.  

Category A: High Priority Agents

• Easily disseminated  
• Cause high mortality  
• Cause public panic and social disruption  
• Require special action for public health preparedness 

Category B: Second Highest Priority Agents

• Moderately easily to disseminate  
• Cause moderate morbidity  
• Require enhanced disease surveillance and public health diagnostic capacity (3, 4, 5) 

Category C: Third Highest Priority Agents

• Could be engineered for mass dissemination in the future  
• Have potential for high morbidity mortality and major health impact  

Agents of Bioterrorism (3, 4, 5)

Biological Agents 

Anthrax

Anthrax is a severe infection caused by the bacterium Bacillus anthracis. In 2001, 22 cases of the disease were reported in the United States after anthrax spores were sent through the mail. Anthrax can be contracted in three different ways. Each type of infection has differing signs and symptoms. Person-to-person transmission of this disease is rare. It can also be naturally occurring as a result of contact with anthrax-infected animals such as sheep and cattle (6). 

Cutaneous Anthrax: the anthrax spores enter the skin through a cut or abrasion, leading to swollen itchy sores on the skin (6). 

• Incubation: 1-14 days after exposure  
• Symptoms: The lesion presents as a painless, pruritic papule on the exposed areas of the skin. Vesicles may develop. After rupture, black eschar develops. 
• Diagnostic testing: Blood culture, gram stain, culture of vesicular fluid. Blood and pleural fluid cultures should be obtained.
  Mortality: If left untreated, this infection has a mortality rate of 20 % 
• Treatment: antibiotic therapy such as penicillin or doxycycline for 7-10 days (6).

Inhalational Anthrax: Develops when anthrax is inhaled through the lungs. T he inhaled anthrax spores travel to the alveoli. Spores can remain dormant up to 60 days (6).  

• Symptoms: During the initial phase of inhaled infection, patients may have very unspecific symptoms such as fever, sweats, fatigue, non-productive cough, dyspnea, vomiting, hemorrhagic meningitis and shock.  
• Diagnostic Testing: Rapid diagnostic test (nasal swab) should be performed in patients suspected of exposure to anthrax to confirm the diagnosis and determine antibiotic sensitivities. CT scanning should be considered if anthrax is suspected.  WBC is typically normal or slightly elevated. Laboratory resources from the CDC can provide confirmatory testing.  
• Treatment: Oral or IV antibiotic ciprofloxacin or doxycycline. Anthrasil is a human immune globulin used in combination with antibiotics (6). 
• Mortality: 45%.

Gastrointestinal anthrax: This is very rare. This occurs from eating undercooked meat from an infected animal. Symptoms include nausea, loss of appetite, vomiting, and fever (6). 

• Incubation: 1-7 days after exposure 
• Mortality: 50% without treatment with treatment 40% (6). 
• Vaccine for all types of Anthrax:  BioThrax (7). 

Plague

The plague also known as the “black death,” is caused by Tersinia pestis and has claimed millions of lives throughout history. The plague most commonly presents as the bubonic form but can also appear in sepsis or pneumonic form. There are approximately 10-15 cases of the plague in the United States per year (6).  

The most common route of infection in humans involves the transmission of the bacteria following a plague-infected fleabite. Person to person transmission does not occur in bubonic or septicemic plague form. However, pneumonic plague is highly contagious. If the plague is aerosolized as a weapon, it could be extremely deadly (6).  

• Incubation: Period: 2-8 days after exposure 
• Symptoms: Symptoms present with a sudden onset of fever, chills, weakness, and swollen lymph nodes (bubo). 
• Mortality: Pneumonic plague has an almost 100% mortality rate if not rapidly treated with antibiotics  
• Treatment: streptomycin, gentamicin, ciprofloxacin, and doxycycline  
• Vaccine: There is currently no vaccine (7) 

Smallpox

The last reported case of smallpox occurred in 1977 in the United States, and it has two different forms. The deliberate introduction to this highly contagious disease could cause a worldwide pandemic in a matter of weeks (6). 

• Incubation Period: 12-14 days  
• Symptoms: Symptoms presently abruptly with a high fever, headache, backache, and malaise. Patients will then develop a maculopapular rash on the face. The rash also develops on the palms of the hands and soles of the feet.  
• Mortality: 55% with treatment. Almost 100% without treatment.  
• Treatment: TYPOXX- is the first drug with an indication for the treatment (6). 
• Vaccine: CBER (7) 

Tularemia

Tularemia is caused by the bacteria Francisella tularensis. It is also known as the “mild plague”. It is incredibly infectious, and simple contact with a culture plate can result in illness. The bacteria causing tularemia have many natural reservoirs, including rabbits, squirrels, muskrats, and cats. The primary source of infection for humans is domesticated rabbits. Tularemia can present in ulceroglandular, glandular, oculoglandular, oropharyngeal, typhoidal, or pneumonic forms (6).  

Person to person contact does not occur. Bioterrorist dispersal could result in many pleuropneumonic cases. Without antibiotics, tularemia would progress to extreme respiratory failure and death (6).  

• Incubation: Period: 1-14 days  
• Symptoms: The symptom onset is rapid with fever, headache, myalgia, sore throat, nausea, vomiting, diarrhea, and dry or productive cough.  
• Mortality: in United States is less than 2%.  
• Treatment: aminoglycosides, macrolides, fluroquinolones, and chloramphenicol (6). 
• Vaccine: There is currently no vaccine available (7).  

Botulinum Toxin

Botulism is caused by Clostridium botulinum, which is a naturally occurring substance in soil. The toxin is derived from a spore-forming bacterium that has neuroparalytic effects. Most cases of botulism result from contaminated food. The most likely bioterrorism action with botulism would include contamination of food and aerosolization. The infection results from the absorption through a mucosal surface, with the intestine absorption being more common than through the lungs (6). 

• Symptoms: Initial presentation includes GI upset that rapidly progresses to cranial nerve abnormalities. Progressive bilateral descending paralysis ensures followed by respiratory failure and death.  
• Mortality: Less than 5 % if treated but approaches 60% if untreated 
• Treatment: Supportive critical care with assisted ventilation, prevention of secondary infection (6). 
• Vaccine: Botulism Immune Globulin Intravenous (7). 

Viral Hemorrhagic Fever

There have been geographically isolated viruses, including Lassa, Ebola, Marburg, and Dengue that fall into the category of infectious agents for viral hemorrhagic fevers. The vectors of these viruses include rodents, mosquitoes, and ticks. Aerosolization is a more likely mode of terrorist dissemination (6). 

• Incubation period: 2-21 days 
• Symptoms: Abrupt onset of fever, myalgia, malaise, headache, vomiting, abdominal pain, and diarrhea. A maculopapular rash develops on the trunk, usually within five days. Later clinical symptoms include hepatic failure, renal failure, neurologic deficits, hemorrhagic diathesis, shock, and multi-organ dysfunction.  
• Treatment: Treatment is supportive. Ribavirin (Virazole) has shown minimal success in the treatment of patients with hemorrhagic fevers. The CDC has recommended giving this to patients with suspected viral hemorrhagic fever pending final diagnosis (6). 
• Vaccine: Ervebo (7)

Chemical Agents 

Chemical agents are another type of biological warfare that exists and pose a threat to health and safety. Most chemical agents are liquids that are turned into vapors. When used as a weapon, they could be easily spread by explosion or spray. Chemical agents are extremely toxic chemicals that are lethal or have incapacitating effects on humans (19). 

• They are cost–effective  
• They may be used at lower levels of concentration to cause panic or disorder 
• Chlorine, phosgene, and cyanides are widely used in the process of chemicals or pharmaceuticals  
• They can be easily transported in the form of water bottles, cold drink cans, ampules, or pens  
• The effect of intentional release varies depending upon the compound’s toxicity, its volatility, concentration, the route of exposure, the duration of exposure, and the environment.  

Classification of Chemical Agents

Chemical warfare agents have differing characteristics and belong to various classes of compounds. They are classified in several different ways, but in general, are classified on their physiological effects produced on humans. They are classified as: 

Blister Agents (vesicants)

• Inhaled or absorbed through the skin  
• They can affect the eyes, airways, skin, and GI tract  
• They can cause large blisters that resemble burns (8) 

Example: Mustard Gas- If exposed, it can take up to 4-8 hours before experiencing symptoms (13)

Treatment involves lotions, eye drops, and pain medication. If an infection develops, antibiotics can be used (13). There is no antidote for mustard toxicity.  

Blood Agents (Cyanogenic agents)

• These are generally inhaled and distributed through the blood  
• They do not affect the blood but rather inhibit the production of blood components 
• Lead to suffocation from delayed or lack of oxygen transport (12) 

Treatment involves oxygen and mechanical ventilation. Treatment aims to dissociate the cyanide ion from the cytochrome oxidase-cyanide complex. This is accomplished by the administration of binders like amyl nitrite, sodium nitrite, and DMAP (14).

Nerve Agents

• Cause hyperactivity of muscles and organs 
• Absorbed through skin, lungs, or by liquid or vapor exposure  
• Can affect eyes, nose, airways, GI tract, muscles, and CNS (12) 
• They are highly toxic and can cause death from a few minutes to a few hours after exposure (19). 

Example: Sarin and VX. Exposure can cause interruption of breathing, muscle weakness, loss of consciousness, convulsions, and death (15)

There is no antidote for nerve agent poisoning (15).

Pulmonary Agents

• Inhaled through lungs  
• Irritating to airway passages  
• In extreme cases, the membranes swell, and the lungs become filled with liquid, and death results from lack of oxygen.  
• Chlorine and phosgene are examples of this class 
• The treatment of phosgene poisoning is palliative. The objective treatment is the prevention of pulmonary edema and the effects of anoxia. This may involve mechanical ventilation and administration of cortisone and sodium bicarb (16).

Riot-Control Agents

• These are compounds that cause temporary incapacitation by irritation of the eyes (Tearing and blepharospasm) as well as irritation of the upper respiratory tract 
• Also known as “tear gas” 

The treatment requires immediate decontamination of clothing and eyes (19).

Psychomimetic Agents

• Chemical agents that consistently produce changes in thought, perception, or mood without causing disturbances in the autonomic nervous system or severe disability  
• LSD is the most well-known member of this group 
• Affected individuals cannot follow a series of instructions or lack concentration  

General supportive management of the patient includes decontamination of skin. The most significant risks to a patient’s life are injuries from their erratic behavior (18).

Toxins

• Poisonous chemical compounds synthesized in nature by living organisms such as bacteria, fungi, terrestrial or marine animals.  
• There are two groups: Protein toxins and non-protein toxins  
• Toxins as agents of warfare are restricted to assassinations or localized terrorist attacks 
• The two most crucial toxin threats are botulinum toxin and Staphylococcus Enterotoxins B. 
• The treatment for toxins is passive immunization with antitoxins (19). 

Radioactive & Nuclear Agents 

“A Radiological Dispersal Device (RDD) is any device that causes the purposeful dissemination of radioactive material without a nuclear detonation.” This can be in the form of a “Dirty Bomb” or other dispersal methods. Radioactive Sources can be solid, aerosol, gas, or liquid (20).  

• Dirty Bomb = Explosive method of dispersion 
• Explosion = radioactive and nonradioactive shrapnel and radioactive dust; radiation contamination, radiation exposure, physical injury, burns, and panic and fear (20). 

Other dispersal methods can involve passive or active dispersion of unsealed radioactive sources. For example, dropping them on water or soil or dropping them from an airborne device (20).  

 A nuclear weapon is a device that uses a nuclear reaction to create an explosion. When a nuclear weapon explodes, it emits four types of energy: a blast wave, intense light, heat, and radiation. Nuclear weapons can be in the form of bombs or missiles (21). The energy to cause a nuclear explosion comes from splitting the two radioactive materials Uranium 235 and Plutonium-239. The bombs that were dropped on Hiroshima and Nagasaki, Japan, in World War II are examples of nuclear explosions. 

When a nuclear weapon explodes, it creates a fireball. Within this fireball, everything is vaporized and carried upward, creating a mushroom-shaped cloud. The material within the once vaporized substance cools into dust particles that drop back down to earth, known as fallout. The fallout is radioactive and contaminates anything that it comes into contact with (21).

Dangers of a Nuclear Weapon

A nuclear weapon, if used, would cause extreme destruction, death, and injury to a large area. Those close to the blast could experience injury or death from the explosion, burns from the heat and fire, blindness from intense light, and radiation sickness.  

People further from the blast but in range of fallout could experience effects of radiation sickness, contaminated food and water, and external or internal contamination from the fallout (21).

Radiation Exposure – Acute Radiation Syndrome (ARS)

Physical Findings Suggestive of ARS:

 *Acute Radiation exposure is the result of a radiological or nuclear incident. 

There are four sub–syndromes of Acute Respiratory Syndrome:  

1. Hematopoietic

Changes in blood cell counts will reflect the radiation dose. Lymphocytes, neutrophils, red cells, and platelets respond to radiation in different ways. The interpretation of lab values will depend on how long after radiation exposure the lab values were measured. Faster drops in absolute lymphocyte count and the absolute neutrophil count will reflect a higher dose of exposure (11). 

2. Gastrointestinal

Nausea and or vomiting can occur soon after the brain, upper GI tract, and whole-body irradiation. Radiation can cause GI mucosal damage and damage to bone marrow elements. Both of these factors can cause GI blood loss. Consider treatment with anti-diarrheal meds, fluid replacement, and antimicrobial agents (22).  

3. Cutaneous

Skin changes that occur earliest (hours to weeks) after exposure include erythema, swelling, edema, blistering, and skin sensitivity. Skin changes that could occur later (days to weeks) after exposure include skin desquamation, hair loss, and skin necrosis.  

The management of cutaneous radiation injuries must be highly individualized. Management may include: wound debridement, fluid replacement, pain management, use of corticosteroids, antimicrobial therapy, and growth factors to enhance granulation (22). 

4. Neurovascular

An increase and decrease in blood pressure and body temperature can occur hours after significant radiation exposure. These changes may reflect clinical infection and CNS irradiation. Fatigue, headache, and anorexia can also happen as well as cognitive and neurological deficits. Consider treatment with glucocorticoids if shock or increased intracranial pressure is present, consider mannitol, control body temperature, and blood pressure, consider CNS imaging (22). 

Blast Injury

Primary blast injury can cause extreme barotrauma affecting air-filled organs leading to pulmonary damage, rupture of tympanic membranes, and rupture of hollow viscera (fatal). A secondary blast injury can lead to fragmentation injuries and penetrating trauma. A tertiary blast injury can be caused by structural collapse or people being thrown by blast force wind. This can lead to crushing injuries, blunt trauma, fractures, amputations, and open or closed brain injuries (23).  

Thermal/Burn Injury

Thermal burn injuries occur by direct absorption of thermal energy through exposed skin. It can lead to burn casualties, eye injuries, and retinal scarring (23).  

Long term effects of radiation:

• Delayed effects of acute radiation exposure  
• Specific organ effects depending on where a given isotope is incorporated 
• Carcinogenesis 
• Mutagenesis (23) 

Management of Patients with Radiation Exposure

If you were presented with a patient with potential radiation exposure, here is a list of things to consider:  

• Look for early clinical signs and symptoms of Acute Radiation Syndrome (see chart above) 
• Use Radiation Bio Dosimetry Tools to estimate whole–body radiation dose (22): 
  • Obtain CBC with differential and platelet count  
  • Input absolute lymphocyte counts into Interactive Calculator to estimate whole–body radiation dose 
  • Repeat CBC every 24 hours if possible, to increase the accuracy of the dose estimate and management  
  • Consider myeloid cytokines and antibiotics if whole–body dose estimate is ≥ 2 (22).

Personal Protective Equipment (PPE)

“Personal protective equipment refers to clothing and respiratory coverings designed to shield an individual from chemical, biological, and physical hazards (24).”  

The type of protection required depends on the incident and the duration of exposure that is anticipated. In general, PPE is more effective against chemical agents because biological agent incidents are not likely to be evident until well after the agent’s release (24).   

There is a Personal Protective Equipment classification system that is used in describing the varying levels of protection:  

 *Information in text box retrieved from Chemical and Biological Terrorism: Research and Development to Improve Civilian Medical Response (24) 

Types of Protection

There are several types of protective equipment, each with its own sets of requirements and uses. Listed are the various common elements of PPE (24):  

Respiratory:

Appropriate respirators should be used to protect against adverse health effects that may be caused by breathing contaminated air 

Eye/Face:

Eye and face protection will protect the user from hazards of potential flying fragments, sparks, or chemical splashes  

Skin:

Skin protection should be used if a user has potential exposure to harmful substances  

Noise:

Ear protection such as earplugs or earmuffs can prevent hearing damage. Exposure to high noise levels can cause hearing loss or impairment. 

PPE Management

PPE requires the implementation of a management program for education and safety purposes. Training for PPE involves the proper mechanics of donning and doffing PPE, the maintenance and care of PPE, the limitations, and the appropriate disposal after use (24).  

PPE Specifically for Biological Agents

A terrorist attack of biological agents presents different needs for PPE than a chemical attack agent. Unless there is pre-incident intelligence of a biological agent, a biological attack would be covert (24). Many of the biological agents have incubation times ranging from hours to weeks between exposure and clinical symptoms; if an aerosolized agent had been used, it is likely to have dissipated from the area before recognition of first responders (24).  

