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 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.

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Nevada Cultural Competence in Nursing (DEI Requirement)

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 

Quality Improvement for Nurses

Introduction   

Welcome to the world of Quality Improvement (QI) in healthcare, a dedicated field committed to continually enhancing patient care and outcomes. Quality Improvement involves a systematic approach to identify, analyze, and address areas for improvement within healthcare processes, ultimately resulting in improved patient safety, satisfaction, and overall healthcare excellence (13). In this course, we will embark on a journey to explore the fundamental principles and practical applications of QI, explicitly tailored for nurses who aspire to make a positive impact in their healthcare settings.

As a nurse, you know the significance of providing high-quality patient care. However, you may wonder how you can actively contribute to improving the systems and processes in your workplace.

Imagine this scenario: You observe a recurring issue with medication administration, where doses are occasionally missed due to workflow inefficiencies. Through this course, you will acquire the knowledge and skills to apply QI methodologies like Plan-Do-Study-Act (PDSA) cycles to investigate such issues, implement changes, and monitor the impact of your interventions. By understanding QI principles and tools, you will be better equipped to collaborate with your colleagues, drive meaningful improvements, and ensure that your patients receive the best care possible.

What is Quality Improvement?

Quality Improvement (QI) in healthcare represents an ongoing, systematic effort to elevate the quality of patient care and healthcare services that involves identifying areas needing improvement, implementing changes, and evaluating the effects of those changes to ensure better patient outcomes (12).

Let’s envision a scenario where a hospital's surgical department grapples with a higher-than-average rate of post-operative infections. Through a QI initiative, the healthcare team can meticulously scrutinize the surgical processes, pinpoint potential sources of infection, and introduce evidence-based practices such as enhanced sterilization techniques or more rigorous antibiotic prophylaxis protocols. Over time, they can gauge the effectiveness of these changes by monitoring infection rates for a reduction.

Commonly used QI methodologies in healthcare include the DMAIC (Define, Measure, Analyze, Improve, Control) process and the Plan-Do-Study-Act (PDSA) cycle. These approaches provide structured frameworks for healthcare professionals to tackle issues systematically and iteratively. For example, imagine a bustling primary care clinic with extended patient wait times.

Here, the PDSA cycle can come into play using the systematic iterative steps below:

1. The team defines the problem (lengthy wait times)
2. The team proceeds to test a change (for example, adjusting appointment scheduling)
3. The team then scrutinizes the results and acts accordingly to refine the process.

History and Background of Quality Improvement 

The history and background of Quality Improvement (QI) in healthcare have a rich and evolving timeline, dating back to the early 20th Century, with significant developments occurring over the years. One pivotal moment in this journey was the introduction of statistical quality control by Dr. Walter A. Shewhart in the 1920s (24). Dr. Shewhart's pioneering work laid the foundation for using statistical methods to monitor and enhance processes, a concept that would become integral to QI initiatives (24). 

In the mid-20th Century, the contributions of Dr. W. Edwards Deming further propelled QI principles forward (7). Dr. Deming emphasized the significance of continuous improvement, active employee engagement, and process variability reduction. His ideas found fertile ground in post-World War II Japan, playing a crucial role in the nation's economic recovery and the emergence of renowned companies like Toyota, famous for its Toyota Production System (TPS), incorporating QI concepts (7). 

Until today, QI has become indispensable to healthcare systems worldwide (16). To illustrate, envision a scenario where a hospital grapples with a high readmission rate among heart failure patients. By scrutinizing historical data and implementing evidence-based protocols for post-discharge care, hospitals can effectively lower readmissions, enhance patient outcomes, and potentially evade financial penalties under value-based reimbursement models (16). 

Models 

At the heart of ongoing transformations in healthcare lies various Quality Improvement (QI) models. These models provide structured frameworks for identifying and addressing areas of improvement within healthcare systems (14). These models offer healthcare professionals a systematic approach to instigate meaningful process changes, ultimately resulting in elevated care quality. See some models below. 

Model for Improvement 

The Model for Improvement is a widely recognized and highly effective framework for Quality Improvement (QI) in healthcare. This is because it empowers healthcare professionals to systematically test and fine-tune their ideas for process improvement, ensuring that changes are grounded in evidence and proven effective (17).  

The Model for Improvement offers a structured and systematic approach to identifying, testing, and implementing changes to enhance healthcare processes and ultimately elevate patient outcomes.  

Developed by Associates in Process Improvement (API), this model revolves around the iterative "Plan-Do-Study-Act" (PDSA) cycle, which forms the foundational structure of QI initiatives (17). The Plan-Do-Study-Act (PDSA) cycle is a systematic approach that guides healthcare teams through quality improvement, and it comprises the four key phases below, each contributing to developing and implementing meaningful changes in healthcare practices (12). 

• Plan: In this initial phase, healthcare teams define the specific problem they aim to address, set clear and measurable goals, and craft a comprehensive plan for implementing the proposed change. For instance, if a hospital seeks to reduce patient wait times in the emergency department, the plan may involve adjustments to triage protocols or streamlining documentation processes. 
• Do: Once the plan is established, the proposed change is implemented, typically on a small scale or within a controlled or pilot environment. This enables healthcare professionals to assess the feasibility and potential impact of the change without making widespread adjustments. 
• Study: The study phase involves rigorous data collection and analysis to evaluate the effects of the change. In our example, the hospital would measure the impact of the new triage protocols on wait times, closely examining whether they have decreased as expected. 
• Act: Based on the findings from the study phase, the healthcare team makes informed decisions about the change. They may adopt the change if it has successfully reduced wait times, adapt it further for enhanced effectiveness, or, if necessary, abandon it.