Apart from smallpox, and plague bacteria, person-to-person transmission of the diseases rarely occur if “universal precautions are maintained (e.g., gloves, gown, mask, and eye protection).” The majority of patients that have been affected by other biological agents can be cared for without specialized isolation rooms or ventilation systems. The hemorrhagic virus infections may be transmissible with blood or aerosol. Therefore, respiratory protection for responders caring for these patients would be required (3). 

If pre-incident intelligence puts rescue personnel at the scene of a release, the same PPE they would employ for a chemical incident will protect from biological agents (24).  

PPE for Radiation Exposure

In all cases where radiation is suspected, first responders should wear personal radiation dosimeters that allow them to read the dose and or accumulated dose in real–time (20,24). 

In the event the first responder is exposed to radiation only even with a high risk of contamination and non-radiation hazards have been excluded, Level C PPE will provide sufficient respiratory and dermal protection. However, in the event a first responder is exposed to a high-risk event of exposure, PPE gives no protection against high energy, highly penetrating forms of ionizing radiation (20).  

Syndromic Surveillance & Reporting Procedures 

Because of the heightened concern of bioterrorism’s potential possibility in our nation and across the world, public health agencies are currently testing new surveillance methods of early detection of illness resulting from a bioterrorism-related pandemic (12). Unlike traditional systems that utilize voluntary reporting from clinical providers to acquire data, syndromic surveillance continuously acquires data through protocols and automated routines. For example, Washington DC syndromic surveillance system collects emergency department data from hospitals within the area. Based on chief complaints, the system identifies possible high priority bioterrorism agents (15). 

Establishing a Diagnosis

Establishing a diagnosis of a potential bioterrorist weapon is essential to a positive and efficient public health response. The diagnosis will guide treatment, medication management, and vaccinations. Diagnosis of a bioterrorist attack can be made through syndromic surveillance or clinical reporting (12).  

Through Syndromic Surveillance

Many symptoms of biological weapons present with nonspecific symptoms in the preliminary stages. Patients with these illnesses seek patient care and are more than likely assigned a nonspecific diagnosis such as “viral syndrome.” The data on patients fitting various syndromic criteria is sent to the health department. This process flags a statistical detection threshold that has been exceeded. At this point, Epidemiologists determine if a preliminary investigation is warranted for further evaluation (25).  

If they deem further investigation necessary, say, for example, a blood culture is taken from several patients. Within several hours a culture yields a presumptive diagnosis of anthrax, therefore, producing a full-scale public health response.  

Through Clinician Reporting

Some patients that have been exposed to a biological agent may have short incubation periods.  

Example: A patient is unknowingly exposed to inhalational anthrax. Respiratory distress occurs in this one person and is hospitalized. The patient is routinely admitted to the hospital and blood cultures are drawn. Within several hours a diagnosis of anthrax Is made. The patient’s physician informs the local health department yielding a full-scale response.  

Health Alert Network

“The Health Alert Network (HAN) is the CDC’s primary method of sharing information regarding urgent public health incidents with public health information officers; federal, state, territorial, tribal, and local public health practitioners; clinicians; and public health laboratories (25).”  

The HAN also collaborates with these groups to develop protocols and relationships that will ensure a solid foundation if the rapid distribution of public health information occurs. The HAN is a national program that provides vital information to state and local levels. The HAN messaging system transmits Health Alerts, advisories, updates, and information services to over one-million recipients (25). 

Health Alert Network Message Types (25)

*The information in this box comes directly from the CDC from information on the Health Alert Network 

Suicide Risk ER Admission

Introduction

This continuing education will help you answer those questions about suicide risk and admission to the ER.

Case Scenario 

Chad, a 27-year-old male, is brought into the emergency department (ER) by paramedics after a suicide attempt. His wife found him unconscious in their apartment after overdosing on medication. He is conscious but visibly distressed and angry as he is wheeled into the ER.

Suicide in the United States 

Having a background knowledge of the risks and statistics of suicide in America is important for ER nurses to have an appreciation of the severity and factors related to suicide.  

Prevalence, Incidence, Demographics, and Statistics 

One suicide is one too many. Suicide is a tragic event and affects the lives of more than the person who took their own life. It impacts family, friends, associates, and others interacting with the individual. Suicide is beyond a cry for help, as the person believes taking their own life is the only solution to their pain and suffering.  

Suicide is the ninth leading cause of death in the United States according to the American Foundation for Suicide Prevention costing $69 billion and the loss of approximately 48,344 lives in 2022 (1). Suicide rates are estimated to be approximately 14.5 per 100,000 individuals (2). From 1999 to 2016, American suicide rates increased by nearly 30%. Risk factors appear to be multifactorial and not always due to a mental health disorder.  

Suicide in the United States has been ranked as one of the highest rates among developed nations and increased by 30% between 2000 and 2020, from 10.4 to 13.5 suicides per 100,000 individuals (3). In the top nine leading causes of death among those ages 10-64, there were almost 46,000 deaths in the United States from suicide in 2020, which is approximately one death every 11 minutes (4).  

The rate of those who think about suicide is higher than those who carry it out. In 2020, 12.2 million Americans admitted to seriously thinking about killing themselves, 3.2 million planned a suicide attempt, and 1.2 million attempted a suicide, not resulting in death (5, 75). During the COVID-19 worldwide pandemic, depression rates increased three-fold, leading to an increase in suicide rates in the U.S., especially for men of color (6). Mental health became a publicly discussed health issue more than ever during the pandemic.  

According to the CDC, firearms account for 50% of suicides in the United States, followed by suffocation (28%), drug poisoning (11%), and non-drug poisoning (3%) (3).  

There has been a steady increase in both completed suicide and suicidal ideation in the past decade, possibly due to the increase in the availability of firearms, but also complicated by the stressful lifestyle of modern society. Interestingly, more suicides occur in rural areas than suburban areas, again possibly due to the availability of firearms (74).  

The American Psychiatric Association Assessment and Management of Risk for Suicide Working Group explains the risk of suicide increases with the following conditions (35): 

• Psychiatric diagnoses: especially mood disorders, psychotic disorders, anxiety disorders, posttraumatic stress disorder, substance use disorders, and disorders associated with impulsivity. 

• Medical conditions: particularly those that are chronic, debilitating, disfiguring, or painful. 

Definition of Terms  

Defining terms related to suicide is important to understand what suicide is, versus suicide attempt and the terms related to self-inflicted death.  

Suicide is defined by the Centers for Disease Control and Prevention and accepted as a standard definition as “death caused by injury to oneself with the intent to die” (3). 

A suicide attempt is the action of self-harm with the intent to cause death without resultant death.  

Suicidal ideation is the continual thinking of self-harm and death but is a broad term describing wishes and preoccupations of death and suicide. Because there is no standard definition for suicidal ideation, it becomes difficult for clinicians, researchers, and educators to identify and even code for it as a diagnosis (7).  

Research indicates those with a mental health disorder are at higher risk for both suicidal ideation and eventual suicide, however, one study collected by the Centers for Disease Control revealed that as high as 50% of those who committed suicide had no known mental health disorder (7). Whether those deceased had a mental illness that was not yet diagnosed or not is unknown.  

A study in the United Kingdom found that as high as 90% of those who successfully committed suicide had disclosed their suicidal ideation to their primary practitioner and 44% within the month of suicide. This points to the standard policy that a suicide threat should always be taken seriously (8).  

The study found that only 22% of those primary care providers believed the threat and suicidal ideation to be a concern as they thought the person would never actually carry out the threat. For all healthcare professionals, this is a huge message and reminder to always take seriously any suicidal ideation of a client.  

Imminent harm: An immediate and impending action that will cause bodily harm to self or others is imminent harm. When a client is assessed to be in imminent harm to themself, such as in an emergency department, an emergency legal code may be initiated to legally restrain the person to keep them safe. Each state may have a different code. The factors to consider include the duration of the risk, the nature of the potential injury, and the timeframe before the potential harm would occur.  

Lethal: An action that is considered lethal, is sufficient to cause death. When discussing suicide, a legal action would cause the end of life of that person.  

Homicide: The deliberate and unlawful killing of another person and is also called murder. Suicide is killing oneself and contrasts with homicide, which is taking the life of another person.  

Classifying Levels of Risk 

Identifying risk factors for suicide is valuable for suicide prevention. Recognizing which factors lead to suicide helps healthcare professionals classify the level of risk to know which level of action is necessary.

Suicide Risk Factors  

Because suicide is multifactorial there are many issues to consider for those that may increase the risk for suicide. There are also protective factors within each category to consider and encourage that may help a person avoid suicidal ideation and behaviors.  

Cultural Factors 

Culture is defined as the customs, beliefs, behaviors, art, communication style, and dietary habits of a particular group based on ethnicity, race, religion, or even social group (10).  

Cultural norms throughout history have had a powerful impact on the individual’s definitions of life, death, wellness, and disease. Historically, in some cultures, self-sacrifice by death could be considered honorable such as the Japanese belief in hari-kari death by disembowelment as a form of seppuku, a ritual suicide.  

Suicide by ethnic groups varies with white European Americans having the highest rates, and American Indians and Native Alaskans the highest of ethnic groups (11).  

Research also reveals that motivations towards suicide vary among different ethnicities. Latinx or Hispanic individuals were more likely to commit suicide for external stressors such as job loss, divorce, abuse, or discrimination, compared to their white counterparts who cite internal feelings of hopelessness and worthlessness (12). Ethnic minorities often demonstrate more feelings of hopelessness due to discrimination and racism, which puts them at risk for suicidal ideation and suicide (13).  

Within culture there is a religious influence among people for their interpretation of the act of suicide. In Christian groups, suicide is considered one of the highest acts against God and is a sin. Other religions may consider suicide as the passing of this one life with a negative consequence for the reincarnation of the next life. Inherent in most cultures however is the sanctity of life and abhorrence of suicide, which in Hindu is termed soul-murder.  

Culturally sanctioned doctor-assisted euthanasia is found in some European cultures and is acceptable only for terminal illnesses (13). Interviews with women after a suicide attempt reveal their feelings of not belonging to either culture as their adolescent experience is vastly different from their parents in the country of origin and they feel neither their parents nor peers understood them.  

This research revealed that depression may not be the only emotion before a suicide attempt but additionally feelings of anger. Whereas the typical white male will commit suicide with firearms, and have access to them, a younger ethnically diverse population may attempt suicide with hanging or over-the-counter medication overdose demonstrating anger turned within.   

Healthcare professionals need to recognize the impact and influence of culture and religion on an individual’s mental health and behaviors, which may either increase or protect against suicidal ideation and behaviors. Application for clinicians is to consider cultural implications along with the generic suicide risk tool that is being used.  

Recognizing that Asian and Latinx Americans are generally motivated by external factors and white European Americans may be more motivated by internal factors can help guide the clinician to inquire about life factors that may impact depression, mental health, anxiety, and suicidal ideation. 

Sometimes the culture itself may create feelings of shame such as the Asian culture of “saving face” versus the shame of letting parents or the general culture down. Some Asian cultures place great emphasis on excelling academically and if a child chooses not to study the topic directed by the parents, or doesn’t have the academic interest or aptitude, the child may experience deep shame and stress (15).  

Protective factors within culture for an individual include feeling a sense of community within their culture. Following cultural norms and expectations appears to be protective as those who commit suicide are described as living without the boundaries of the culture such as being isolated and deviant.  

Protective factors for any culture appear to be a sense of connectedness and purpose in life. Some people who still experience feelings of worthlessness or hopelessness may still find protection from feeling connected to their culture, family, an individual, or divine responsibility to honor the sanctity of life (13). Teaching traditional values and spirituality within the culture is a protective factor for youth (16).  

Geographic Factors

Research shows geographic factors that matter in the incidence and prevalence of suicide.  

Those in rural areas, including Veterans, have a higher incidence of suicide, which may be due to the availability of firearms (17). The only exception to that locality factor is African American males who have an increase in suicide in urban areas.  

Living in rural areas may also promote social isolation, barriers to access to medical care for counseling and mental health treatment, and dangerous work conditions such as in farming communities. In addition to living in isolated areas, such as rural communities, geographic factors include living in negative and dangerous or disturbing neighborhoods in urban areas.  

Protective factors include programs that help recognize people in isolated rural communities. Veteran programs can be helpful to those in rural areas who choose more isolated areas but can still promote a sense of community and belonging.  

Telemedicine has been extremely helpful during the COVID-19 pandemic in delivering mental health and general medical care to people in isolation even in urban areas and can be used more in rural settings. The trend of embracing telemedicine during and after the pandemic has helped improve access to healthcare despite poor or no insurance. Sometimes people who have used telemedicine and screened positive for suicide risk are directed to an emergency department, where ER nurses can continue the screening and crisis management.  

Economic Factors 

External environmental factors such as unemployment and poverty play a role in despair. Areas with people below the poverty line and those who are unemployed do have an increased rate of suicide (18). Eviction and home foreclosure also increase the risk of suicide. Interestingly, a significant worsening of financial status was more significant as a risk towards suicidal ideation than chronic poverty (19).  

Poor economic status also contributes to the lack of resources for mental health counseling and medications. The application for healthcare professionals is to assess the individual’s ability to afford psychiatric medications including simple SSRIs.  

Protective factors could include robust financial resources, but suicide occurs even among wealthy or economically stable individuals.  

Home and Family Factors 

Family dynamics and a sense of belonging are key factors that can be either contributors to suicidal risk or protective factors (20). Even when a person may have a sense of family, they may still have a belief that they don’t want to be a burden, which can outweigh the home and family support, as seen in elderly suicide or those with terminal illnesses.  

Studies reveal that the perception of a hostile home environment, criticism, invalidation, and lack of support for life choices increases suicidal ideation and behaviors of not just youth but adults (21, 22). Because suicide attempts are 20 times greater than completed suicide, interviews from persons who attempted suicide reveal family disharmony, parental divorce or arguments, sibling conflicts, and lack of support as factors that contributed to their sense of urgency to disappear from life.  

Family factors also include a family history of suicide. Physical and genetic predispositions to mental health may be involved, but also important are the pattern of poor stress management and dysfunctional interpersonal dynamics. A history of physical, emotional, or sexual abuse, including incest, is a sign of dysfunctional family dynamics. A recent family loss and difficulty grieving can also be a risk factor.  

Adverse childhood events (ACEs) accelerate mental health disorders and despair and create negative health outcomes in adulthood (23). The key message for healthcare professionals is to consider family dynamics beyond the individual at risk for suicide. Family intervention and group counseling and support may be needed in addition to the individual attention given for more effective risk management.  

Protective factors for home and family include the strength and support a person may feel within a family unit. A sense of validation for their existence by loving family members is powerful. If an individual has mental health disorders or chooses an alternative lifestyle, support and understanding are protective against feelings of isolation and hopelessness.  

Mental and Emotional Health 

Studies reveal that although mental health disorders are found in approximately 50% of those who commit suicide, it is not a consistent factor for all cases of suicide. The more specific mental health issues include intrapersonal thoughts of a persistent sense of hopelessness, worthlessness, shame, guilt, meaninglessness, and a feeling trapped with no way out (24). Those with a sense of loneliness, separation, isolation, and feeling unloved, or rejected have an increased risk of suicidal ideation and behaviors (24).  

In completing suicide screening tools, researchers have noticed that some people will skip the question of previous suicide attempts leading to a false conclusion of lower risk. Significance for clinical personnel is to review the entire instrument for completion before scoring.  

Although depression is a recognized precursor to suicide it is not the only factor and is not always present. (23). Screening for depression in all individuals ideally should be done but screening is not adequate if there are no solutions or resources for the person, which could make the depression worse by creating a sense of hopelessness. 

It is estimated that up to 18 million adults and 7% of the adult population have depression at any time (25). According to the American Society on Aging, up to two-thirds of elder suicides were related to untreated or undiagnosed depression. Not everyone who has depression should be placed in restraints and confinement for protection. Some screening instruments have fallen out of use after not being able to demonstrate valid and reliable identification of risk factors, such as the SAD screening tool (9).  

Protective factors include strong mental and emotional health, but that is difficult for anyone to stay consistent all the time. Life itself is inherently difficult but the concept of resilience is key. Can you bounce back from a bad day within a short period, or do you linger in a state of despair or negative emotions? The ability to be resilient through life’s difficulties is key.  

Mental health status and emotional strength can either increase suicide risk or add protection. 

Depression 

Depression is unfortunately a common emotion and is seen in at least 10% of adults at any time in the United States. Depression is a condition that follows and is interlaced with other health conditions such as the following (36). Depression is the most common mental health disorder as the issues of perceived isolation, hopelessness and lack of purpose are reported for those with suicide attempts and completed suicide.  

Conditions that often correlate with depression: 

• Cancer: 25% of cancer patients experience depression.  

• Stroke: Up to 27% of post-stroke patients (more than 1/4 of all stroke patients) experience depression.  

• Heart attack: 1 in 3 attack survivors experience depression. 

• HIV: Depression is the second most common mental health condition of those with HIV.  

• Parkinson’s Disease: 50% experience depression. 

• Eating Disorders: approximately 33-50% of clients with anorexia have a comorbid mood disorder, such as depression (37).  

• Substance Use Disorder: Over 20% of Americans with a mood disorder, including anxiety or depression have an alcohol or substance use disorder.  

• Diabetes Mellitus: approximately 1/3 of all people with diabetes experience depression (Holt, et al, 2014).  

• Polycystic ovary syndrome (PCOS): 20% of women with PCOS experience depression. (38).  

Each of these conditions creates an additional risk of dissatisfaction with life and self-harm. Recognizing the prevalence of depression in the adult population is a call for healthcare professionals to screen all patients with simple questions for suicidal ideation.  

Physical Factors 

There are interesting theories based on physical factors that may impact the brain’s ability to think clearly and avoid self-harm. One theory proposes that low cortisol levels are seen in people who commit suicide, which may represent a lack of natural fight-or-flight response to stress. Low cortisol levels were found in the family history of suicide or suicide attempt. Lower than normal cortisol levels were also found in those who reported suicidal ideation. (26). 

Another physiologic-based theory shows that microglial cells, found in activation of inflammation and stress are found concentrated in the prefrontal cortex of those who committed suicide. Excess microglial cells affect the concentration of neurotoxic waste products compared to neuroprotective metabolites (27).  

Glutamine is a dietary amino acid related to mood and sense of well-being and inflammation may also cause alterations that may contribute to a lack of cognitive flexibility, increased impulsivity, poor memory, depressed mood, and suicidality (28).  

There is emerging interest in identifying any genetic mutations that may increase the risk of suicidal ideation. Several studies have identified that gene mutations in families of those with increased incidence of depression include variants of the FKBP5 gene (29).  

Risks for suicide are multifactorial and the research continues as suicide for any person and family is devastating.  

Social Factors 

Social isolation, feelings of not being socially accepted, or socially significant such as immigrants or ethnic minorities, are at risk for suicidal ideation and behaviors. The social construct is also related to culture as it involves interpersonal relationships.  

Evidence shows that education, social status, and employment play an important role in suicidal ideation and behavior. Social factors include being male, unemployed, a lone person in a household, and divorced, widowed, or separated are strongly associated with death by suicide (30). 

Protective social factors involve positive interpersonal relationships. Healthcare primary care providers, such as nurse practitioners, can refer individuals at risk for individual and group counseling and resources to develop improved emotional intelligence and interpersonal skills.

At-Risk Populations  

Identifying at-risk populations comes from demographic information about the incidence and prevalence of suicide in the United States. Statistics reveal important information about the increased risk for some individuals, which is worth recognizing. Health departments and national organizations can better create prevention and education programs based on this data.  

For example, knowing that Veterans in rural areas are at increased risk of suicide due to isolation and poor access to mental health resources allows Veteran agencies to better accommodate those needs, which has been helpful. As noted in the above-listed risk factors several population groups have been recognized to be at greater risk. 

Gender 

There is a higher incidence of suicide among males worldwide compared to females.  Studies reveal that although the incidence of suicide is low in white males over age 75, those men who do attempt suicide have higher success rates. It is estimated 40 per 100,000 men over age 75 will commit suicide. Gender makes a difference as to the means of committing suicide. 

When men attempt suicide, it is with more lethal and violent means such as with guns and ropes. Women over age 75 have much lower rates of 4 per 100,000 and are often less successful with suicide efforts and commonly use less lethal methods such as drug overdose attempts. Women are twice as likely to attempt suicide but when men have greater completion rates than women.  

Age 

The risk of suicide affects people differently in different age groups. There are two age groups with an increased incidence of suicide which include young adults from 25-34, and again a surge in reported attempts and completed acts in the elderly from age 75-84.  

Adolescents with any of the above risk factors of depression, mental health disorders, race, dysfunctional family situation and substance use are at greater risk of suicide.  

“During 2019, approximately one in five (18.8%) youths had seriously considered attempting suicide, one in six (15.7%) had made a suicide plan, one in 11 (8.9%) had made an attempt, and one in 40 (2.5%) had made a suicide attempt requiring medical treatment” (31). 

According to the Suicide Prevention Center, suicide was the second leading cause of death for youth ages 10 to 14, and adults ages 25 to 34 in 2020. Suicide was the third leading cause of death for people ages 15 to 24, the fourth leading cause of death for ages 35 to 44, and the seventh leading cause of death for ages 55 to 64 (32). 

Image Source: CDC, 2021 

Race 

Ethnic groups with the highest rates of suicide and suicidal attempts are people of color, non-Hispanic whites, and native American Indians. Race, ethnicity, and culture were discussed earlier.  

Diagnosis of Substance Use Disorder 

Individuals with substance use disorders (SUD) are at a significantly greater risk of suicide for both males and females than those who don’t partake of addictive substances (72). Most research connecting substance use disorders with suicidal ideation and behaviors was conducted with Veterans, but another study examined the general population and found similar results (72). Using multiple substances is extra risky. Alcohol substance use disorder was the most common substance in the historical use of suicide attempts and completed suicide.  

It is acknowledged that SUD and mental health disorders often are seen together. It is understood that the SUD condition is often an effort to deal with difficult mental health issues, family, and social issues and even loneliness and despair. When the combination of SUD and mental health disorders is not treated effectively, individuals often see suicide as a viable way to “make it all go away.”  

The key message for healthcare professionals is to increase screening for substance use disorders. Using the Substance Use Brief Intervention and Referral to Treatment (SBIRT) method of asking simple screening questions should be done at each client interaction.  

Military and Veterans  

According to the National Veteran Suicide Prevention Annual Report, there are approximately 6000 veteran suicides annually, and 22 veteran suicides each day. The rate of suicides among this unique population is 1.5 times greater than the rate of non-military and veterans (33).  

The Veterans Affairs Department (VA) recognizes the incidence of post-traumatic stress disorder (PTSD) among veterans who have served in the military and offers free services and education for prevention. Online website training, smartphone apps, and free counseling are available for veterans, healthcare professionals, and families.  

In examining factors that contribute to the increase in suicide among our veterans several contributors have been identified. Transitioning out of the military and into civilian life is the most delicate time as military personnel often struggle to find their new routine and job, culture, new interpersonal relationships, often physical pain from injury, and new purpose (33 The first year of transition has been called “the deadly gap.”  

Studies confirm that human beings crave a sense of belonging, which many veterans identify with in their military service. Once they leave that association, they often find a culture gap and few people understand what they may have experienced in war and military service. Veteran suicides represent almost 14% of all suicides even though their population as a group only represents 8% of the adult population (34).  

Substance Use Disorder is also a contributor to the veterans’ population which compounds their risk for suicidal ideation and possible suicide (72). Many contributors to this increased risk have been explored such as risk-taking behavior personality that may have drawn them into the military initially, the use of substances to deal with traumatic military experiences, and the skill of firearms. The following diagram depicts these factors for our veterans. 

 (33) 

Our veterans deserve the best medical and psychological care for their service to our country. The role of healthcare professionals, especially primary care providers, is to offer effective screening and education of resources that are available.  A challenge is the limited knowledge many medical professionals have about veterans’ resources, which can be difficult to navigate.  

Diagnosis of Mental Illness and PTSD 

Although it has been assumed all those who commit suicide have a mental health disorder, statistics show only 50% of those who commit suicide had a diagnosed mental health disorder at the time. In contrast, according to the Psychiatric Association Practice Guidelines for Psychiatric Evaluation of Adults, as high as 90% of people who commit suicide meet the diagnostic criteria for one or more mental health illnesses (35).  

Healthcare Providers  

A unique population at risk for suicidal ideation and behaviors are the very professionals the general population relies on for healthcare when they are in a suicidal crisis. The emotional and often physical stress of the healthcare job itself can place workers at risk.  

Healthcare workers face a unique set of obstacles that increase the risk of suicide. Their demanding nature, long hours, high-stress levels, and exposure to trauma all combine to exacerbate vulnerability, increasing suicide risks. Healthcare providers also endure emotional strain when managing patient suffering and ethical dilemmas while striving to provide optimal care within resource-constrained settings.  

As mental illness is still perceived with great stigma in healthcare communities, individuals seeking help for mental health problems might avoid seeking assistance altogether, leading to underreporting and untreated issues of this nature. These factors combine to put healthcare professionals at an increased risk for suicide compared to the general population.  

A study in the Journal of American Medical Association revealed physicians to have significantly higher suicide rates compared to general populations, underscoring the critical need for targeted interventions and support systems in healthcare industries to combat this significant threat (77). 

Suicide among nurses was publicized more during the worldwide COVID-19 pandemic when nurses and healthcare workers functioned with little sleep between shifts, managed without adequate personal protective equipment, and stood by the bedsides of dying patients on ventilators that couldn’t survive the initial onslaught of the mysterious virus and worked despite fears of exposing their own family and loved ones.  

The PTSD they experienced was influenced by feelings of hopelessness when no matter what they did could not stop the fatal power of the virus.  Tragically the caregivers in trauma and critical care units often experience PTSD themselves, which we know is a risk factor to suicidal ideation.  

Nurses are in a unique position to add mental health screening questions to the intake form of their patients. Likewise, taking time for self-care has become not only acceptable but a popular statement of permission to do what we should have been doing all along: healing the healers.  

LGBTQIAS2+ Population 

This unique population has been at increased risk for suicide due to the essential elements found in those with suicidal ideation and behaviors such as hopelessness for acceptance, often lack of family support, and lack of customized health resources.  

Special Populations at Risk 

Youth and Suicide 

Suicide in youth most occurs between the ages 13-21 (69). Suicide by gender also reveals that teen girls from 12-19 are the highest incidence. Thankfully, suicide under the age of 5 is difficult to find in research and statistics. Risk factors include the lack of support and resources, or perceived by the teen, to help them address life’s challenges of critical decisions, high expectations at home, school, athletics, or anything of a competitive nature.  

Mental health disorders are found in 90% of teen suicides. The most common disorder is depression. Other common disorders include anxiety and eating disorders that create distress for the individual. About 33% of suicides were proceeded by a suicide attempt or call for help.  

As high as 50% of teens who committed suicide had a family member with a mental health disorder. It is supposed that the youth was modeling the maladaptive behaviors seen in the home. Divorce, violence in the home, and negative interpersonal relationships outside the home, such as a romantic breakup, have a great impact on young minds and can become fatal when they are not taught problem-solving skills.  

Veterans and Military Personnel 

A unique population at risk are our veterans and military personnel due to the added violence they have been exposed to and access to lethal means. Screening should be done by primary care providers, but that means the provider must be aware of their military history and service. Veterans Affairs has created extra programs after recognizing their unique added risk.  

Suicide and the COVID-19 Pandemic 

Not only did the coronavirus, known as Covid-19, cause the death of millions worldwide, but it created a never-before seen burden on healthcare workers who were exposed to the virus themselves, as they cared for dying patients. The rates of mental health distress, depression and anxiety soared among healthcare workers, which led some to suicide in an often-hopeless environment without adequate personal protective equipment and effective therapies.  

It is estimated that in 2020 Covid-19 affected 213, 237, 126 individuals worldwide pending adequate reporting, and result in 4,452,903 deaths including some healthcare professionals. 

(70). Those numbers continue to change and still increase each month.  

As the burden of new mutations of Covid, including the BA.5 subvariant, take their toll on our vulnerable populations, the nursing shortage has worsened across America. A projected shortfall of 44,500 nurses is estimated by 2030 based on the current workforce and estimated need in hospitals. In the past two years exhausted nurses have left the bedside leaving gaps in direct patient care and facility administrators scrambling for compassionate and competent healthcare workers. Even nurses loyal to the profession have changed their bedside role. 

A silver lining through the Covid-19 pandemic has been the new awareness of mental health challenges and stress among healthcare workers. Because of devasting suicides among “our own” more attention to the emotional resilience and well-being of our workers began. Hospitals and administrators began offering counseling, services, and screening.  

Much is still needed but at least we as professionals have begun to recognize the healing of our professionals. Just as nurses are taught the risk factors and signs for suicide risk in the general population, we are now being taught to recognize those same signs in our colleagues including irritability, depression, truancy on shifts, appearance of disinterest and just going through the motions at work. Healthcare workers are also at greater risk for substance use disorders due to the increased stress of work and accessibility to medications and mind-altering substances.  

Elderly and Suicide 

Worldwide suicide rates show that increasing in age increases the risk of suicide, especially of those with chronic disease, or living alone. In the United States, assisted suicide is not a legal option, yet those who experience loneliness after a spouse dies, or have no family members to rely on are at increased risk for self-harm to end it all.  

Primary care providers can follow up with care screening questions to identify risk factors. The challenge is always having the time in the insurance reimbursement squeeze of time. Offering seniors access to community services to prevent loneliness such as interest groups or those offered through accountable care organizations in your community can be helpful. Case managers have a unique role as well in being able to make routine phone calls to assess for risk and provide resources.  

ER Suicide Screening and Assessment  

Generally, the first medical professional in the hospital the individual will encounter after a suicide attempt is an ER nurse. The ER nurse is in a unique position to approach the person with compassionate and competent care.  

Nurses deliver unconditional care and compassion for patients who are hurting both physically and emotionally. It is often the nurse who serves as the advocate for the patient by providing resources and communication with the family. A careful screening and assessment of all patients for suicide risk is important, especially in the ER as ER nurses encounter a large cross-section of individuals needing immediate help.  

The Interview Process and Asking about Safety 

Nurses, nurse practitioners, and healthcare workers can improve the ability to identify those at risk for suicidal ideation and behaviors with appropriate and effective screening questions. Often when a provider is unsure about a suspicion for the client’s risk of suicide, completing an objective screening tool can help clarify the risk factors and client’s mental state.  

Just by taking this continuing education course, the topic of suicide and recognition of those at increased risk hopefully becomes forefront in your mind. A screening tool beyond a checklist is more valuable and allowing privacy for a client to complete the assessment is also valuable to get genuine responses. This assessment can be completed ideally in an emergency department by the nursing staff.  

Screening Tools 

The Joint Commission's NPSG 15.01.01 now requires healthcare professionals to use a validated tool to assess suicidal risk for all patients with reasons for seeking healthcare is the treatment or evaluation of a behavioral health condition (40).  

When using a suicide risk tool in an emergency department, those patients who were ambivalent about living had a double increased risk of suicide and those with active suicidal ideation who had active thoughts and plans of suicide had a three-fold increase in probability of suicide within 30 days (41, 73).  

Various screening tools and instruments exist and may be used differently in a primary care office setting versus an emergency department.  

The most common screening tools used in office settings are:  

• P4 Screener: a 4-question screening tool that asks the “4 P’s” of past suicide attempts, a plan, probability of suicide, and preventive factors (42).  

• PHQ-2 Patient Health Questionnaire 2: this is a simplified 2-question screening for those at risk for harm to themselves or others. (43).  

• PHQ-9 Patient Health Questionnaire 2: this is the 9-question version of the PHQ-2.  

• Columbia-Suicide Severity Rating Scale (C-SSRS): questionnaire to assess suicidal behavior and reveal suicidal ideation for pediatrics to adults (44).  

The most common suicide risk screening tools used in emergency departments with strong validity and reliability include:  

• Ask Suicide-Screening Questions (ASQ): a 4-question screening tool for pediatric & young adults who present with medical complaints. It is recommended to administer without the parent/guardian being present.  

• Manchester Self-Harm Rule (MSHR): uses 4 questions to identify the ED patient's risk of suicide or repeating self-harm based on their history. 

• Risk of Suicide Questionnaire (RSQ): a 4-question screening tool suitable for 8 years through adult; it takes 90 seconds to complete. 

The Joint Commission has approved these additional screening instruments as valid and reliable:  

• Beck Hopelessness Scale (BHS): a 20-item questionnaire measuring pessimism and hopelessness (7).  

• Beck Scale for Suicide Ideation (BSI): a 21-item self-report instrument for detecting and measuring the current intensity of the patients’ specific attitudes, behaviors, and plans to commit suicide during the past week. The first 5 questions can be used as a screening tool (50).  

• Scale for Suicide Ideation-Worst (SSI-W): a 19-item rating scale that measures the intensity of patients’ specific attitudes, behaviors, and plans to commit suicide at the period when they were the most suicidal. It takes 10 minutes to complete (7).  

• Death/Suicide Implicit Association Test (IAT): developed by Harvard to test implicit thoughts towards death and suicide.  

• Geriatric Suicide Ideation Scale (GSIS): a 30-item questionnaire assessing suicidal ideation on a Likert scale and customized for ages 65+ (45).  

• Nurses Global Assessment of Suicide Risk (NGASR): useful for new nurses in completing a clinical assessment.  

• Scale for Suicidal Ideation (SSI): a classic 19-item questionnaire for clinicians or self-ratings (paper or computer-based).

Recognition of Warning Signs  

Unfortunately, despite decades of research to identify possible risk factors of suicide, there is no one clear profile person or set of behaviors that reliably identify a suicidal personality. The conclusion from numerous studies is that suicidal thoughts and behaviors are due to a complex interaction of psychological, biological, environmental, interpersonal, and cultural factors. (46) 

Unlike physical conditions that be assessed and identified visibly or with diagnostic instruments, the emotional components of suicidal ideation are complex and there is no one single screening instrument that is always reliable. What research does conclude is that by using any screening tool, and with the genuine sincerity of the practitioner, someone at risk may feel safe enough to open up. 

The approachability and authentic compassion of the provider is a key factor in a client honestly expressing suicidal thoughts. Unfortunately, many healthcare providers are working with tight time constraints and limited client interaction, especially in urgent care settings. Practitioners working in a primary care office setting may also not even consider a client is at risk for suicide when the primary chief complaint is something common or mundane.  

In one study, five categories of identifying factors should be assessed to identify those at risk for suicidal ideation or behaviors.  

Effective suicide screening instruments should assess these components (47).  