The PDSA cycle's iterative nature means adjustments can be made, and the cycle repeats until the desired improvement is achieved (12).

Lean Model 

The Lean model, initially conceived in the manufacturing sector, has found considerable success and applicability in healthcare as a potent tool for process enhancement and waste reduction (22). At its core, Lean thinking revolves around the principles of efficiency and value optimization because it focuses on refining processes to eliminate wasteful elements while simultaneously delivering care of the highest quality (22).  

Healthcare organizations have adopted Lean methodologies to tackle many challenges, from reducing patient wait times to improving inventory management and elevating overall patient satisfaction (22). For instance, when a hospital is challenged with prolonged wait times in its outpatient clinic, it can apply Lean principles to systematically analyze the patient flow, pinpoint bottlenecks, and streamline processes.  

This might involve reconfiguring furniture to enhance flow, adjusting appointment scheduling, or implementing standardized work procedures. The ultimate objective is to cultivate a patient-centric, efficient environment that ensures timely access to care while meticulously conserving time and resources. 

Another integral aspect of Lean thinking is the unwavering commitment to continuous improvement and the pursuit of perfection through the systematic identification and eradication of various forms of waste (19). The forms of waste are often categorized into seven types: overproduction, waiting, unnecessary transportation, overprocessing, excess inventory, motion, and defects (19). By keenly identifying and addressing these forms of waste, healthcare organizations not only enhance the utilization of resources but also curtail costs and elevate the overall quality of care delivery. 

Six Sigma model  

The Six Sigma model is a robust and widely adopted healthcare method for improving processes and reducing mistakes (9). It was first used in manufacturing but is now used in healthcare to make processes more consistent and improved by finding and fixing mistakes and inefficiencies (9).  

An example is when a hospital is concerned about the accuracy of medication dosing for pediatric patients, a Six Sigma team might include: indicating the problem, gathering data on mistakes regarding dosing, and finding out why the mistakes happened. The strategy may encompass the implementation of standardized dosing protocols, refining staff training programs, and closely monitoring the medication administration process to ensure that mistakes are eliminated. 

Six Sigma uses a framework called DMAIC (Define, Measure, Analyze, Improve, Control) to make improvements. This framework utilizes data-driven tools to discern problems, quantify their origins, develop practical solutions, and institute control mechanisms to sustain improvements (11). Through this systematic journey, healthcare organizations position themselves to deliver care of elevated quality, curtail costs, and bolster patient safety.  

TeamSTEPPS model 

TeamSTEPPS, which stands for Team Strategies and Tools to Enhance Performance and Patient Safety, is a teamwork and communication model designed explicitly for healthcare settings (4). Developed by the U.S. Department of Defense and the Agency for Healthcare Research and Quality (AHRQ), TeamSTEPPS focuses on improving patient safety by enhancing team collaboration, communication, and decision-making among healthcare professionals (4). 

One key element of TeamSTEPPS is using structured communication techniques to prevent errors and misunderstandings. For instance, during patient handoffs from one healthcare provider to another, TeamSTEPPS emphasizes using a structured tool like SBAR (Situation, Background, Assessment, Recommendation) to convey critical information succinctly and accurately. This ensures that essential patient details are noticed, reducing the risk of adverse events (18). 

In a surgical team scenario, TeamSTEPPS principles can be applied to improve teamwork and communication among surgeons, nurses, and anesthesiologists. The model encourages briefings before procedures to set clear objectives, huddles during surgery to address emerging issues, and debriefings afterward to reflect on the process and identify areas for improvement. By fostering a culture of open communication and mutual respect, TeamSTEPPS contributes to safer, more efficient healthcare delivery (4). 

IOM Six Domains of Patient Care 

The Institute of Medicine (IOM), now known as the National Academy of Medicine, introduced the Six Domains of Quality in Healthcare as a framework to assess and improve the quality of patient care (14). These domains, introduced in 2001, encompass various aspects of care delivery and patient experience, helping healthcare organizations and providers identify areas for improvement (14). The domains serve as pillars for assessing the different dimensions of care delivery, ensuring that healthcare organizations and providers address the holistic needs of patients (14).  

Definitions  

The Six Domains of Patient Care are essential for providing high-quality healthcare. See definitions of each of the IOM's six domains of patient care below. 

• Safe: Safety is the foundational domain, emphasizing the importance of reducing the risk of patient harm. This includes preventing medical errors, preventing infections, and ensuring the safe administration of medications. Healthcare organizations implement safety protocols and engage in continuous monitoring to minimize risks (14). 
• Effective: Effective care ensures that patients receive evidence-based treatments and interventions that result in the desired outcomes. It involves using the best available scientific knowledge to make informed decisions about patient care avoiding unnecessary or ineffective treatments (14). 
• Patient-Centered: Patient-centered care focuses on individualizing healthcare to meet each patient's unique needs and preferences. It involves respecting patients' values and preferences, engaging them in shared decision-making, and delivering care with empathy and compassion (14). 
• Timely: Timely care emphasizes reducing delays in healthcare delivery. It includes providing care promptly and avoiding unnecessary waiting times for appointments, tests, and treatments. Timely care is especially critical in emergencies (14). 
• Efficient: Efficiency in healthcare means maximizing resource utilization and minimizing waste while providing high-quality care. This domain emphasizes streamlining processes, reducing unnecessary costs, and optimizing healthcare resources (14). 
• Equitable: Equitable care underscores the importance of providing healthcare that is fair and just, regardless of a patient's background, socioeconomic status, or other factors. It aims to eliminate healthcare access and outcomes disparities among different patient populations (14). 

Measures 

Measures in the context of the Institute of Medicine (IOM) six domains of patient care refer to the metrics and indicators used to assess and evaluate the quality of care provided in each domain. According to (14), the measures below are essential for monitoring and improving healthcare services. See details below. 

• The "Safe" domain measures focus on tracking and reducing adverse events and medical errors. Key indicators include rates of medication errors, hospital-acquired infections, falls, and complications from procedures. Safety measures also assess the implementation of safety protocols, such as hand hygiene compliance and patient identification bracelets. 
• Measures in the "Effective" domain assess how evidence-based practices and treatments are utilized. These measures include adherence to clinical guidelines, appropriate use of medications, and the success rates of medical interventions. Additionally, outcomes such as patient recovery, remission, or improvement are indicators of the effectiveness of care. 
• The "Patient-Centered" domain focuses on assessing the patient’s experience and satisfaction with care. Patient surveys and feedback are standard measures, evaluating aspects like communication with healthcare providers, involvement in decision-making, and overall satisfaction with the care received. Healthcare organizations also measure shared decision-making and respect for patient preferences. 
• Measures related to the "Timely" domain evaluate the efficiency of healthcare delivery. Key metrics include waiting times for appointments, diagnostic tests, and procedures. Additionally, measures track the timely delivery of urgent care and the avoidance of unnecessary delays in treatment. 
• Efficiency measures aim to quantify resource utilization and the reduction of waste in healthcare. Metrics may include the cost of care per patient, length of hospital stays, and resource allocation efficiency. Improvement in resource utilization and cost-effectiveness are vital indicators of efficiency. 
• Measures within the "Equitable" domain assess disparities in healthcare access and outcomes among different patient populations. Healthcare utilization and outcomes data are stratified by demographics, socioeconomic status, race, and ethnicity to identify and address inequities. Key indicators include access to preventive care, healthcare utilization rates, and health outcomes across various demographic groups. 

Nursing Quality Indicators 

According to (5), nursing quality indicators are essential metrics used to evaluate and improve the quality of nursing care in healthcare settings. These indicators provide valuable insights into nursing practice and patient outcomes, helping healthcare organizations and nursing staff deliver safe, effective, patient-centered care. Let's delve into some key nursing quality indicators and their significance below. 

Patient Falls 

Patient falls are a critical quality indicator in nursing care since they can result in severe injuries and complications for patients (5). As a result, healthcare organizations measure and monitor the rate of patient falls to identify trends and implement preventive measures.  

For example, when a hospital notices an increase in the rate of falls among elderly patients in a particular unit, they may introduce interventions such as nonslip flooring, improved lighting, and patient education as fall prevention strategies to reduce the incidence of falls. 

Medication Administration Errors 

Ensuring accurate medication administration is crucial in nursing practice because medication errors can lead to adverse events, including patient harm or death (5). Nursing quality indicators related to medication administration errors include the rate of medication errors and adherence to medication reconciliation processes (5). For instance, nurses are encouraged to verify patient allergies and cross-check medication orders to prevent errors. If there is an increase in medication errors in a healthcare facility, it may prompt a review of medication administration protocols and additional staff training.

Pressure Ulcers (Bedsores) 

Pressure ulcers are a quality indicator of patient skin integrity since they develop when patients remain immobile for extended periods (5). As a result, healthcare organizations measure the incidence and prevalence of pressure ulcers as an indicator of the quality of nursing care (5).  

Patient Satisfaction 

Patient satisfaction is a patient-centered nursing quality indicator since it reflects the overall patient experience and perception of care (5). Surveys and feedback mechanisms are used to measure patient satisfaction. For example, a scenario might involve patients receiving post-discharge surveys that assess various aspects of their hospital experience, including nurse responsiveness, communication, and pain management. Healthcare organizations can use this feedback to identify areas for improvement and enhance patient-centered care. 

In summary, nursing quality indicators encompass a range of metrics that evaluate nursing care quality, patient safety, and patient experiences. By monitoring and responding to these indicators, healthcare organizations and nursing staff can continuously improve their quality of care, leading to better outcomes and increased patient satisfaction (5). 

Data Collection 

Quality improvement data collection is a critical component of healthcare quality initiatives, providing the necessary information to assess the current state of care, identify areas for improvement, and monitor progress over time (2). Accurate and meaningful data collection enables healthcare organizations to make informed decisions, implement evidence-based interventions, and ultimately enhance patient outcomes. Let's explore the methods of data collection below. 