• Internal psychopathology (e.g., anxiety disorders; mood disorders; hopelessness; emotion dysregulation; sleep disturbances) 

• Demographic factors (e.g., age; education; employment; ethnicity; gender; marital status; religion; socioeconomic status) 

• Prior suicidal thoughts and behaviors (e.g., prior deliberate self-harm, non-suicidal self-injury, suicide attempt, suicide ideation) 

• External psychopathology (e.g., aggressive behaviors; impulsivity; incarceration history; antisocial behaviors; substance abuse) 

• Social factors (e.g., abuse history; family problems; isolation; peer problems; stressful life events) 

Studies have identified common thought patterns of those who begin to entertain suicidal thoughts as when people perceive themselves to be a burden and don’t have a sense of belonging. These negative thought patterns begin to overcome the instinct of fear of death (48). When a person’s negative thought processes dwell on non-existence, it is said they develop the capability to die.  

Repeated exposure to negative events and thoughts perpetuates the feelings of being burdensome and not belonging. If emotional pain is greater than connectedness and purpose the risk of suicide becomes greater.  

The feeling of hopelessness was key, and an important concept for healthcare professionals to assess. Using standardized tools to assess for the lack of purpose, belonging, and hope are the critical concepts to assess and screen for. 

The concern is that there is no one perfect screening tool, and results vary based on the provider’s personal prejudices, time constraints by the provider and the medical team to assess and address risk factors, cultural considerations of the client, cognition of the client, and current management of mental health disorders (49).  

Assessing Lethality  

After recognizing risk factors and warning signs, a nurse should assess the lethality and possibility of fatal actions by the client. Some warning signs may actually be indicative of depression and not a true risk for self-harm, however other behaviors may be indicative of a fatal act.  

Death or survival depends on various risk factors that affect the degree of lethality. When completing a lethality assessment, three parts should be considered including 1) the degree of planning for suicide, 2) the potential of perceived lethality by the person, and 3) the accessibility to the means to carry out the desired action (51).   

A suicide inquiry examines the ideation, plan, behavior, and intent of the client. Assessment tools ideally should be culturally appropriate and continue to be developed yet take time. Although many people have suicidal thoughts, not all will move forward to lethal actions.  

It is important to recognize that suicidal thoughts can also move across a spectrum so the client with same risk factors may be at higher risk pending environmental and mental health triggers. Recognizing which risk factors can be modified is also important for a provider when making interventions and recommendations.  

Identifying protective factors have not been as researched as risk factors but according to the National Center for Injury Prevention and Control, Division of Violence Prevention has identified the following such as effective clinical care, access to healthcare and interventions, support from medical professionals and family members, problem solving skills, and cultural and religious beliefs that discourage suicide (52).  

Levels of Risk 

Completing the screening survey is just one step, however, the practitioner needs to identify the score and level of risk. Just documenting the risk assessment score is not adequate.  A meta-analysis study revealed that despite recognizing of warning signs and clear risk factors on an assessment, 95% of those did not commit suicide however 50% of those who did were in the low-risk categories (53). Perhaps less important than a score is to truly assess the client’s physical behaviors and emotional affect, and then take appropriate actions.  

It is important to distinguish between active and passive suicidal ideation. Active suicidal ideation is when a person has a conscious desire for self-harm and death as a result. The means of inflicting death should not be the key focus, but rather the thought process and person’s expectation that their attempt could be fatal is the primary concern (54).  

An example of an active suicidal ideation assessment item is the Modified Suicidal Ideation Scale (Miller et al, 1991) which asks questions such as:  

• "Over the past day or two, when you have thought about suicide, did you want to kill yourself? How often? A little? Quite often? A lot? Do you want to kill yourself now?"  

Examples of passive suicidal ideation assessment items include:  

Scale for Suicidal Ideation (SSI) with questions to measure "passive suicidal desire.” 

• 0 = Would take measures to save [one's own] life 

• 1 = Would leave life/death to chance 

• 2 = Would avoid steps necessary to save or maintain life 

European Depression Scale (55) that asks: 

• "In the past month, have you ever wished you were dead?" 

Documenting Suicide Risk  

Documenting suicide risk must be done as always after a provider’s visit, as in any documentation of a visit. The name of the risk screening tool and score should be included in the notes, along with interventions for safety and client/family education.

Healthcare Provider Training  

Due to the continual high rates of suicide and suicide attempts, more effective suicide prevention strategies are needed. Ideally, if we knew exactly how to prevent suicide, there would be no more suicides, however the reality is much more complicated. Several ideas have been proposed including better training for practitioners to screen and interview effectively, and to reduce access to firearms (56).  

The Joint Commission has issued recommendations for healthcare professionals and primary care providers to do the following before a client leaves an appointment or the ER:  

1. Review each patient’s personal and family medical history for suicide risk factors. 
2. Screen all patients for suicide ideation using a brief, standardized, evidence-based screening tool. 
3. Review screening questionnaires before the patient leaves the appointment or is discharged. 
4. Act based on the assessment results to inform the level of interventions needed (40). 

Teaching family members and friends to support someone in a suicide crisis requires clear guidance (75).  

Healthcare professionals can begin the public awareness of how to help such as the following actions:  

• Talk openly and honestly. Don’t be afraid to ask questions like: “Do you have a plan for how you would kill yourself?” 

• Remove means such as guns, knives, or stockpiled pills. 

• Calmly ask simple and direct questions, like “Can I help you call your psychiatrist or counselor?” 

• If there are multiple people around, have one person speak at a time. 

• Express support and concern 

• Don’t argue, threaten, or raise your voice. 

• Don’t debate whether suicide is right or wrong. 

• Try to model calmness in your own body. 

• Be patient with the person. 

• Use the phrase “It’s safe for you to share your feelings with me because I care about you.”  

• Let the person know there are healthcare professionals who can help them with their thoughts. 

Recognition of Warning Signs  

According to the National Alliance on Mental Illness, recognizing warning signs and behaviors of someone about to commit suicide include the following:  

• Increased alcohol and drug use 

• Aggressive behavior 

• Withdrawal from friends, family, and community 

• Dramatic mood swings 

• Impulsive or reckless behavior 

• Collecting and saving pills or buying a weapon 

• Giving away possessions 

• Tying up loose ends, like organizing personal papers or paying off debts 

• Saying goodbye to friends and family 

Treatment and Management of Clients at Risk 

Treatment and management of clients at risk for suicide is based on the unique risk factors and needs of the individual client. Several strategies including different therapies have been studied and are available.  

Medical Management of Mental Illness 

According to the National Institute of Mental Health (NIMH) as high as 46% of those who committed suicide had a mental illness (2). Management of clients with mental illness is one important treatment strategy. When clients with mental illness are not treated appropriately with effective pharmacological management or counseling, the risk of suicidal ideation increases.  

The concerning mental health issues include intrapersonal thoughts of a persistent sense of hopelessness, worthlessness, shame, guilt, meaninglessness, and a feeling trapped with no way out (12). A combination of depression, anxiety, or psychological disorders can compound the feelings of hopelessness. Research shows that both pharmacological treatment and cognitive behavior therapy for mood disorders including depression and bipolar disorder, which are among the most common disorders in the world, have better outcomes than either strategy alone (61).  

Currently, antidepressant medications used for mood disorders include monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants. In the past two decades, the more commonly prescribed agents that block the reuptake of serotonin, norepinephrine, or dopamine known as selective serotonin reuptake inhibitors (SSRIs) and serotonin/noradrenaline-reuptake inhibitors (SNRIs) (62).  

Cognitive Behavior Therapy (CBT) has been the most researched therapy for the treatment of mood disorders and shows statistically significant improvements in mood for participants. ER nurses can also help patients obtain access to mental health services in their community. Knowing and sharing which mental health services are available is a way of advocating for patients experiencing depression and stress.  

Management of Substance Abuse 

As substance use disorder is associated with an increase in suicide risk, the ER nurse should screen for substance use. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs (5). The SBIRT model is the practice of having healthcare professionals, from physicians, nurses, nursing assistants, medical assistants and any medical person who interacts with patients, screen for substance use and abuse. If the patient’ screen is positive, the healthcare professional refers them to available programs and community resources. SBIRT is an early and brief intervention of screening questions and takes less than 5 minutes. An additional history, physical exam, and clinical diagnosis of substance abuse disorder take an additional 10-20 minutes. The time for asking screening questions and offering resources is billable to Medicare/Medicaid. The screening and referral to treatment includes a patient encounter, history, physical exam, clinical diagnosis, and plan for care specific to the concern of substance abuse.  

A key aspect of SBIRT is the integration and coordination of screening, early intervention, and treatment components into a system of care. The link between substance uses and suicidal ideation has been documented (5).  

It is estimated that a person with a substance abuse addiction must be asked at least 10 times by a healthcare professional before they even move towards contemplation in the behavior change process. You may be person #2 or #10 but it takes screening without judgment, in the spirit of help and coaching to move a person forward to begin to consider substance use. Many people in a substance abuse pattern want to stop but don’t know how or what their resources are.  

Simple questions to begin with include “Do you smoke?” If yes, then ask about the frequency of daily consumption and years smoked to calculate pack years. The next important question is simply to ask if they have a desire to stop smoking. If the answer is yes, then you can offer programs and resources. If the answer is no, then let them know you are concerned about their health and you are available with resources when they’re ready to stop.  

Each time you have a patient encounter, simply go through the same questions and eventually the person may begin to be in the contemplative stage of change. For alcohol and illicit drug use using the CAGE format is an acronym to help you remember to ask certain questions.  

Many people with a substance use disorder may feel like they are in a CAGE and just need help to get out.  

C: Have you ever felt you needed to Cut down on your drinking? ... 

A: Have people Annoyed you by criticizing your drinking? ... 

G: Have you ever felt Guilty about drinking? ... 

E: Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover? 

Learning how to become comfortable with asking the screening questions takes practice and you can overcome any hesitation you may feel that you are prying into their personal life by practicing simple questions. Asking the screening questions is a strong start and then referring clients to effective resources for cessation and recovery is the next important component of SBIRT.  

You need to learn what resources are available in your community such as free Alcoholics Anonymous meetings and groups, and more. A simple Google search is a good place to start. There are also many free national resources such as the 1-800-quit-now phone lines that will offer resources to individuals seeking help.

Suicidal ER Admission  

ER nurses play a strong role in caring for a patient being admitted after a suicide attempt, one who verbalizes a high threat of suicide, and those who screen at risk for suicide.  

When patients who have attempted suicide arrive at an ER for evaluation and admission, several critical steps must be followed to ensure their safety and provide appropriate care. Initial assessment takes place in the triage area where a nurse assesses and prioritizes care based on the severity of injuries sustained and mental health status.  

Nurses working in triage play an invaluable role in quickly recognizing patients in need of immediate medical assistance, particularly those at risk of further harm or worsening health conditions.  

After receiving reports from paramedics regarding any attempted suicide attempts and methods used in attempts, as well as interventions taken en route to hospital care, the nurse gathers pertinent details to share with the provider.  

This report aids emergency room physicians and clinicians with their evaluation and treatment plan. Following triage and initial assessment, the nurse conducts a full physical exam on the patient to assess physical health issues because of attempted suicide as well as any injuries from the attempt (78).  

This assessment includes vital signs monitoring, wound examination, and neurological testing to detect trauma or intoxication symptoms. Nurses conduct mental health evaluations to detect any psychiatric conditions or risks and assess an attempter's suicide risk.  

Safety must always come first when caring for such individuals. Nurses work closely with hospital security to create an atmosphere conducive to patient safety and staff wellbeing. Security measures implemented may include continuous observation of patients and removal of potentially hazardous objects from the area near them; in addition to maintaining a calm, supportive atmosphere in the emergency department (ER).  

Working closely together between nurses and security staff is vital to effectively address safety concerns and avoid additional injury. Security staff may assist in de-escalating volatile situations and assuring physical safety for both patients and others in the emergency setting.  

Together with nurses and security personnel, nurses and security personnel can manage admission processes for those who have attempted suicide efficiently and compassionately while offering comprehensive emergency care in this setting. 

Labs and Diagnostic Tests 

Healthcare providers assessing suicidal patients in medical settings typically order laboratory and diagnostic examinations to evaluate physical health issues, identify any underlying medical conditions, and assess any self-inflicted injuries sustained during evaluation. These tests may differ based on an individual patient's presentation, medical history, and clinical judgment.  

Some common lab and diagnostic tests that might be done for someone post-suicide attempt or in an acute suicide crisis include (80):  

• Full Blood Count (CBC): This provides detailed information regarding red and white blood cell counts, platelet count, and hemoglobin levels of an individual patient. Abnormalities in these parameters could indicate serious medical conditions like infection, anemia, and other blood disorders.  

• A Comprehensive Metabolic Panel (CMP) measures various organ function markers including electrolyte levels, kidney, and liver enzyme levels such as creatinine urea nitrogen ratios as well as liver enzyme activity including Alanine Amitransferase, Aspartate Amitransferase levels as well as glucose concentration levels.  

• Urinalysis: Urinalysis evaluates both physical and chemical characteristics of urine samples to detect metabolic imbalances or organ dysfunction, including any trace amounts of blood, proteins, glucose, or abnormal cells present. Urinary tract infections, kidney dysfunction, or metabolic disorders may all be detected using simple labs and then a simple ultrasound. 

• Drug Screening: Toxicology screening may also be conducted if substance abuse or overdose is suspected. This process typically includes clinical interviews, standardized assessment tools, and collaboration between mental health providers.

Legal and Ethical Issues with Suicide 

Even with the best intentions to help people at risk for suicide, there are legal and ethical issues to consider. Privacy and the right to choose are still key concepts in our society. ER nurses are the frontrunners in seeing the legal side of protecting patients often against their will. When a patient is brought into the ER after a suicide attempt or threat of suicide, the admitting provider may write an order for a 72-hour emergency hold. This is about the legal statute that a person may be held against their will if they are deemed a threat to themselves or others.  

Ideally ER admission for suicide should include a safe and compassionate environment, however, most emergency departments (EDs) lack the facilities, staff or expertise required to respond appropriately when dealing with mental health emergencies. Furthermore, most EDs tend to be noisy and disorganized environments unsuitable for de-escalating behavioral health crises. Retrofitting emergency departments to handle behavioral health and suicidal patients is expensive for many hospitals.  

Even with adequate funding in place, psychiatric patients frequently experience more stigma and bias when receiving emergency care, including being made to undress without privacy as they may be placed in a hallway for easier monitoring, prolonged boarding times, and minimal therapeutic support during that period (79). ED patients generally don't benefit from much therapeutic assistance during that time. Basic needs like showering, brushing teeth, using the phone, and eating can be extremely challenging for psychiatric patients in ER settings.  

An emergency department mental health evaluation does not aim to initiate or provide even short-term mental healthcare but to assess an individual's risk of self-harm (80). Such assessments only consider admission or discharge requirements without providing recommendations for actual treatments or recommendations to manage conditions that have arisen during evaluations. 

As part of an overall suicide risk screening in an emergency department (ED), brief screening for suicide risk has limited sensitivity in identifying which patients pose the highest risk. However, low-risk patients can still be identified, and those in which psychiatric holds and real-time psychiatric consultation while in the ED may no longer be necessary allowing more expeditious discharge from the ED. 

The role of the ER nurse in admitting a suicidal patient is a careful and delicate one due to the potentially lethal outcomes if a patient is discharged unsafely. Suicidal patients may be admitted into a psychiatric unit where security is provided at a higher level and psychiatric consultations are given. Ideally, the patient will be able to receive further assessments and referrals for appropriate services. Unfortunately, an ER nurse may never know the outcome of their careful attention to the suicidal patient, but knowing the nurse did all possible within their scope can still help. ER nurses can make a difference by becoming more active in public legislation for safe facilities for mental health patients, improvements in hospital policy development and staffing, and effective use of existing screening tools.

Case Study Continues 

Due to careful and compassionate care from an emergency room nurse, Chad, the 27-year-old male who was brought into the ER after a suicide attempt was admitted and provided with appropriate psychological evaluation and referral for counseling services. After arriving at the emergency department following an attempted suicide attempt, he was met with kindness from a dedicated nurse.  

Recognizing how urgent his condition was, she swiftly coordinated his admission process, so he received immediate medical care. With compassion and professionalism, the nurse conducted a detailed assessment, covering both physical and mental aspects of her patient's illness. Once stable, he continued receiving support from the nurse as his condition stabilized over time.  

Recognizing the necessity for psychological evaluation and counseling services, the nurse collaborated closely with the healthcare team to facilitate the transition of the patient to appropriate mental health resources. The nurse advocated on behalf of his patient's needs, making certain he received follow-up care and support to address mental health concerns and reduce future self-harm risk. Through careful intervention and a compassionate approach by this ER nurse, the patient felt heard, understood, and supported during a vulnerable moment in his life.  

With access to comprehensive mental health services as well as ongoing support services available at his disposal, his journey toward recovery was enabled thanks to a compassionate ER nurse who made such a significant difference when needed the most. 

Resources 

* Call the National Suicide Prevention Lifeline1-800-273-TALK (8255). Here is a list of international suicide hotlines. 

* Text TALK to 741741 for 24/7, anonymous, free counseling. 

* Call the SAMHSA Treatment Referral Hotline, 1-800-662-HELP (4357), for free, confidential support for substance abuse treatment. 

* Call the RAINN National Sexual Assault Hotline, 1-800-656-HOPE (4673), for confidential crisis support. 

* Call Trevor Lifeline, 1-866-488-7386, a free and confidential suicide hotline for LGBT youth. 

* 7 Cups and IMAlive are free, anonymous online text chat services with trained listeners, online therapists, and counselors. 