• Clinical Outcome Collection: Clinical outcome data collection is essential for assessing the effectiveness of healthcare interventions (2). For example, consider a scenario where a hospital is implementing a quality improvement project to reduce surgical site infections (SSIs) following orthopedic surgeries. Data collection would involve tracking the number of SSIs occurring over a specific period and collecting information on patient characteristics, surgical techniques, and post-operative care protocols. By analyzing this data, the healthcare team can identify trends, risk factors, and areas for improvement, ultimately leading to targeted interventions to reduce SSIs. 
• Patient Satisfaction Survey Data Collection: Patient satisfaction surveys are valuable tools for collecting data on patient experience (2). A primary care clinic that aims to improve patient satisfaction may administer surveys to patients after each visit, asking about aspects of care such as communication with healthcare providers, wait times, and overall experience. The collected data can reveal areas of strength and areas requiring improvement. For instance, if survey results consistently indicate longer-than-desired wait times, the clinic can adjust scheduling practices or implement strategies to reduce wait times and enhance patient satisfaction. 
• Process Measures Data Collection: Process measure data collection focuses on evaluating the efficiency and effectiveness of healthcare processes (2). For instance, in a medication reconciliation scenario, a healthcare organization might collect data on the accuracy and completeness of medication lists during care transitions. By tracking the frequency of medication reconciliation discrepancies, they can identify process inefficiencies and implement standardized protocols for reconciliation, leading to safer care transitions and reduced medication errors. 
• Adverse Event Reporting Data Collection: Adverse event reporting is a crucial mechanism for collecting data on incidents that result in patient harm or near misses (2). For example, consider a scenario where a nurse administers the wrong medication dose to a patient but catches the error before any harm occurs. Reporting this near-miss event allows the healthcare organization to investigate the root causes, implement preventive measures, and share lessons learned with the care team to prevent similar incidents in the future. 

Types of Data 

Data types play a crucial role in understanding the current state of care, identifying areas for improvement, and implementing evidence-based interventions (2). Let’s explore the different types of data used in quality improvement below. 

• Quantitative Data: Quantitative data involves numerical measurements and is particularly useful for assessing the frequency and extent of specific events or outcomes (2). For instance, in a hospital's quality improvement project focused on reducing hospital-acquired infections, the team collects quantitative data on the number of infections over time, allowing them to track trends and measure the impact of interventions, such as hand hygiene protocols or disinfection practices. 
• Qualitative Data: Qualitative data provides insights into the "why" and "how" behind healthcare processes and patient experiences (2). This data type is collected through interviews, focus groups, and open-ended surveys. For example, in a primary care setting aiming to improve patient satisfaction, qualitative data may be collected through patient interviews to gather in-depth information about their perceptions of care. Qualitative data can uncover nuances and provide valuable context to complement quantitative findings (2). 
• Patient-Reported Data: Patient-reported data includes information directly provided by patients about their health, symptoms, experiences, and preferences. Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are standard data collection tools. In a scenario involving chronic disease management, patients with diabetes may be asked to complete a PROM assessing their quality of life and symptom management. This data helps healthcare providers tailor care plans to individual patient needs and preferences (2). 
• Process Data: Process data track the steps and activities involved in healthcare delivery to help assess the efficiency and effectiveness of care processes. For example, in a surgical quality improvement initiative, process data may include the time from patient admission to surgery, surgical team checklist completion, and adherence to anesthesia protocols. By collecting and analyzing process data, healthcare organizations can identify bottlenecks and areas for improvement in care delivery processes. 

In summary, quality improvement data collection relies on various data types, including quantitative, qualitative, patient-reported, and processed data. Each data type contributes to a comprehensive understanding of healthcare quality and supports evidence-based decision-making to enhance patient care and outcomes. 

Identification Stage  

The identification stage for quality improvement data collection is a critical initial phase where healthcare organizations and teams define what data to collect, why it is relevant, and how it aligns with their quality improvement goals (23). This stage is essential for ensuring meaningful data collection efforts will lead to actionable insights. Let's explore the identification stage in more detail. 

• Defining Objectives and Goals: During this stage, healthcare organizations must clearly define the objectives and goals of their quality improvement initiative (23). For instance, a hospital aiming to reduce readmission rates for heart failure patients may set a specific goal of reducing readmissions by 20% within the following year.  
• Selecting Relevant Metrics: Identifying the right metrics and data points is crucial, and organizations should choose metrics that directly relate to their quality improvement goals (23). Continuing with the example of reducing heart failure readmissions, relevant metrics might include the number of heart failure patients readmitted within 30 days, the reasons for readmission, and patient characteristics. By selecting these metrics, the organization ensures that data collection efforts are aligned with their specific improvement goal. 

• Determining Data Sources: Healthcare organizations must identify where the necessary data will be sourced (23). This may involve looking at electronic health records, claims data, patient surveys, or other sources. For instance, to collect data on heart failure readmissions, the hospital may extract relevant information from electronic health records, including admission and discharge dates, diagnosis codes, and patient demographics. 
• Creating Data Collection Protocols: Establishing clear data collection protocols is essential for consistency and reliability (23). Healthcare teams should define how data will be collected, who will be responsible for data collection, and the frequency of data collection. For example, in a hospital project aiming to improve hand hygiene compliance, data collection protocols might specify that trained observers will monitor hand hygiene practices at random intervals and record their findings on standardized forms. 

By carefully navigating the identification stage, healthcare organizations ensure that their quality improvement data collection efforts are purposeful and aligned with their goals. This sets the stage for collecting meaningful data to drive evidence-based decisions and interventions to enhance healthcare quality. 

Gathering Stage  

The gathering stage of quality improvement data collection is crucial for healthcare organizations to collect the identified data based on their quality improvement objectives and goals (23). This stage involves systematically collecting data from various sources and often requires careful planning and coordination to ensure data accuracy and completeness. Let's delve into the gathering stage in detail below. 

• Data Collection Methods: To gather data, healthcare organizations must determine the most suitable methods for collecting the identified data, which may involve a combination of electronic health records, patient surveys, direct observations, and administrative databases (23). For example, in a quality improvement project aimed at reducing hospital readmissions, data may be collected by reviewing electronic health records to track patient outcomes, conducting patient surveys to gather feedback on discharge instructions, and analyzing administrative data to identify trends in readmission rates. 
• Ensuring Data Accuracy and Consistency: Data accuracy is critical in the gathering stage, and organizations must implement procedures to collect data consistently and without errors (23). For instance, if a healthcare facility is collecting data on medication administration, nurses may use standardized protocols to accurately record medication administration times and doses. Regular training and quality checks may also be implemented to maintain data accuracy. 
• Timely Data Collection: Timeliness is another important aspect of the gathering stage, and data should be collected promptly to ensure it is current and relevant for analysis and decision-making (23). In a scenario involving tracking patient outcomes, healthcare teams may set specific intervals for data collection, such as collecting post-surgical complication data daily or weekly, depending on the project's requirements. 
• Data Security and Privacy: Protecting patient data is a paramount concern in healthcare. As a result, healthcare organizations must adhere to strict privacy and security protocols during the gathering stage to ensure that patient information is handled confidentially and complies with applicable laws and regulations, such as the Health Insurance Portability and Accountability Act (HIPAA) (23). For example, when collecting patient-reported data, organizations may anonymize responses to protect patient identities and comply with privacy regulations. 

By effectively managing the gathering stage, healthcare organizations can ensure that they collect accurate, timely, and secure data that will serve as the foundation for subsequent analysis and quality improvement efforts. 

Analysis stage  

The analysis stage for quality improvement data collection is a critical phase where collected data is processed, examined, and transformed into actionable insights. This stage involves various analytical techniques and tools to identify patterns, trends, and areas for improvement (2). Let's explore the analysis stage in detail below. 

• Descriptive Analysis: Descriptive analysis is the initial step in data analysis, focusing on summarizing and presenting data meaningfully (2). For example, in a quality improvement project aimed at reducing patient wait times in an emergency department, an analysis may involve calculating and displaying key statistics, such as average wait times, 95th percentile wait times, and the distribution of wait times (2). These descriptive statistics provide an overview of the current situation and help identify areas that need attention. 
• Root Cause Analysis (RCA): Root cause analysis is a critical aspect of the analysis stage, as it helps pinpoint the underlying causes of issues or problems (2). In our scenario, if the analysis reveals prolonged wait times in the emergency department, RCA may involve a thorough investigation into the factors contributing to the delays. Potential root causes include staffing shortages, inefficient triage processes, or bottlenecks in diagnostic testing. Identifying these root causes is essential for developing effective interventions. 
• Statistical Analysis: Statistical analysis plays a vital role in quality improvement by examining the relationships between variables and testing hypotheses (2). In reducing hospital readmissions, statistical analysis may be used to identify factors associated with readmission risk. For example, healthcare teams can use logistic regression to analyze patient data to determine which variables, such as comorbidities or medication adherence, are statistically significant predictors of readmission risk. This information can guide the development of targeted interventions for at-risk patients. 
• Benchmarking: Benchmarking involves comparing an organization's performance data with industry standards or best practices to identify performance gaps (2). When a hospital is looking to improve patient satisfaction, benchmarking may involve comparing its patient satisfaction scores to those of similar hospitals or national averages. Identifying areas where the hospital falls behind benchmarks can inform strategies for improvement, such as implementing best practices from higher-performing institutions. 

The analysis stage is critical for transforming raw data into actionable insights and understanding healthcare quality factors (2). Through descriptive analysis, root cause analysis, statistical techniques, and benchmarking, healthcare organizations can gain valuable insights that drive evidence-based decisions and interventions to improve care quality (6). 

Benchmarking 

The benchmarking stage in quality improvement data collection is a crucial phase where healthcare organizations compare their performance against established benchmarks or best practices (1). This gives healthcare organizations a clear understanding of their position relative to recognized standards and allows them to effectively identify areas for improvement, prioritize, and focus their improvement efforts (5). Let's delve into the benchmarking stage in detail below. 

• Defining Benchmarks: In the benchmarking stage, healthcare organizations must define the benchmarks or standards against which they will measure their performance. These benchmarks can be internal (comparing current performance to historical data) or external (comparing to industry standards, best practices, or similar organizations) (1). For example, a primary care clinic seeking to improve appointment scheduling efficiency may choose to benchmark its appointment wait times against industry benchmarks for acceptable wait times. 
• Collecting Comparative Data: Gathering data that allows for a meaningful comparison is critical in benchmarking, so healthcare organizations must collect data from relevant sources to measure their performance against the chosen benchmarks (1). Continuing with the appointment scheduling example, the clinic may collect data on the time it takes to schedule an appointment, the number of scheduling errors, and patient feedback. This data is then compared to industry benchmarks or best practices. 
• Identifying Performance Gaps: The benchmarking process reveals gaps or disparities between an organization's performance and the benchmarks to highlight improvement areas (1). For instance, if the clinic discovers that its appointment wait times are significantly longer than industry benchmarks, this identifies a performance gap that needs to be addressed to enhance patient access and satisfaction. 
• Developing Improvement Strategies: Healthcare organizations can develop targeted improvement strategies once performance gaps are identified. These strategies are based on evidence from the benchmarking process and aim to align performance with or exceed established benchmarks (1). In our scenario, the clinic may implement strategies such as optimizing appointment scheduling processes, enhancing staff training, or using technology to improve scheduling efficiency. 

Change Models in Healthcare 

Change models are essential frameworks used in healthcare, including nursing, to guide and manage the effective implementation of quality improvement initiatives (15). These models offer structured approaches to initiate, plan, execute, and sustain changes in healthcare practice (15). Let’s discuss some prominent change models used in nursing quality improvement below. 