Veterans Crisis Line 1-800-273-8255 or text 838255 or go to veterancrisisline.net 

Conclusion 

Suicide remains one of the leading causes of death in the United States. Risk factors have been identified and solutions proposed. Various prevention strategies include mental health awareness, public awareness for suicide prevention and detection, addressing limited access to lethal weapons, addressing unique concerns for high-risk sub-groups such as offering school-based resources for youth, educating healthcare primary care providers as the gatekeepers, staffing crisis hotlines, and promoting more free counseling services with legislation and tax funds.  

Suicide is a complex issue and there are no single solutions. It will continue to require a multifactorial approach that addresses the cultural, economic, political, social, and religious factors. Every effort as a Nurse Practitioner to truly connect with your patients, provide screening, and offer real resources, is a life that may be saved.

Nevada HIV: Stigma, Discrimination and Bias

Introduction   

One of the toughest challenges faced by people living with HIV is social stigma and discrimination. As we go through this course, please imagine a close family member or friend was recently diagnosed with HIV and you are comforting them with this life-changing news. Education is a powerful tool to reduce this stigma, as myths and inaccurate information continue to exist.

Overview of Human Immunodeficiency Virus (HIV) 

Human immunodeficiency virus (HIV) is the virus that can destroy or impair immune system function and lead to acquired immunodeficiency syndrome (AIDS), which is known as the most advanced stage of HIV infection (14). 

Etiology

This virus is unevenly distributed among races and genders.  

• 39 million people globally were living with HIV (in 2022). 
  • 37.5 million adults  
  • 1.5 million children  
  • 53% of all people living with HIV were female.
• 1.3 million people became newly infected with HIV in 2022. 
• Roughly 630,000 people died from AIDS-related illnesses or complications in 2022. 
• At the end of December 2022, only an average of 76% of all people living with HIV were accessing antiretroviral therapy. 
• 9.2 million people living with HIV did not have access to antiretroviral treatment in 2022. 
• AIDS-related mortality has declined by 55% among women and girls and by 47% among men and boys since 2010. 

HIV prevalence among the adult population is roughly 0.7% (15). However, it is much greater in certain populations. Populations that face the greatest impact include sex workers, homosexual men who are sexually active with men, those who inject illicit drugs, transgender individuals, and those in prison (15). 

Pathophysiology 

The virus attaches to the CD4 molecule and CCR5 (a chemokine co-receptor); the virus' surface fuses with the cellular membrane to enter into a T-helper lymphocyte (7). After integration in the host genome, the HIV provirus forms and then goes through transcription and viral mRNA production. HIV proteins are then produced in the host cell and can release millions of HIV particles that have the potential to infect other cells (7). This leads to the destruction of the cell-mediated immune (CMI) system, primarily by eliminating CD4+ T-helper lymphocytes, which are vital to this system. 

• Acute HIV infection: Describes the period immediately after infection with HIV when an individual has detectable p24 antigen or has HIV RNA without diagnostic HIV antibodies.  
• Recent infection: Describes the 6 months following infection. 
• Early infection: This may refer to acute or recent infection. 

Stages of HIV 

Those who do not receive treatment typically progress through three stages. However, HIV treatment can slow or prevent progression of the disease. Significant advances in HIV treatment have led to such slowed progression that Stage 3 (AIDS) is less common now than in the early years of HIV.  

Stages of HIV (4): 

• Stage 1: Acute HIV Infection 

• • There is a large amount of HIV in the blood, making the virus very contagious. 
  • Flu-like symptoms are common. 
  • It is important for those who have symptoms and/or possible exposure to get tested. 

• Stage 2: Chronic Infection 

• • Also called asymptomatic HIV infection or clinical latency. 
  • HIV is still active and continues to reproduce in the body. 
  • People may not have any symptoms or get sick during this phase but can transmit HIV. 
  • People who take HIV treatment as prescribed may never move into Stage 3 (AIDS). 
  • Without HIV treatment, this stage may last a decade or longer or may progress faster.  

• Stage 3: Acquired Immunodeficiency Syndrome (AIDS) 

• • The most severe stage of HIV infection. 
  • Possible high viral load and high likelihood of transmission. 
  • People with AIDS have badly damaged immune systems. They can get an increasing number of opportunistic infections or other serious illnesses. 
  • Without HIV treatment, those in Stage 3 (AIDS) typically survive about three years.

Introduction   

One of the toughest challenges faced by people living with HIV is social stigma and discrimination. As we go through this course, please imagine a close family member or friend was recently diagnosed with HIV and you are comforting them with this life-changing news. Education is a powerful tool to reduce this stigma, as myths and inaccurate information continue to exist.

Symptoms

Many patients may be asymptomatic following exposure and infection. The average time from exposure to onset of symptoms is 2 to 4 weeks, although in some cases, it can be as long as 10 months.  

A constellation of symptoms, known as an acute retroviral syndrome, may appear acutely. Although none of these symptoms are specific to HIV, their presence of increased severity and duration is an indication of poor prognosis.  

These symptoms are listed below (7): 

• Fatigue 
• Muscle pain 
• Skin rash 
• Headache 
• Sore throat 
• Swollen lymph nodes 
• Joint pain 
• Night sweats 
• Diarrhea 

Complications 

A complication of HIV disease is its progression to acquired immunodeficiency syndrome (AIDS). AIDS occurs when lymphocyte count falls below a certain level (200 cells per microliters) and is characterized by one or more of the following (7): 

• Tuberculosis (TB)  
• Cytomegalovirus 
• Candidiasis 
• Cryptococcal meningitis  
• Cryptosporidiosis 
• Toxoplasmosis  
• Kaposi sarcoma
• Lymphoma
• Neurological complications (AIDS dementia complex)
• Kidney disease 

If not treated, HIV can have profound effects on the brain and brain function. Individuals living with HIV should be screened for neurocognitive impairment in a clinical setting, with support for management and neurorehabilitation. 

HIV is highly transmissible during acute infection; rapid initiation of antiretroviral therapy (ART) reduces transmission and early viral suppression to preserve immune function. Essentially, healthcare workers must recognize the significant clinical benefits of early detection for the individual with HIV.  

Removing barriers (such as stigmas) to seeking testing and treatment = LIFE

Antiretroviral Therapy (ART) 

Antiretroviral Therapy (ART) has transformed the prognosis of HIV from being a condition with declining health that leads to certain death, to a manageable long-term condition, with an expectation of good health and associated quality of life lifespan similar to the non-HIV population.  

Clinical Management of HIV 

When HIV infection is diagnosed, immediate care is crucial. ART dramatically reduces HIV-related morbidity and mortality, and viral suppression prevents HIV transmission. 

The following recommendations support clinical decision-making (6): 

• Clinicians should recommend antiretroviral therapy (ART) to all patients diagnosed with acute HIV infection.  
• Clinicians should inform patients about the increased risk of transmitting HIV during the acute infection phase and for the 6 months following infection in patients who choose not to begin ART.  
• As part of the initial management of patients diagnosed with acute HIV infection, clinicians should: 

• • Consult with a care provider experienced in the treatment of acute HIV infection.  
  • Obtain HIV genotypic resistance testing for the protease, reverse transcriptase, and integrase genes at the time of diagnosis. 

• Patients taking post-exposure prophylaxis (PEP): When acute HIV infection is diagnosed in an individual receiving PEP, ART should be continued pending consultation with an HIV care provider. 
• Patients taking pre-exposure prophylaxis (PrEP): The risk of drug-resistant mutations is higher in patients who acquire HIV while taking PrEP, so clinicians should consult with an experienced HIV care provider and recommend a fully active ART regimen.  

The clinicians should implement treatment to suppress the patient’s plasma HIV RNA to below-detectable levels (6). 

The urgency of ART initiation is even greater in the following individuals: 

1. Pregnancy  
2. Acute HIV infection  
3. 50 years and older 
4. Presence of advanced disease  

For these patients, every effort should be made to initiate ART immediately, ideally on the same  

Studies suggest that nearly 25% of all people living with HIV are not accessing antiretroviral therapy. HIV prejudice, unfair stigmas, discrimination, and bias likely correlate with this finding. 

Counseling 

Communication and interaction immediately following the initial diagnosis of HIV is critical for an ongoing therapeutic relationship. Empathy, compassion, confidentiality, trust, and hope should be paramount. Remember to explain that HIV treatment has dramatically changed the prognosis and future of those living with HIV and emphasize that life can continue very close to the way it did before, while also emphasizing the importance of beginning medication. 

A reactive HIV screening result should prompt a care provider to counsel the patient about the benefits and risks of ART and HIV transmission risk, including the consensus that undetectable equals untransmutable (U=U).  

Patient education and counseling include: 

• Confirming the diagnosis of HIV 
• Managing disclosure (if indicated) 
• Adhering to the ART regimen 
• Communication with the care team to address any potential adverse effects of medications or other concerns 
• Clinic visits 
• Case management for medications required for lifelong therapy 
• In-depth education on ART; including pharmacy selection, insurance requirements and restrictions, copays, and refills. 
• Psychosocial support management 
• Referring to substance use and behavioral health counseling (if indicated) 
• Assessing Health Literacy  

• • National Library of Medicine: 

1. 1. An Introduction to Health Literacy 
   2. Health Literacy Tool Shed 

• • Agency for Healthcare Research and Quality: 

1. 1. Short Assessment of Health Literacy—Spanish and English 
   2. Rapid Estimate of Adult Literacy in Medicine—Short Form 
   3. Short Assessment of Health Literacy for Spanish Adults 

The Devastation of an HIV Diagnosis

Those living with HIV have a completely different story and a very different approach to how they see and think of their HIV status. Several studies have documented and analyzed the psychological impact of an HIV diagnosis. It is meaningful to take a moment and focus on perspectives upon receiving a diagnosis of HIV from actual individuals who have dealt with this experience. 

Bella shares, “When I got diagnosed with HIV in March 2008, I was totally devastated and felt that my whole world had been blown apart.” 

Jack explains, “Close friends, family, anybody, even new people that I’d meet, I just felt that I couldn’t, I suppose I felt quite, quite worthless because I didn’t have the, [sighs] I felt like I’d lost something, I just found everything so tiring, I didn’t have anything to give, I didn’t feel that I had anything worthwhile to kind of contribute, I don’t know, I was just kind of like shell shocked I suppose.” 

“A found poem” has been constructed from the interview transcript of Noelly: 

"What Really Stands Out” poem by Noelly (5)

Themes emerged from the studies. A key theme developed in the analysis of the experience of receiving a diagnosis of HIV was ‘unwelcome and problematic changes in identity.’ Essentially, a separation of their lives into who they were, then following the diagnosis, who they are now (5). These individuals living with HIV often feel they have lost their previous identity and are now defined by this disease. 

To compound this devastation, these individuals are further isolated by unfair treatment, discriminatory practices, and bias. Stigmas and discrimination impact patients in their quality of life with HIV through social isolation, stress, emotional coping, and denial of social and economic resources.  

HIV-related stigmas are often associated with psychological distress, including depression, anxiety, and suicidal ideation. Furthermore, stigmas in healthcare settings are considered one of the major barriers to optimal treatment for those with HIV or AIDS. Numerous studies suggest that experiences of HIV-related stigmas resulted in lower access to HIV treatment, low utilization of HIV care services, poorer antiretroviral therapy (ART) adherence, and thus poorer treatment outcomes (12).  

The majority of HIV-related stigma research and theory is based on Goffman’s (1963) work. According to Goffman, stigma can be defined as “an attribute that links a person to an undesirable stereotype, leading other people to reduce the bearer from a whole and usual person to a tainted, discounted one” (12).  

Imagine this label of “tainted” or “discounted” was applied to your loved one or yourself. Reflect on the emotions you may experience. Would it be anger, hopelessness, or confusion? Isolation and psychological distress will most likely follow this experience of discrimination. 

A helpful model for breaking down the impact of HIV stigma includes the four dimensions: 

• Personalized stigma 
• Concerns about sharing status 
• Negative self-image 
• Concern with public attitudes about people with HIV 

Stigmas are said to challenge one’s humanity. Stigmas are significantly studied within social psychology. Research has aimed to understand the mechanism by which categories are constructed and linked to stereotyped beliefs, and which stigmas generate and perpetuate health inequities.  

A major goal is to dismantle the stigma that continues to be significantly troublesome for people living with HIV today, encouraging proper healthcare access and treatment. 

Defining Stigma, Discrimination, and Bias

A stigma is an attitude or belief that places a mark of disgrace associated with a particular circumstance, quality, or person (9). HIV stigmas are negative attitudes and beliefs about people who have acquired HIV. The stigma is a prejudice that comes with labeling an individual as part of a group that is believed to be socially unacceptable. 

Here are a few examples: 

• Believing that only certain groups of people can get HIV. 
• Making moral judgments about people who take steps to prevent HIV transmission. 
• Feeling that people deserve to get HIV because of their choices. 
• Believing that those living with HIV have a morality issue. 

Stigmas occur at multiple levels, including interpersonal, institutional (health organizations, schools, committees, and workplaces), community, and legislative levels.  

There are different ways in which HIV-related stigmas can manifest. Stigmas have cognitive, affective, and behavioral manifestations. The stigma is associated with a deviation from a constructed ideal or expectation and can often result in the unfair and unjust treatment of an individual based on their HIV status.  

The unjust treatment that manifests from a stigma is known as discrimination. Discrimination takes many forms, including isolation, ridicule, and physical and verbal abuse. 

Bias occurs when prejudices influence outcomes and decisions (9). This can manifest as denial of services and employment based on HIV status rather than equality or merit. 

The mechanism for these processes is based on societal patterns and dominant cultural beliefs in which the undesirable difference is identified and located in an individual or group; these differences amongst people are articulated and labeled as either good or bad. Labeled individuals experience status loss and discrimination that leads to unequal outcomes (e.g. health, economic, social).  

Myths about HIV

The spread of myths and false information about HIV must stop for the stigma surrounding HIV to dissipate. The myths have continued to spread regardless of the evidence and research that disproves them. Those in the healthcare field can have a meaningful impact on providing education to all individuals and refute misconceptions. 

Myth #1: HIV is a “death sentence”. 

Truth: With proper treatment, individuals living with HIV can live a normal life span (11). “Since 1996, with the advent of highly active, antiretroviral therapy, a person with HIV with good access to antiretroviral therapy (ART) can expect to live a normal life span, so long as they take their prescribed medications,” says Dr. Amesh A. Adalja, a board-certified infectious disease physician and senior scholar at the Johns Hopkins Center for Health Security (10). 

Myth #2: HIV can be easily spread by casual contact. 

A recent survey found the following inaccurate responses and beliefs about the transmission of HIV: 

• It can be transmitted by kissing  
• It can be transmitted by spit/saliva  
• It is spread only among homosexuals 
• It is spread by mosquitoes 
• It can be transmitted by toilet seats 
• It can be transmitted through urine 
• It can be transmitted by sharing utensils, cups, and plates.  

Truth: HIV is only transmitted by coming into direct contact with certain body fluids from a person with HIV who has a detectable viral load.  

These fluids include: 

• Blood
• Semen (cum) and pre-seminal fluid (pre-cum) 
• Rectal fluids 
• Vaginal fluids 
• Breast milk 

For transmission to occur, the HIV in those fluids must enter the bloodstream of an HIV-negative person through the following: 

• A mucous membrane (rectum, vagina, mouth, or tip of the penis) 
• Open cuts or sores 
• Direct injection (from a needle or syringe) 

Myth #3: If someone has sex with an individual with HIV, the virus will automatically be transmitted. 

Truth: Individuals living with HIV who take HIV medication as prescribed and maintain an undetectable viral load will not transmit HIV to their HIV-negative partners. 

Myth #4: Those living with HIV cannot safely have children. 

Truth: HIV can be transmitted from a mother to her baby during pregnancy, birth, or breastfeeding. This is called perinatal transmission. This is the most common way that children get HIV. However, if a woman with HIV takes the medications as prescribed throughout pregnancy and childbirth and gives HIV medication to her baby for 4 to 6 weeks after birth, the risk of transmission can be less than 1% (4).  

Testing all pregnant women for HIV and starting HIV treatment immediately has significantly lowered this occurrence.

Forms of Discrimination in Healthcare 

Discrimination includes many different actions, attitudes, and behaviors. It is not simply a negative interaction but can come in the form of HIV testing without consent, refusal of care and treatment, and breach of confidentiality. It also comes in the form of irrational self-protection measures that communicate a fear of this person. 

Universal Precautions for Care 

Imagine how you would feel if every encounter with you, someone applied an unreasonable amount of Personal Protective Equipment (PPE) to come near you. Would this make you feel as if they viewed you as “contagious” or “contaminated”? This act is not only unnecessary but also disrespectful and demeaning.

The evidence-based approach recommended is referred to as "universal precautions." Universal precautions are a standard set of guidelines to prevent the transmission of bloodborne pathogens. Blood and body fluid precautions should be consistently used for ALL patients, including those with HIV. Unless a condition or situation requires additional PPE, universal precautions should be followed in the same manner as it would with any patient (3). 

Guidelines for Universal Precautions (3): 

1. All healthcare workers should routinely use appropriate barrier precautions to prevent skin and mucous membrane exposure when in contact with the blood or other body fluids of any patient.  
2. Gloves should be worn for touching blood and body fluids, mucous membranes, or non-intact skin of all patients, for handling items or surfaces soiled with blood or body fluids, and for performing venipuncture and other vascular access procedures.  
3. Gloves should be changed after contact with each patient.  
4. Masks and protective eyewear or face shields should be worn during procedures that are likely to generate blood droplets or other body fluids. 
5. Gowns or aprons should be worn during procedures that are likely to generate splashes of blood or other body fluids. 
6. Hands should be washed immediately after gloves are removed. 
7. Take precautions to prevent injuries caused by needles, scalpels, and other sharp instruments or devices during procedures 
8. Healthcare workers who have exudative lesions or weeping dermatitis should refrain from all direct patient care and from handling patient care equipment until the condition resolves. 
9. Isolation precautions should be used as necessary if associated conditions, such as infectious diarrhea or tuberculosis, are diagnosed or suspected. 