• Kotter's 8-Step Change Model: Developed by Dr. John Kotter, this model emphasizes the importance of creating a sense of urgency, building a guiding coalition, and sustaining the change (15). For instance, in a nursing scenario focused on reducing hospital-acquired infections, the 8-step model would involve creating urgency by highlighting the impact of infections on patient safety, assembling a coalition of nurses and infection control specialists, and sustaining change by monitoring infection rates over time and continually reinforcing hygiene protocols. 
• Lewin's Change Management Model: Lewin's model consists of three stages: unfreezing, changing, and refreezing (15). Let's consider implementing a new electronic health record (EHR) system in nursing. Nurses first "unfreeze" by acknowledging the need for a new system and undergoing training. Then, they "change" by adopting the EHR and adjusting workflows. Finally, they "refreeze" by becoming proficient and maintaining the new system's use as a standard practice. 
• PDSA Cycle (Plan-Do-Study-Act): This model emphasizes iterative cycles of planning, implementing, observing, and adjusting (15). For instance, if a nursing unit aims to improve patient handoffs, they might "plan" by identifying handoff best practices, "do" by implementing changes, "study" by assessing the impact on patient outcomes, and "act" by making further refinements based on their findings. This continuous cycle allows for gradual, data-driven improvements. 
• ADKAR Model: The ADKAR model focuses on individual change management, and this could apply to a scenario where nurses are adopting new pain management protocols (15). Nurses would first need awareness of the change (A), followed by desire (D) to participate, knowledge (K) of how to implement the new protocols, ability (A) to do so, and reinforcement (R) to sustain the change over time. 

In summary, change models provide structured approaches to drive quality improvement initiatives in nursing, and by applying these models, nurses and healthcare organizations can systematically plan, implement, and evaluate changes to enhance patient care, safety, and outcomes (15).

Implementing Change 

Implementing changes for quality improvement in nursing is a multifaceted process that requires careful planning, effective communication, and the engagement of healthcare professionals at all levels. According to (15), successful implementation ensures that desired changes are integrated into daily nursing practice, improving patient outcomes. Let’s explore key strategies and considerations for implementing changes in nursing quality improvement below. 

• Engage Interdisciplinary Teams: According to (15), collaborative engagement is crucial when implementing changes in nursing practice, and healthcare organizations should assemble interdisciplinary teams that include nurses, physicians, administrators, and other stakeholders. For example, in a scenario involving the adoption of a new pain management protocol, nurses can collaborate with physicians to ensure the consistent application of evidence-based pain management practices. This team approach facilitates a shared understanding of the change and fosters buy-in from all parties. 
• Effective Communication: Clear and consistent communication is essential during the implementation phase, so nurses should communicate the rationale behind the change, its expected benefits, and the specific steps involved (15). For example, suppose a hospital is transitioning to a new electronic health record system. In that case, nurses can attend training sessions to understand its features and communicate effectively with patients about how it will enhance their care. This ensures that all stakeholders are informed and can adapt to the change seamlessly. 
• Training and Education: Providing adequate training and education is critical to equip nursing staff with the knowledge and skills to implement the change effectively (15). In the case of introducing a new wound care protocol, nurses would require training on the updated practices, wound assessment techniques, and the use of new wound care products. In addition to initial training, ongoing education would ensure that nursing staff stay current with best practices to provide quality care confidently. 
• Continuous Monitoring and Feedback: According to (15), implementing change is an ongoing process that requires constant monitoring and feedback since feedback mechanisms allow for adjustments and refinements to the change process. As a result, nursing quality improvement initiatives benefit from the regular collection and analysis of data to assess the impact of the change. For example, suppose a hospital introduces a sepsis screening tool. In that case, nurses can track the number of patients screened, identify missed cases, and evaluate whether early interventions have reduced sepsis-related mortality rates. By engaging interdisciplinary teams, fostering effective communication, providing training and education, and implementing continuous monitoring and feedback mechanisms, nurses can successfully implement changes that improve the quality of patient care and enhance overall healthcare outcomes (8). 

Evaluating Change 

Evaluating change for quality improvement in nursing is a critical phase that involves assessing the impact and effectiveness of implemented changes on patient care outcomes, safety, and the overall quality of healthcare services. According to (15), rigorous evaluation ensures that improvements are sustained, and necessary adjustments are made. Let’s explore key strategies and considerations for evaluating changes in nursing quality improvement below. 

• Establishing Clear Evaluation Metrics: To evaluate change effectively, it is essential to define clear and measurable evaluation metrics, and according to (15), these metrics should align with the specific objectives of the change initiative. For example, suppose a nursing unit has introduced a new hand hygiene protocol to reduce hospital-acquired infections. In that case, evaluation metrics may include the number of infections before and after the change, adherence to hand hygiene guidelines, and patient satisfaction scores related to cleanliness and infection prevention. 
• Data Collection and Analysis: Data collection is a fundamental component of the evaluation process, and nursing teams should collect relevant data using standardized methods and tools (15). In our scenario, data on infection rates can be collected regularly, and statistical analysis can be performed to determine whether the change has had a statistically significant impact. Nurses can then use run charts or control charts to visualize trends in infection rates over time, allowing for early detection of any potential issues. 
• Patient and Staff Feedback: Patient and nursing staff feedback is invaluable in evaluating change since patients' perspectives on the quality of care and their experiences following the change can provide insights into the initiative's effectiveness (15). Additionally, nursing staff can provide feedback on the practicality and feasibility of the new practices. For instance, nursing staff may suggest further improvements in infection control procedures. 
• Sustainability and Continuous Improvement: Evaluating change is not solely about assessing immediate outcomes but also ensuring sustainability and continuous improvement. According to (15), nursing teams should determine whether the positive effects of the change are maintained over time and whether there is room for further refinement. For example, when a nursing unit has reduced infection rates, regular audits and monitoring should continue to ensure sustained compliance with hygiene protocols. 

• Enhancing Medication Safety: Medication errors can have severe consequences for patients (6). A quality improvement project may target medication safety by introducing barcode scanning systems for medication administration, implementing double-check procedures for high-risk medications, and providing ongoing training to nursing staff. The project's effectiveness can be assessed by monitoring the number of medication errors reported and verifying that the new safety measures reduce the occurrence of such errors. For example, a nursing team could reduce the incidence of wrong-patient medication administration by implementing barcode scanning during medication administration. 

• Improving Nurse-to-Patient Ratios: Adequate nurse staffing levels are crucial for patient safety and quality of care (6). A quality improvement project may involve adjusting nurse-to-patient ratios based on patient acuity levels, introducing workload management tools, and conducting regular staffing needs assessments. In this case, the project's success can be measured by tracking patient outcomes, nurse workload, and patient satisfaction scores. For example, a nursing unit could reduce nurse burnout and improve patient care by optimizing staffing ratios during peak hours. 

• Enhancing Discharge Planning and Care Transitions: Effective care transitions from the hospital to home or other healthcare settings are essential to preventing readmissions and ensuring continuity of care (6). A quality improvement project may focus on improving the discharge planning process, including patient education, medication reconciliation, and post-discharge follow-up. Success can be assessed by monitoring readmission rates and patient-reported experiences. For example, a nursing team could work on reducing hospital readmissions by ensuring that patients receive thorough discharge instructions and have access to follow-up care. 

The above examples illustrate the diverse range of quality improvement projects in nursing, each addressing specific challenges to enhance patient safety and care quality.

Conclusion

In conclusion, this course provides essential knowledge and skills valuable for nurses aiming to deliver high-quality, safe, patient-centered care. Quality improvement in nursing is not merely a theoretical concept but a practical approach that can be applied to various aspects of healthcare, and one critical aspect to remember is the importance of interdisciplinary collaboration. As frontline caregivers, nurses must collaborate with physicians, administrators, pharmacists, and other healthcare professionals to drive improvements in healthcare delivery.  

As nurses continue to play a pivotal role in healthcare delivery, the knowledge and skills gained from this course will empower them to lead and actively participate in quality improvement initiatives. By applying quality improvement principles, nurses can contribute to better patient experiences, patient outcomes, and overall healthcare quality. 