Breach of Confidentiality 

Patients with HIV may mistrust medical providers’ handling of their medical information which is a reason for them not to utilize health services and treatment. Essentially, the fear of compromised confidentiality can lead to becoming reluctant to seek HIV testing and counseling. This impacts the health outcomes of those living with HIV and impacts the community as a whole.  

All members of the healthcare team must protect confidential information. Examples of breach of this duty include the following: 

• Accessing confidential information, in any form, without a "need to know" to perform assigned duties.  
• Leaving confidential information unattended in a non-secure area. 
• Disclosing confidential information without proper authorization. 
• Discussing confidential information in the presence of individuals who do not have the need to know to perform assigned duties. 
• HIV status should never be relayed to anyone who is not directly involved in their care. An example would be if the nurse told another nurse that their patient had HIV, but this nurse was not involved in their care. 
• Improper disposal of confidential information. 
• Disclosing that a patient or employee is receiving care (except for authorized directory purposes).

Federal and Nevada State Laws Regarding HIV Discrimination 

HIV criminalization is a term used to describe laws that criminalize otherwise legal conduct or increase the penalties for illegal conduct based on a person’s HIV-positive status.  

HIV criminalization for potential exposure is largely a matter of state law. Federal legislation addresses criminalization in discrete areas, such as blood donation and prostitution. These laws vary as to what behaviors are criminalized or what behaviors result in additional penalties. Several states criminalize one or more behaviors that pose a low or negligible risk for HIV transmission. 

In 2021, Nevada reformed their HIV criminal laws to reflect evidence rather than irrational fear. 

SB 275 repeals NRS 201.205, which is an HIV-specific criminal offense with a penalty of up to ten years in prison and replaces it with a misdemeanor offense. The misdemeanor offense has the following restrictions: 

• Requires intent to transmit, conduct likely to transmit, and actual transmission. 
• This applies to the intentional transmission of any communicable disease 
• If someone uses means to prevent transmission or if the individual subject to transmission knows the defendant has a communicable disease, knows conduct could result in transmission and consents. 

Other changes to Nevada’s law include: 

• Repeal of the category-B felony for engaging in or soliciting prostitution after a positive HIV test. 
• Repeal of mandatory HIV testing provisions for individuals arrested for prostitution, arrested for a sexual offense, or coming into the custody of the Department of Corrections. 
• Amendments to provisions regarding testing for communicable diseases following incidents in which first responders come in contact with bodily fluids. 
• Repeal of a provision permitting confinement of persons living with AIDS 
• Removal of many stigmatizing references to HIV and AIDS in the public health code. 
• Amendments regarding the duties of individuals living with communicable diseases and public health officials’ authority to order testing, treatment, isolation, or quarantine.

Ethical Principles in Healthcare: Autonomy, Beneficence, Non-Maleficence, Justice 

Did you know that the nursing profession is the leading trusted profession for honesty and ethics, and has sustained the title for 20 consecutive years (16)? This speaks volumes and should speak to our humanity in the fight to end HIV stigmatization. 

Ethical principles should guide nurses to uphold the trust placed upon their shoulders. The topic of nursing ethics is broad, complex, and evolving. The American Nurses Association (ANA) developed a code that serves as a foundation for ethical nursing practice. The code consists of seven ethical obligations and nine provisions that outline the ethical responsibilities of nurses.  

7 Ethical Obligations 

The 7 ethical obligations within the AMA’s Code of Ethics for Nurses: 

1. Accountability 
2. Justice 
3. Nonmaleficence 
4. Autonomy 
5. Beneficence 
6. Fidelity 
7. Veracity 

Accountability is considered a priority among the ethical principles in nursing. Accountability is when a nurse is responsible for their own choices and actions in the course of patient care. Each nurse is responsible for any inherent bias and cannot place blame on society or cultural norms. 

Justice refers to fair and impartial care, as treating each patient fairly, regardless of their circumstances, is essential to better patient outcomes.  

The following factors should never result in partiality or lower standards of care: 

• HIV Status 
• Age 
• Race 
• Sexual orientation 
• Ethnicity 
• Religion 
• Socioeconomic status 

9 Ethical Provisions 

These provisions can individually apply to the treatment of those living with HIV:  

Reducing Stigmas and Discrimination 

At this point in the course, we invite you to reflect on your own experiences and recognize any bias toward those with HIV. We will apply a technique from cognitive behavioral therapy, identify a thought or concept, challenge its truthfulness, and then dismantle false conceptions. 

Education and Training 

Healthcare employees, HIV prevention researchers, and service providers should receive formal education in their academic programs and their workplaces to learn how implicit bias influences the practice of medicine and impacts outcomes. Training should effectively develop skills to reduce negative behaviors and mitigate negative outcomes associated with these biases. Institutions and organizations should also develop and implement initiatives to identify disparities and inequities in their services and practices. 

The Power of Language 

Language has been a central theme in efforts to dismantle the stigma around HIV (8). When healthcare providers write or speak about HIV, the words they choose have the power to passively maintain ignorance and bias. However, they also have the power to convey respectful and accurate representations and perspectives on those living with this condition. 

You may be inadvertently using stigmatizing language, so it is imperative to recognize this harmful language, stop using it, and join in the effort to reduce its use by others. 

Let's Talk about it! 

Speaking about HIV should not be taboo. The more a topic is discussed, the more it becomes normalized. Talking openly about HIV provides opportunities to correct misconceptions and help others learn more about HIV. Remember to be mindful of how you talk about HIV and people living with HIV. Discussions can be in-person or online; locations can include family, friends, support group members, workplace interactions, social media, and blogs. Get comfortable with saying things like “I was HIV tested and it was a very simple process”. 

Educating children and young people to understand how stigmas are formed and operate can help dismantle the continuation of stigmas surrounding HIV.  

The Power of Community 

Studies show that individuals with strong social support are less likely to feel stigmatized than those who are isolated. If you notice someone is uncomfortable seeking comfort from friends and family, encourage them to contact their local public health department to find HIV support groups within the community.  

The HIV Prevention Trials Network developed the LOC Community Engagement Program (CEP) which supports community advisory structures such as Community Working Groups (CWGs) and site Community Advisory Boards (CABs) to represent the participant community. These groups can raise research-related issues or concerns that may impact the participants, community, or study.  

Using a cognitive behavioral therapy approach to understand relationships between thoughts, feelings, physical responses, and coping behaviors can be helpful. 

Promoting individual-level coping skills and group-based social support focused on the following: 

1. Decreasing negative feelings toward self and others living with HIV 
2. Increasing planned and strategic HIV sharing with others and building supportive 
3. Networks to reduce fears and feelings of rejection 
4. Building skills to address HIV-related discrimination and other forms of stigma. 

Advocacy and Policy 

Reducing the stigma associated with HIV is critical for improving public health outcomes, encouraging individuals to seek testing and treatment, and supporting those living with HIV. An interprofessional approach can lead to meaningful change.  

Early access to treatment and adherence to the treatment regimen reduces susceptibility to opportunistic infection associated with AIDS and increases life expectancy. To maintain this, clinical treatment guidelines that outline compassionate and unbiased delivery modes of health, treatment, and psychosocial support are required. Healthcare workers play a vital role in this process.  

Here are some effective strategies that healthcare workers can use to reduce HIV stigmas: 

1. Education to Counter Myths and Misconceptions 
   1. Provide accurate information to patients, communities, and even colleagues about HIV transmission, prevention, and the reality that an HIV diagnosis is a manageable health condition. 
   2. Debunk Myths: Actively challenge myths and misconceptions about how HIV is transmitted. Clarify that it cannot be spread by casual contact such as shaking hands, sharing dishes, or hugging.
2. Empathy and Nonjudgmental Care 
   1. Show Genuine Empathy: Use supportive and empathetic communication, which is essential for making patients feel valued and understood. 
   2. Avoid Judgment: Practice nonjudgmental care and treat all patients with the same level of compassion and professionalism, regardless of their HIV status. 
3. Confidentiality and Privacy 
   1. Ensure Confidentiality: Strictly adhering to confidentiality laws and regulations regarding privacy will build trust and encourage patients to seek and continue treatment. 
   2. Respect Privacy: Discuss sensitive information privately and discreetly to prevent inadvertent disclosure. 
4. Encourage Inclusive Language 
   1. Use Appropriate Language: Employ language that is respectful and free from stigmas.  
   2. Correct Stigmatizing Language: Gently correct peers and patients when they use stigmatizing language, explaining why it is considered harmful. 
5. Visibility and Public Advocacy 
   1. Promote Positive Representation: Support and promote stories and data that highlight the normal and productive lives that people with HIV lead. 
   2. Engage in Advocacy: Participate in public speaking, media interviews, or social media campaigns to advocate for people living with HIV and to educate the public. 
6. Professional Development and Training 
   1. Engage in regular training on the latest HIV research, treatments, and approaches to care that emphasize dignity and respect. 
   2. Cultural Competence: Train in cultural competency to better understand and address the diverse backgrounds and experiences of patients with HIV. 
7. Support Networks and Resources 
   1. Provide Resources: Offer information about local support groups and other resources that may help individuals with HIV feel supported and less isolated. 
   2. Encourage Social Support: Promote engagement with community networks which can provide practical and emotional support. 
   3. Integrate HIV care with other health services to normalize treatment and reduce the isolation of HIV-specific services. 
   4. Peer Involvement: Include peer counselors who are living with HIV in the care team to provide relatable experiences and hope. 

By adopting these strategies, healthcare workers can significantly reduce the stigma surrounding HIV and improve both the mental and physical health outcomes for people living with HIV. This not only helps in managing the disease but also integrates support for individuals into everyday life, promoting a more inclusive and compassionate healthcare environment.

Conclusion

As we conclude our exploration of discrimination in the context of HIV/AIDS, we reflect on the profound lessons learned and the pressing challenges that remain. Throughout this course, we have examined the multifaceted nature of stigmas and discrimination—its roots, its manifestations, and the devastating impact on individuals and communities. Discrimination against people living with HIV/AIDS is not only a violation of human rights but also a significant barrier to effective HIV prevention, treatment, and care.  

Through education, advocacy, and policy change, we can challenge misconceptions, change negative behaviors, and foster an environment where all individuals, regardless of their HIV status, are treated with dignity and respect. Let us take forward the call to action to advocate for inclusive policies, promote HIV awareness, and support the ongoing fight against the stigma.

End of Life Process

Introduction   

Have you ever cared for someone who was dying, known someone who was in hospice, or just wondered what happens as we die? What exactly does “end of life” refer to? End of life is a broad term, and its meaning can vary from person to person. End of life is a time when death is approaching, usually in a matter of days.

This occurs in various patients experiencing a variety of ailments including end stage cancer, dementia, chronic diseases, and someone who may have organ failure after an accident (3). 

Oftentimes, caregivers have little to no experience in caring for a patient experiencing the end-of-life process and can easily find themselves feeling overwhelmed, confused, and burned out. Understanding what to expect during the final weeks and days of life is imperative to cope with the changes as they occur.

These changes can vary from person to person. Although patients progress through the end-of-life process differently, there is usually a recognizable pattern of decline that occurs. To provide the best possible care and prepare both the dying patient and their family members, it is important for the nurse and caregiver to be able to distinguish the phases of the end-of-life process: transitioning, actively dying, and final moments. 

Transitioning

The transitioning phase, otherwise identified as the pre-active phase, usually signals that a person is approaching the last two-to-three weeks of their life. During this time, caregivers might start to notice obvious changes, an increase in sleeping, for example. A transitioning person can sleep upwards of twenty hours per day. This significant increase is part of an overarching decrease in the patient engaging with the world and day-to-day life.  

Beyond sleeping, examples of this disengagement include interacting less with friends and family, less desire to do one’s usual activities, and a lack of interest in things that were once pleasurable. Additional signs of a patient transitioning include increased weakness and decreased mobility.  

These changes typically include a decline in function, becoming non-ambulatory, chairbound, and ultimately, bedbound. Patients may begin to fall during this time. Progressively, the patient will become more dependent on their caregivers to assist them with activities of daily living (ADL), which include bathing, eating, transferring, toileting, and continence. They will likely become bedbound. 

Another indicator that someone may be transitioning is a change in nutrition and intake. Eating and drinking less is an expected part of decline during this time. Many patients will report a lack of appetite, taste changes, and an overall lack of interest in food and liquids. Changes in swallowing may further complicate a person’s ability to eat and drink. 

It is not uncommon to downgrade a person’s diet during the transition phase. This might include going from a regular diet, down to soft, and finally, to pureed. Liquids are usually given in small amounts and with an added thickener. These changes are necessary to prevent choking and aspiration. Fluid overload is a risk at this point and can detract from one’s comfort, cause swelling, or crackles in the lungs. 

“Approximately 43% of all palliative patients are affected by terminal agitation, which can manifest as restlessness, sweating and patients’ statements as verbal or facial expressions and defensive reactions” (5).  

Increased agitation, anxiety, and restlessness may also arise during the transitioning phase. Terminal agitation and terminal restlessness are both unique to the last week or so of someone’s life and are often caused by physiological changes that occur during the end-of-life process but can also be a result of medication or emotional changes. Even if the patient had been calm previously, it is important to note that these symptoms may still occur.  

Signs of terminal agitation include an inability to remain still, picking at items in the surrounding environment, and increased confusion. Fortunately, there are medications that can be given at the end of life to promote comfort and stop these symptoms when they arise. Lastly, it is not uncommon for the transitioning patient to have visions of and talk to deceased friends and family – both are normal and could sometimes be interpreted as a welcoming sign from loved ones. 

Active Dying

Following the transition phase, most patients will then enter the final phase of the end-of-life process, the active dying period. This precedes imminent death. It can be hard to determine precisely when this stage begins. This phase usually lasts only two to three days and showcases significant signs of patient decline that differ from the previous phase, including a decrease in alertness and responsiveness.

For example, a patient may go from a semi-comatose state to comatose or obtunded and minimal reaction should be expected (1). Their eyes may be open or shut, and there is little movement in all extremities. This period can be described as a deep sleep. 

Caregivers often describe it as a time of waiting. Cognitive changes, in combination with the previous changes in swallowing, make the intake of food, liquids, and medications unsafe. The patient is at high risk for aspiration. Mouth swabs can be used to hydrate the oral cavity and to do mouth care.

Medications that are liquid or can dissolve under the tongue are safe and can be used to manage symptoms at the end of life. Hospice patients are provided a comfort kit of medications to use should symptoms arise.  

Additionally, changes in vitals are expected during this phase, and they typically do not cause the patient any discomfort. For example, temperature fluctuation is common at the end of life. It is not abnormal to have an elevated temperature during the active dying phase. This can be remedied with cooling measures such as a cool towel on the forehead or a fan to cool down the room. The skin may feel clammy as well.  

Following, changes in blood pressure and heart rate may also occur. Blood pressure begins to trend lower during the pre-active phase and can become very low during the last few days of life. The heart rate will usually trend upward and can be well over 100 beats per minute, however, this is just something for the hospice nurse to note and is not usually treated.  

Symptom management at the end of life can be difficult. Failure to adequately control symptoms can have a negative impact on one’s quality of life. These symptoms may include pain, respiratory distress, GI issues, and mobility changes (2).  Pain while dying is one of the most common areas of concern for someone who is actively dying, and of course, no one wants to see their loved one in pain during their final days of life. The body becomes very sensitive to the slightest movement or touch, which can present challenges for caregivers when considering that the patient still needs to be cleaned, changed, and repositioned.  

When the patient is no longer verbalizing their comfort, verbal pain cues must be assessed. These include grimacing, a furrowed brow, frowning, and possibly moaning. In some cases, repositioning can be an effective pain-relieving measure. Thankfully, pain can be treated up until death occurs.

Opioids are commonly used in end-of-life care, due to their ability to effectively manage pain without hastening death. Morphine is an example of a commonly used opioid (4). Nonpharmacological measures can also be used to relieve pain. This may include things like repositioning and soothing music. 

Decreased urination is also common during the active dying phase. This is completely normal and expected. Caregivers may find that they do not need to change diapers as often. Urine may also appear darker in color, appearing a deep amber color due to more concentrated urine. 

Excessive secretions can lead to something commonly known as the “death rattle.” This term is almost synonymous with the last days of life. It can be described as a moist sound that is audible when someone breathes and is a good indicator that death is near. The secretions collect in the throat due to a lack of coughing and the inability to clear them out (8).

Turning the patient on his or her side may help the secretions drain, and there are medications that can be administered to help dry them out. It is important to note that not everyone will experience this, and by the time it occurs, there is a disconnect within the patient, and he or she is not likely to experience any discomfort. 

Maintaining skin integrity and preventing pressure injuries is also an important consideration during this time. With all the other previously mentioned changes occurring, it can be hard to provide the attention that the skin requires. Like other organs, the skin begins to fail in an actively dying patient (9).

This does not necessarily mean that pressure injuries and skin breakdown are inevitable. It is important to consider goals of care during this time. An aggressive approach to preventing skin breakdown might not be what the patient wants or necessarily needs. Measures for pressure injury prevention might include repositioning, use of pillows for elevation, hygiene, and moisture management. 

Final Moments

It can be hard to imagine the final moments of someone’s life. This is especially true for caregivers and families who have witnessed steady decline throughout both stages of dying. There are likely to be signs that death is possible at any moment. A patient can be expected to be comatose with little to no response when death is imminent. The obtunded patient appears to be in a deep sleep. They are no longer verbally or physically responsive to voice or tactile stimulation.  

In addition to changes in vitals described previously, changes in respiration usually occur. This is typically the most obvious change. Patterns can vary from shallow and fast to deep and slow. Periods of apnea are also normal. Cheyne-stokes breathing may also be present (3). 

 Skin changes are also expected; pallor, cyanosis, and mottling are signs that death is near. The body may begin to feel cool, especially in the hands and feet. Comfort medications can still safely be used up until death occurs. As mentioned before, foods and liquids should not be given at this point. Caregivers should continue to talk to the patient, as their hearing will remain until the end. 

Hospice 

Most people wish to die peacefully at home. Unfortunately, for many, this is not the case. Over 30% of people die in a hospital setting (6). Hospice is a form of palliative care and involves caring for the terminally ill as they begin the end-of-life process. A terminally ill patient has a life expectancy of 6 months or less. This is a comfort focused approach to care. The natural process of dying is accepted and allowed to proceed.  

No life prolonging treatments or procedures are elected.  Choosing a hospice allows both patients and their caregivers to achieve their end-of-life care goals. Hospice care includes an interdisciplinary team composed of nurses, physicians, aides, chaplains, and social workers. It includes symptom management, and emotional and spiritual support. There is also a bereavement team that is available after death. Medicare part A covers hospice services nearly completely. 

Hospice care can be a short or long journey, with many ups and downs. For some, the prognosis might be obvious, but for others, it might be filled with many questions and much uncertainty. The benefits of hospice care are proven and can lead to a peaceful death. “The main care focus for patients is symptom management, which improves the quality of the remainder of their life.  

Palliative care involves not only the patient but also their family members. Other measures are also taken so that the patients can live life comfortably and maintain dignity” (7).  Both caregivers and patients seek to understand what end of life care entails and how to maintain comfort at end of life. Hospice clinicians should spend time providing education on this process to all of those involved. 

Spiritual Considerations at End of Life 

Taking care of the dying should be looked at from a holistic point of view. Addressing the physical needs of someone who is dying while ignoring any spiritual needs would be doing a disservice. Spirituality is considered the meaning of life. It may include religion, beliefs, or family traditions. It can mean different things to different people.  

During end-of-life care, it has been shown to be disrupted in patients. Spiritual needs tend to be greater at the end of life.  It is also frequently overlooked by healthcare professionals (10). Palliative care workers can help address spiritual needs in their patients by showing compassion, humility, and openness.  

Dying patients may be conflicted spiritually due to things like guilt and unresolved issues. When spirituality is addressed appropriately, patients can more positively cope with illness. Caregivers of the dying should be aware of the relationship between a terminal prognosis and unmet spiritual needs.  

Conclusion

Hopefully, this has been an informative piece and a guide on what to expect during end-of-life care. No two people experience death and dying in the same manner, and it can be challenging both physically and emotionally during the end of life. Proper symptom management during this time is crucial in ensuring that one dies comfortably. One should also consider any unmet spiritual needs and how, if unaddressed, could lead to poor patient outcomes.  

Palliative care at the end of life can be a great help for caregivers.   Hospice can be a great resource in managing symptoms and providing support up until death and beyond.  Most people do not have experience in caring for a dying person and need education and assistance throughout the journey. Not everyone who is dying will experience all the symptoms mentioned in this course, and it is important to note that everyone experiences the end-of-life process in their own way and at their own pace. 

Tirzepatide for Type 2 Diabetes and Weight Management

Introduction   

The emergence of the drug tirzepatide is becoming more popular and widespread and is being utilized among those with diabetes and also those who desire to lose weight. It is one of the newest diabetic drugs given by injection that also triggers dramatic weight loss in those who use the injections.

The U.S. Food and Drug Administration (FDA) approved tirzepatide in 2022 for individuals with diabetes, particularly Type 2 Diabetes. The FDA officials have not approved tirzepatide yet for weight loss, but they are currently tracking the medication and may have a recommendation for its approval by the end of this year. Clinical trials have shown that individuals with an elevated body mass index (BMI) and who did not have diabetes lost a considerable amount of weight when they received tirzepatide (1).

Advanced Practice Registered Nurses (APRNs) need to understand how to safely prescribe tirzepatide and the reasoning as to why it causes weight loss for specific individuals.

Drug Classification

Tirzepatide is part of a class of medications called glucose-dependent insulin tropic polypeptide (GIP) receptor and glucagon-like peptide-1 (GLP-1) receptor agonists. It comprises a 39 amino acid linear synthetic peptide conjugate to selective receptor agonists in preclinical and clinical trials.

Tirzepatide is used for treating Type II diabetes in adults as an adjunct to diet and exercise. It is also used for weight loss in some individuals and has gained increased attention as a new therapeutic agent for glycemic and weight control.

Social media has had a significant influence and increased the desire to use tirzepatide, and while individual results vary, the weight loss in adults ranged from 12 – 25 pounds.

Online pharmacies, diet clinics, and medical spas are implementing thousands of ads on social media to capitalize on a surge of interest in the drug.

Indications of Usage

The use of tirzepatide is being used for both Type II diabetes and weight control in certain patients. It has been a game changer for people living with Type II diabetes. The drug’s primary use is as an adjunct to diet and exercise to improve glycemic control in adults with diabetes.

The drug has also proven beneficial for weight loss in patients experiencing obesity, and those who are taking the highest dosage have shared a body weight reduction of 15.7% (2). Tirzepatide is an injectable prescription medication used together with diet and exercise, and it is not yet known if it can be used safely with patients who have had pancreatitis.

It is important to remember that it is not to be used for patients with Type I diabetes, but it is safe for Type II diabetic patients. Also, the safety of tirzepatide has yet to be discovered for children and those under 18; therefore, the medication should not be used for this age group.

In studies conducted with or without diabetic medicines, 75% – 90% of patients taking tirzepatide reached an overall A1C of less than 7% with an average starting A1C of 7.9 – 8.6% across the following dosages – 5mg, 10mg, and 15mg. The study results were measured at weeks 40 and 52 (3).

Use of Tirzepatide with Diabetic Patients

Tirzepatide can be used for patients with Type II diabetes in combination with a diabetic-friendly diet and exercise. The drug works by lowering the patient’s overall blood sugar and also improves the A1C results of patients over some time. The injection has been approved by the FDA to treat Type II diabetes and is administered once weekly (4).

It is considered the first in a new class of medications – a dual glucose-dependent insulin tropic polypeptide (GIP) and glucagon-like-peptide-1 (GLP-1) receptor antagonist. The mechanism of how it works mimics two gut hormones (GIP and GLP-1). These hormones are essential in how patients digest food and regulate blood glucose after meals. The hormones also play a role in making individuals feel fuller and curb specific food cravings.

The provider can prescribe tirzepatide before attempting other diabetic medications if a patient has a BMI of 30 or greater or 27 or greater with weight-related conditions and if the drug is combined with a personalized weight loss plan that addresses physical activity, nutrition, and lifestyle changes.

However, due to the cost and some insurance companies not covering the injection unless the patient has both diabetes and obesity, the provider must carefully consider prescribing this medication.

Case Study

The patient states this ‘miracle drug’ is worth paying for out of pocket!

Jeff Capron, a 53-year-old Boonville, New York, web developer, started taking tirzepatide in December 2022. His friend had reported good results with the medication, so Jeff looked into the research studies behind it and then spoke with his primary physician.

The physician said, “Yeah, let’s give it a shot,” even though he did not have much experience with it. The physician did not have an opinion one way or the other than looking at the data set and seeing no reason why they could not try it.

Jeff’s hemoglobin A1C went from 10.1% to 6% in 3 months, which was very promising. “I never had that kind of experience with any medication for diabetes.” There is a range in how much A1C reduction people experience with tirzepatide, but many people taking it can get their A1C under 7% — an ideal goal for people with Type 2 diabetes.

Jeff experienced constipation and a little trouble sleeping early, but both issues disappeared quickly. He says, “I wake up in the morning, and my fasting blood sugars are normal.”

The medication took effect, he says, within 12 hours. He compared the feeling to having a gastric bypass.

“You cannot overeat food. As soon as you overeat, you almost feel ill.” While it generally takes a few months to notice effects like A1C reduction and significant weight loss, side effects such as lower appetite may be felt immediately.

Weight loss was not his primary goal, but he lost about 35 pounds on the medication in the first five months. He also lost his sweet tooth. “I can maybe count three sweet things I have eaten since December.”

Jeff found that his appetite slowly recovered days after taking tirzepatide. “You take the shot every Sunday, and by Saturday, you start to get a lot of appetite,” he says. “It does not seem to affect your weight. If I eat a little bit more on Saturday night, on Sunday, the scale will not move one way or the other.”

Jeff is allergic to hornets, so he already carries an auto-injector. He was not worried about using another drug delivered through a needle. “It’s just a push button,” he says. It also helped that his wife is a nurse. “So, I had her with me the first time to ensure I was doing it right. I didn’t even feel it.”

When Jeff was first prescribed tirzepatide, his insurance covered it. The company has since removed that benefit. He has filed an appeal but pays about $1,000 monthly out of pocket for his weekly injections. He plans to keep paying as long as necessary.

He considers the financial burden well worth it. “I have never had a medication that worked as well before for chronic conditions,” Jeff says. “I’ve been blown away by it. For me, it’s a miracle drug. It got rid of my diabetes” (4).

Use of Tirzepatide for Weight Loss Management

As mentioned, this medication is indicated for patients with a BMI of >30 or a BMI of >27 with qualifying comorbidities. Obesity can become a chronic lifetime disease, and for conditions such as these, the patient needs to implement therapy for the lifetime of the disease.

In a study conducted for tirzepatide, there was a dramatic increase in effectiveness compared to traditional nonsurgical interventions such as diet, exercise, and lifestyle changes. However, it has been noted that taking tirzepatide on an ongoing basis is recommended and necessary to maintain any weight loss achieved from the medication.

If a patient stops taking the drug, likely, it will no longer work (5).

Public health officials have expressed concerns about using the drug long-term. Still, data is currently lacking regarding long-term effectiveness, treatment duration, and maintaining weight reduction once the therapy is discontinued.

A recent trial consisted of 783 participants with a BMI greater than 30, and these participants agreed to take either a 10mg or 15mg dose of tirzepatide over 36 weeks. The injection is given once weekly, so this would equal a total of 36 injections.

By the end of 36 weeks, participants lost more than 21% of their body weight. After 36 weeks, participants continued on tirzepatide or received placebo treatment for the following year. The patients needed to be made aware of which treatment they were receiving.

Those still taking tirzepatide injections weekly after 88 weeks lost an additional 7% of their body weight, and those taking the placebo regained 15% at the end of 88 weeks (5).

Common Side Effects and Contraindications

Side Effects

Patients vary immensely with different experiences and side effects related to tirzepatide; however, the following are the most common side effects experienced by those taking the medication:

• Nausea
• Decreased appetite
• Vomiting
• Diarrhea
• Indigestion
• Constipation
• Stomach Pain

Tirzepatide usually does not cause fatigue, leaving one feeling weak, tired, and low energy. However, fatigue can be a common side effect of Type II diabetes.

It is important to note that most individuals who experience nausea, vomiting, and diarrhea episodes do so while the dosage increases, and typically, the symptoms decrease over time. G.I. effects were more prominent in those taking tirzepatide than those taking the placebo. The individuals not in the placebo group were more likely to stop treatment due to the unpleasant side effects (3).

Contraindications

Tirzepatide may cause thyroid tumors, including thyroid cancer, and it is essential to watch for possible symptoms, such as swelling or a lump in the neck, hoarseness, shortness of breath, or trouble swallowing.

Tirzepatide should also not be prescribed to any patient with Type 1 Diabetes.

One of the main ways that tirzepatide works is by stimulating the release of insulin from the pancreas, and due to this fact, there have not been many studies and clinical trials that include those with Type I diabetes.

However, this is not to say that prescribers have never ordered tirzepatide for those with Type I diabetes. Still, it is essential to note that if prescribed, it would be in addition to traditional insulin therapy.

• Personal or family history of a type of thyroid cancer known as medullary thyroid carcinoma (MTC).
• Any history of Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).
• Patients who are allergic to the actual medication or any of its ingredients.
• Younger than 18 years of age

Safe Prescribing Practices, Guidelines, and Considerations for Providers

Safe Prescribing Practices

As with all prescribed medications, safe standards of care must be implemented and followed to ensure patient safety is maintained. The same applies to providers considering prescribing tirzepatide, and specific criteria must be met beforehand. The following information discusses guidelines involving exclusion and inclusion criteria for providers to prescribe tirzepatide (6) accurately.

Guidelines

Exclusion Criteria – If present, the following indicates that the patient should not receive tirzepatide:

• Diagnosis of Type I diabetes
• Personal or family history of medullary thyroid carcinoma or with Multiple Endocrine Neoplasia syndrome type 2
• Severe gastrointestinal dysmotility
• History of pancreatitis
• Pregnancy
• Proliferative Diabetic Retinopathy (PDR), severe Nonproliferative Diabetic Retinopathy (NDR), clinically significant myalgic encephalomyelitis (M.E.), or diabetic macular edema (DME) unless the risks/benefits have been discussed with the patient and are documented in the patient's health record along with monitoring plans and follow-up with an eye specialist who is informed at the time of initiation.

Inclusion Criteria – All of the following must be met for tirzepatide to be prescribed:

• Diagnosis of Type II diabetes
• A BMI of 25 or greater
• Inadequate glycemic control on at least 1mg of semaglutide injection plus two or more glucose-lowering drugs
• Change needed to achieve goal A1C is less than 1%.
• Goal A1C should be based on those recommended in the Diabetic Guidelines.
• Adherence to current diabetic medications as evidenced by a review of the prescription refill history during the six months.

Additional Inclusion Criteria – All of the following must be met for tirzepatide to be prescribed:

• Patients with atherosclerotic cardiovascular disease or chronic kidney disease
• Patients of childbearing potential who are using oral contraceptives

Inclusion Criteria for Weight Loss

• BMI of >30 or >27 with patient weight conditions.

Considerations for Providers

There are specific considerations that prescribers must be aware of when contemplating if a patient should receive the medication tirzepatide. The following is imperative and must be considered each time the medication is prescribed to a patient:

• Clinical Indications – indicated for treating adults with insufficiently controlled diabetes mellitus as an add-on therapy to diet and exercise; as monotherapy when metformin is considered inappropriate due to contraindications or intolerance; and other medicinal products for treating Type II diabetes.
• Monitoring of medication – routine monitoring of serum calcitonin or thyroid ultrasound is of uncertain value but is recommended for early detection of Medullary Thyroid Cancer (MTC).
• Cost – the average price for tirzepatide ranges from $1,071-$1,351 without any coupons or insurance. Savings Card – manufacturer provided; patients can pay as little as $25 monthly for up to 12 injections. Savings Card – manufacturer provided; patients can pay as little as $25 monthly for up to 12 injections.
• Benefits and Risks – One must evaluate the effectiveness of diabetes and the weight loss experienced. Some of the risks must be evaluated, such as increased cost of medication, unpleasant gastrointestinal side effects, poor insurance coverage, and drug shortages. The FDA has warned that the medicine can cause thyroid C-cell tumors in rats, and it is not sure whether tirzepatide causes similar tumors.

How long does it take for tirzepatide to begin working?

Tirzepatide will start to lower one's blood sugar levels immediately, but it can take 8 to 12 weeks to reach one's target A1C goal.

Compared to other diabetic treatments, studies have shown that it can take eight weeks to reach an A1C target of less than or equal to 7% and 12 weeks to get an A1C of less than or equal to 6.5%. Significant weight loss can occur as early as 28 weeks.

Safe Administration

It is essential to follow the correct steps for safe administration of tirzepatide as listed below:

• The recommended starting dosage is 2.5mg, injected subcutaneously once weekly. The 2.5mg dosage is for treatment initiation and not for glycemic control.
• After four weeks, increase the dosage to 5mg, injected subcutaneously once weekly.
• If additional glycemic control is needed, increase the dosage in 2.5mg increments after at least four weeks on the current dose.
• The maximum dosage is 15mg, injected subcutaneously once weekly.
• If a dose is missed, instruct patients to administer it as soon as possible, within four days (96 hours) after the missed dose. If more than four days have passed, skip the missed dose, and administer the next dose on the regularly scheduled day. In each case, patients can then resume their regular once-weekly dosing schedule.
• The day of weekly Administration can be changed, if necessary, as long as the time between the two doses is at least three days (72 hours).
• Before initiation, train patients and caregivers on proper injection techniques.
• Instruct patients using the single-dose vial to use a syringe appropriate for dose administration (e.g., a 1ml syringe capable of measuring a 0.5 mL dose).
• Administer the medication once weekly, any time of day.
• Inject the medication subcutaneously in the abdomen, thigh, or upper arm.
• Rotate injection sites with each dose.
• Inspect the medication visually before use. It should appear clear and colorless to slightly yellow. Do not use the medicine if particulate matter or discoloration is seen.
• When using the medication with insulin, administer it as separate injections and never mix. It is acceptable to inject tirzepatide and insulin in the same body region, but the injections should not be adjacent.

Does the tirzepatide injection hurt when administered?

Pain from the injection site has not been reported as a common side effect, but it may occur.

Due to the injection being given subcutaneously, slight pain or discomfort can occur.

Alternatives to Tirzepatide for Weight Loss Management

In some instances, patients need to be aware of alternatives to tirzepatide in case they cannot take the actual injection for whatever reason. In cases such as these, there are alternative supplements that can be purchased over the counter, and they include the following (7):

• PhenQ – top OTC choice – comprehensive weight loss solution that targets specific body regions, facilitates prompt fat loss, and expedites the weight loss journey.
• PhenGold – the most potent OTC weight loss alternative – one of the top weight loss supplements that boost metabolism, making one less hungry, less tired, and an overall improved feeling.
• Capsiplex BURN – the best choice for men – helps to burn fat faster and keep blood sugar levels in check. It helps to keep one's muscles, curbs hunger, gives one more energy, and torches stubborn fats.
• Trimtone – the best choice for women – helps women to lose weight, eat less, increase metabolism, burn extra calories, and boost energy.
• Prime Shred – best fat burner for men – boosts metabolism, keeps muscles intact, increases energy, and helps maintain focus.

The advanced practicing nurse or prescriber needs to inform patients about alternative options such as these in an effort for individuals to understand that other choices are available and can be used. Many individuals need to be more knowledgeable about alternatives besides tirzepatide due to the extra hype from social media sources that promote advertisements related to tirzepatide only but do not mention the other options.

Why does social media influence and encourage patients to take tirzepatide?

Social media trends can be helpful but can also become harmful by setting unrealistic expectations and promoting a diet culture mentality. They can create an unhealthy obsession with "clean" eating, especially in the younger populations.

Due to this, many individuals take the medication despite any occurrence or history of Type II diabetes, and the drug can ultimately become misused.

It has been noted that there is an influx of patients requesting this medication for weight loss instead of the intended purpose, which is to help control Type II diabetes.

Tirzepatide represents one of the most recent non-medical treatments aimed at managing the symptoms of Type II diabetes. While it is not indicated for weight management, diabetic patients who receive it frequently report a significant reduction in body weight.

 Empirical evidence suggests the efficacy of tirzepatide in weight management, and certain physicians currently endorse the Administration of the medication as a therapeutic and effective means to overcome obesity.

What are some severe side effects of tirzepatide that can impact patient safety?

The Administration of tirzepatide can benefit many individuals, but some severe side effects must be mentioned.

These include thyroid tumors, thyroid cancer, pancreatitis, hypoglycemia, serious allergic reactions, kidney issues, severe stomach problems, vision changes, and gallbladder issues. All these side effects must be taken seriously and reported, as they can lead to life-threatening

Conclusion

Medications like tirzepatide are game changers for those patients with type 2 diabetes that have failed other medications. Unfortunately, several companies seek to profit from its weight-loss benefits through aggressive marketing campaigns that limit the available supply and increase the costs for those who need it. As healthcare providers, we need to use sound clinical judgment and follow the exclusion/inclusion criteria and other guidelines before prescribing this medication, so we do not unintentionally cause harm while looking to appease our patients who request this.

Semaglutide and Type 2 Diabetes

Introduction   

In 2017, the FDA approved the semaglutide injectable (Ozempic) for treating type 2 diabetes. The drug has experienced widespread acceptance due to its positive effects on weight loss and lowering of chronic health risks. The drug has risen in popularity over the past few years, as many well-known actors/actresses/songwriters, and more came forward, publicly sharing their weight loss journey.

This rise in popularity has also resulted in significant shortages of this medication, negatively impacting the lives of the diabetic community, local pharmacies, and healthcare providers. The goal of this continuing education course is to educate and empower the healthcare provider in all aspects of this drug regimen: clinical indications, patient education, cost options, and benefit/risk analysis.

Diabetes Overview

Diabetes is a chronic medical condition. Despite advances in diet, medications, and monitoring devices, diabetes diagnoses continue to grow at staggering rates. The Institute for Health Metrics and Evaluation (IHME) reports that over 529 million people worldwide are currently living with diabetes, and that number is expected to grow to 1.3 billion in only 30 years. While the risk factors for diabetes are vast in number (poor diet, inadequate activity, obesity, sedentary lifestyles, daily stressors, and more), the sad reality is that this chronic medical condition will most likely linger on for generations to come despite our efforts to contain this health epidemic (1).

According to the latest research on diabetes, there are over 37 million people in the United States alone with diabetes as of 2022. Statistically, approximately 28 million of them have a confirmed diagnosis, while another estimated 8 million are experiencing symptoms, without an official diagnosis. Diabetes currently ranks as the 7^th leading cause of death in the United States (2).

Types of Diabetes

In basic terms, diabetes is an impairment in one’s ability to either adequately produce or utilize insulin, which results in elevated levels of circulating glucose. Chronically elevated glucose levels affect blood vessels at every level, causing chronic inflammation and raising the risk of heart disease, stroke, blindness, and atraumatic amputations.

There are three main types of diabetes:

Type 1 diabetes is thought to be an autoimmune disease. Approximately 5-10 percent of people with diabetes are diagnosed with type 1 diabetes. The diagnosis usually occurs in early childhood, and results in a lifetime use of insulin to regulate blood glucose levels.

Type 2 diabetes is thought to be related to dietary and lifestyle choices. It accounts for nearly 90-95 percent of diabetes diagnoses. Usually occurring later in life (adult-elderly population), it is believed to be related to factors such as diet, activity, weight gain, and related factors. Type 2 diabetes is usually controlled by diet and exercise, in addition to oral medications, although injectable insulin may be included in the treatment plan.

Gestational diabetes refers to elevated glucose levels occurring during pregnancy for patients who are not diabetic at the onset of pregnancy. This version of diabetes usually resolves itself post-partum, although a woman may develop type 2 diabetes later in life, unrelated to pregnancy.

Type 2 diabetes in children: no longer a “later in life diagnosis”

Children are now being diagnosed with type 2 diabetes at an alarming rate. Despite widespread education and an increased awareness of diabetes, our up-and-coming generation is unhealthier than ever. Many families lack access to healthy food for their families, due to both general socioeconomic challenges and an increased rate of food insecurity. (19)

The CDC recommends care providers have resources for diabetic patients and their families, such as food and nutrition programs, budget-friendly diabetes meal plans, how to save money on diabetes care, and coping strategies for diabetes. (19)

Diabetes Signs and Symptoms, Diagnostic Testing

There are various ways to test for diabetes. The fasting blood sugar (FBS)/ fasting glucose level is a simple way to test for diabetes.

The normal fasting glucose level is below 100mg/dl. The fasting glucose result of 100-125mg/dl indicates prediabetes and results above 126mg/dl indicate diabetes.

The hemoglobin A1C blood test is another test used to confirm the diagnosis of diabetes. The patient does not need to be fasting for this test; thus, it is easier to order this test regardless of the time of day. This blood test reflects the average glucose level over the period of 2-3 months.

The normal A1C level is below 5.7%. Test results between 5.7%- 6.4% indicate prediabetes. Test results above 6.5% indicate diabetes.

A random glucose reading above 200mg/dl, done at any time of day, indicates diabetes.

The diagnosis of diabetes is by blood tests, and for improved accuracy, should be based on two separate readings, done (at least) a day apart. In the case of fasting and random blood tests, dietary intake (large amounts of carbohydrates in a single meal) may adversely affect test results. This is not the case when using A1C testing for a confirmation diagnosis, as the results are the average of a 2–3-month span.

Target blood levels for a person with diabetes (3).

Target blood glucose levels for people with diabetes are as follows:

• Fasting glucose 80-130mg/dl.
• Postprandial blood glucose level- less than 180mg/dl
• A1C level 7-8%.

These target ranges are general guidelines. Patient-specific ranges will be dependent on a variety of factors, including preexisting comorbidities, overall health status, age, and activity levels.

The hallmark signs/symptoms of diabetes

1. Polyuria- increased urination
2. Polydipsia- increased thirst
3. Polyphagia-increased hunger/appetite

The truth is, as healthcare providers, you will have patients who have no hallmark signs and symptoms of diabetes; the diagnosis will be found during annual preventive examinations often unrelated to any chronic disease. For this reason, many insurance companies now cover numerous preventive screenings, including diabetes screenings, as part of their wellness and prevention initiatives. These tests are often approved based on a patient's age, or preexisting conditions, rather than outright signs and symptoms.

Lifestyle Interventions and the Diabetes Prevention Program

The initial diagnosis of diabetes can be managed in a variety of ways, depending on the severity of the illness at the time of diagnosis. Lifestyle interventions (behavior modification education) are of utmost importance in the care and management of people with diabetes. Research over the past few decades has consistently shown that such interventions have immense positive effects on the successful long-term management of diabetes.

The official Diabetes Prevention Program was created in 2010 (4) and confirmed the effects of lifestyle interventions in the management of diabetes:  Lifestyle interventions decreased the incidence of type 2 diabetes by 58% compared with 31% in the metformin-treated group. Thus, these findings now serve as the blueprint, if you will, for all-inclusive, patient-specific disease management guidelines. These lifestyle interventions will be discussed in detail later in the program.

Additional Resources on Diabetes Prevention

• Detailed History of the Diabetes Prevention Program
• Detailed on the National DPP Lifestyle Change Program

Semaglutide

Semaglutide is an injectable drug used in the treatment of type 2 diabetes. It was approved by the FDA in May of 2017.

It is a once-a-week injectable and belongs to the drug class known as glucagon-like peptide-1 receptor agonists (GLP-1RAs) (5). It has been referred to as a “miracle weight loss drug” among those who are living with obesity, despite frequent side effects, unusually high out-of-pocket costs, drug shortages, and weight regain when attempting to stop using the medication.

GLP-1 receptor agonist: Hormone Review

GLP-1 RAs are a class of medications used to treat Type 2 diabetes, and in some cases, obesity treatment. They are also known as GLP-1 receptor agonists, incretin mimetics, and GLP-1 analogs.

Ghrelin and Leptin (6)

Ghrelin and Leptin are two hormones that greatly influence appetite and the sensation of fullness. Often referred to as the “hunger hormone.” Ghrelin is responsible for many functions, including playing a key role in metabolism through glucose and insulin regulation.

Ghrelin, produced in your stomach, signals your brain when you are hungry, and results in increased food intake.

Leptin, conversely, is produced in your fat cells, and signals to the brain when you have eaten enough (by a decrease in appetite).

Glucagon-like peptide-1 receptors

Known as GLP1 receptors, Glucagon-like peptide-1 receptor proteins are located in the beta cells of the pancreas as well as in the neurons in the brain. GLP-1 receptors are involved in the regulation of blood glucose levels and affect the secretion of insulin. These cells encourage the release of insulin from the pancreas, increase the volume of beta cells, and reduce the release of glucagon. In doing so, they increase the feeling of fullness during and between meals, suppressing the appetite and slowing gastric emptying.

What is meant by receptor agonist and antagonist?

The term agonist refers to any substance that mimics the actions of a hormone in producing a specific response: a receptor antagonist blocks a response from occurring.

Opioids are examples of receptor agonists in that they produce responses such as analgesia.

Naloxone/Narcan is an example of a receptor antagonist, in that it binds to a receptor site and decreases/blocks a response from occurring.

Semaglutide mechanism of action (7)

GLP-1 agonists work in several ways to positively affect glucose levels. Their mechanism of action includes the following:

• Increasing (stimulating) insulin secretion by the pancreatic beta cells.
• Decreasing the production of glucagon, a hormone that raises blood glucose levels
• Decreasing (slowing) gastric emptying
• Decreasing appetite (and thereby reducing food intake) by creating a sensation of stomach fullness

Through these mechanisms of action, semaglutide results in a lowering of serum glucose/A1C levels, which lowers the risk of cardiovascular events. Studies have also shown that semaglutide resulted in weight loss (approximately 8-14 pounds on average {dose dependent results}.

Side Effects of Semaglutide

Common side effects of semaglutide (8)

Common side effects may include any of the following:

• Nausea and vomiting
• Headache
• Diarrhea and stomach pain
• Upset stomach, indigestion, constipation, flatulence

These side effects usually subside within a few weeks, as the patient becomes acclimated to the medication.

Serious side effects of semaglutide

• Hypoglycemia- enhanced/worsened when used in combination with other diabetes medication. Symptoms may include drowsiness, confusion, weakness, irritability, and headache.
• Symptoms may include abdominal pain and distension, nausea and vomiting, fever, and back pain.
• Diabetic retinopathy. Symptoms may include blurred vision, vision loss, and diminished night vision.
• Kidney damage/injury/failure. Symptoms may include fatigue, nausea, diminished urine output, confusion, and edema of extremities.
• Gallbladder disease. Symptoms may include gallstones, abdominal pain, nausea and vomiting, and poor appetite.

Black Box Warning (9)

Semaglutide has a Black Box Warning for thyroid cancer. This is the most serious warning from the Food and Drug Administration (FDA) and is intended to alert consumers to the potential risks of a medication.  This black box warning was issued when research found that the drug increased the risk of thyroid tumors in animals.

It is not known if semaglutide actually causes tumors in humans.

Contraindications

• Semaglutide is contraindicated in people with a personal or family history of MTC (medullary thyroid cancer) or in patients with multiple endocrine neoplasia syndrome type 2.
• Known hypersensitivity to semaglutide or any of the product components

Cautions

As noted under “serious side effects”, there have been reports of new illnesses or worsening of existing health conditions occurring “post-marketing”. Thus, healthcare providers are strongly encouraged to continue ongoing surveillance of any patients on semaglutide therapy. In addition, there is insufficient data available regarding the use of semaglutide by pregnant women. Women are therefore highly encouraged to stop any treatment with semaglutide for at least 2 months prior to a planned pregnancy.

Dosing

Semaglutide is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus (T2DM). It is looked upon favorably to reduce the risk of cardiovascular events in adults with T2DM and a preexisting history of cardiovascular disease. This drug is FDA-approved for use in people with diabetes, with a BMI of 27% or higher (a BMI of 25-29.9% is considered overweight).

Semaglutide (Ozempic) is available as an injectable prescription medication. Doses include 0.5mg, 1mg, or 2 mg, once weekly.

The injection should be administered subcutaneously to the abdomen, thigh, or upper arm. Injection sites should be rotated, and given as a single injection.

Start at 0.25 mg once weekly. After 4 weeks, increase the dose to 0.5 mg once weekly.

• If additional glycemic control is needed, increase the dose to 1 mg once weekly after at least 4 weeks on the 0.5 mg dose.
• If additional glycemic control is needed, increase the dose to 2 mg once weekly after at least 4 weeks on the 1 mg dose

Administer once weekly at any time of day, with or without meals.  The maximum dose recommendation is 2mg/weekly once weekly.

Note: The initial 0.25-mg dose is intended for treatment initiation and is not effective for glycemic control

Missing Dose Guidelines

• If the missed dose is ≤5 days: Administer dose as soon as possible
• If missed dose >5 days: Skip the missed dose and administer the next dose on the regularly scheduled day; patients can then resume their regular once-weekly dosing schedule

Administration Day Guidelines (10).

The administration day each week can be changed, if necessary, as long as the time between 2 doses is at least 2 days (>48 hours)

Dose Availability (packaging)

• 2mg/1.5mL (1.34mg/mL); delivers doses of 0.25mg or 0.5mg per injection or four to eight doses per injection pen
• 4mg/3mL (1.34mg/mL); delivers 1mg per injection or 4 doses per injection pen
• 8mg/3mL (2.68 mg/mL); delivers 2mg per injection or 4 doses per injection pen

Treatment Goals- Effects on A1C and Weight (11)

A majority of adults who were placed on injectable semaglutide for diabetes management achieved a target A1C under 7% and were able to maintain it.

• Dose specific effects on A1C were as follows:
• 0.5mg dose injection yielded a 1.4% decrease
• 1.0mg dose injection yielded a 1.6% decrease
• 2.0 mg dose injection, in combination with diabetes pills, yielded a 2.1% decrease in A1C.

Adults taking semifluid injectables for diabetes management also noted weight loss.

• 8-pound weight loss reported with 0.5mg dose injection
• 10 pounds weight loss reported with 1.0mg dose injection
• Up to 14 pounds of weight loss reported with a 2.0mg dose injection

Prescribing insights: Long-Term therapy for a chronic condition?

Semaglutide is viewed favorably as a treatment option for Type 2 diabetes. It appears to lower A1C levels and body weight in the majority of patients, lowering their risk of future cardiovascular events.

The question of long-term medication use, for a chronic health condition, is being heavily discussed in the media. While a percentage of people can decrease or eliminate the need for chronic medications through significant lifestyle changes, there have been reports of weight gain in those who stopped taking this injectable medication.

Without intense lifestyle behavior modification education, there is a heightened risk of weight regain in the absence of such medications. Leaders in the treatment of obesity and related illnesses have commented that this drug is intended for long-term use.

Examples of this include the following:

“GLP-1 medications [like Ozempic] are designed to be taken long-term... They are chronic medications for the treatment of chronic conditions (both diabetes and obesity) (12)". - Christopher McGowan, M.D., a gastroenterologist specializing in obesity medicine and endobariatrics

“As with many chronic conditions, most people who use the drugs for diabetes or weight loss will need to keep taking them to keep benefiting from them. Depending on your individual situation, and without sustained lifestyle changes, it is likely you would need to be on these medications indefinitely to maintain weight loss (13)." - Dr. Cecilia Low Wang, a UCHealth expert in endocrinology, diabetes and metabolism.