Final Reflection Questions 

1. What have you learned from this course? 
2. Why is interdisciplinary collaboration essential for nurses to effectively implement quality improvement initiatives in healthcare settings, and how can nurses foster collaboration among healthcare professionals? 
3. How does the concept of continuous learning and adaptation align with the dynamic nature of healthcare, and what strategies can nurses employ to stay current with evolving best practices and guidelines? 
4. In what ways does Quality Improvement benefit both healthcare providers and patients?  
5. What are the potential challenges in implementing QI initiatives in a healthcare organization? 
6. In what ways has QI in healthcare become intertwined with the broader goals of healthcare reform, such as improving patient outcomes and reducing healthcare costs? 
7. What role does leadership play in the effective implementation of QI models? 
8. How can leaders promote a culture of continuous improvement within healthcare organizations? 
9. How do QI models facilitate interdisciplinary collaboration among healthcare professionals to drive improvements in patient care? 
10. What challenges might healthcare organizations face when attempting to adopt and sustain QI models, and how can these challenges be overcome? 
11. How does the "testing and learning" concept in the PDSA cycle align with the principles of evidence-based practice in healthcare? 
12. In what ways do QI models promote patient-centered care and patient safety, and can you provide examples of tangible improvements in these areas achieved through QI initiatives? 
13. How can the Six Sigma model contribute to the reliability and consistency of healthcare processes? 
14. Safe: What steps can healthcare organizations take to minimize the risk of medical errors and adverse events? 
15. Practical: How do healthcare providers ensure that evidence-based treatments and interventions lead to positive patient outcomes? 
16. Patient-centered: Why is it important to involve patients in their care decisions, and how can healthcare professionals effectively engage patients in the decision-making process? 
17. Timely: What are some key factors contributing to delays in healthcare delivery, and how can these delays be reduced to improve timeliness? 
18. Efficient: How can healthcare processes and workflows be streamlined to enhance efficiency and reduce waste? 
19. Equitable: What are some barriers to achieving healthcare equity, and how can healthcare organizations address these disparities? 
20. How can nurses actively involve patients in data collection to enhance patient-centered care? 
21. What tools or technologies are available to streamline data collection processes in nursing practice? 
22. How can nurses effectively collaborate with interdisciplinary teams to gather comprehensive data for quality improvement initiatives? 
23. What strategies can nurses employ to maintain patient privacy and confidentiality while collecting sensitive healthcare data? 
24. What methods can nurse use to analyze and interpret the data they collect to identify areas for improvement? 
25. Why must nurses regularly review and assess the data they collect to drive continuous quality improvement in healthcare settings? 
26. Regarding patient falls, what strategies can healthcare organizations implement to reduce the incidence of patient falls, and how can nursing staff actively contribute to fall prevention efforts? 
27. How can nurses ensure the accurate and safe administration of medications, and what measures can be taken to minimize medication errors? 
28. What are the key nursing practices and interventions that can prevent the development of pressure ulcers in hospitalized patients, and how can nursing staff collaborate to achieve this goal? 
29. Why is patient satisfaction an important nursing quality indicator, and what actions can nurses take to enhance the overall patient experience? 
30. What impact do nurse-to-patient staffing ratios have on the quality of nursing care, and how can healthcare organizations ensure safe nurse staffing levels? 
31. How can nurses enhance patient education to promote better understanding and self-management of their health conditions? 
32. How can you ensure that the data collected is reliable and valid? 
33. What role does standardization play in data collection for quality improvement? 
34. How can you establish baseline data for comparison in your quality improvement project? 
35. What challenges or obstacles might you encounter when collecting data for quality improvement? 
36. How frequently should data be collected to monitor progress in a quality improvement project? 
37. How can you involve frontline staff in the data collection to ensure accuracy? 
38. What measures can be taken to protect patient privacy and confidentiality during data collection? 
39. How can you analyze the data collected to identify trends or patterns? 
40. What actions should be taken if the data collected indicates a problem or deviation from the desired outcome? 
41. What strategies can ensure that data collection remains an ongoing and sustainable practice in healthcare quality improvement efforts? 
42. What are the potential challenges or resistance nurses might encounter when implementing changes using these models? 
43. How can a guiding coalition or interdisciplinary team be effectively assembled to support nursing quality improvement efforts? 
44. What strategies can nurses employ to sustain changes and prevent reverting to previous practices once implemented? 
45. How can nursing leaders ensure that staff have the necessary knowledge and skills to embrace the changes outlined in these models? 
46. How can nurses use these change models to promote a culture of continuous improvement in healthcare settings? 
47. How can nurses ensure their implementation changes align with evidence-based best practices and clinical guidelines? 
48. What potential challenges or barriers might nurse teams encounter when trying to implement changes for quality improvement? 
49. What strategies can address resistance to change among nursing staff and promote their active participation in the implementation process? 
50. How can nursing leaders effectively communicate the expected outcomes and benefits of the change to gain support and commitment from their teams? 
51. What are the advantages of using data and performance metrics to monitor the progress and impact of change implementation in nursing practice? 
52. How can nursing staff ensure that changes are sustained and become integral to their daily practice rather than temporary modifications? 
53. Why is it crucial to consider the sustainability of change when evaluating its long-term impact on nursing quality improvement? 
54. What challenges or obstacles might nurse teams encounter when collecting and analyzing data for change evaluation, and how can these challenges be addressed? 
55. How can nursing leaders encourage a culture of continuous improvement among their teams as part of the change evaluation process? 
56. What strategies can be employed to ensure that the feedback and insights gathered during the evaluation phase are actively used to refine and optimize nursing practices? 
57. What are the potential consequences of not conducting thorough and systematic evaluations of changes in nursing practice for quality improvement? 
58. How can nursing staff and healthcare organizations ensure that the lessons learned from change evaluations are applied to future improvement initiatives to enhance patient care outcomes? 

Workplace Violence Against Nurses

Introduction   

The role of the registered nurse, while fundamentally dedicated to the care and wellbeing of patients, has long been fraught with challenges that extend beyond the complexities of medical care. One such pressing concern is workplace violence, an issue that nurses confront with alarming frequency. Recent statistics show that healthcare workers, particularly nurses, are at a higher risk for workplace violence compared to other professions.  

Given the vital role nurses play in patient care and the broader healthcare system, it is imperative to understand the scope, sources, and solutions to this pressing issue. This continuing education course is dedicated to arming nurses with the knowledge, tools, and strategies to recognize, respond to, and prevent incidents of workplace violence, thereby ensuring their safety and the uninterrupted provision of quality care. 

Workplace Violence  

Definitions 

The Occupational and Safety Health Administration (OSHA) (3) defines workplace violence (WPV for the purpose of this course) as any act or threat of physical violence, harassment, intimidation, or other threatening, disruptive behavior that occurs at the work site.  This can also include verbal, written, or acts of sabotage against an individual while they are at work. 

Workplace violence crosses all demographic barriers and is indiscriminate in who it can and does affect. Even seeing workplace violence influences morale, attendance, and the overall well-being of employees and their co-workers.  

Types of Violence  

Currently, there are four categories of workplace violence according to the American Nurses Association (5).  

1: Criminal Intent - normally involves theft from the business or employees. 

Example: Carol is working on documentation and notices a person lingering in the hallway. Carol doesn’t really think anything of it, assuming they are family members of one of the patients. Several minutes later, the person exits quickly from the supply room and down the stairs. Carol calls security to let them know, but they can’t locate the individual. After looking through the supply room, they find that several containers of wound dressing supplies are missing.  

2: Customer/client/patient - the individual becomes violent with employees while receiving services. 

Example: David was updating a family on their father’s critical condition. David could tell the family was upset, but the patient’s son seemed more frustrated than the others. During David’s explanation, the son grabbed David’s clipboard and yelled, “You’re not doing anything! You’re just letting him die!” The son then threw the clipboard at David’s head. David blocked the clipboard with his arm, receiving a rather deep cut as a result. Security became involved, and David had to go to the ER for treatment.  

3: Worker on worker - an employee bullies, attacks, or threatens another employee. 

Example: Emily was rounding when Dr. G. came onto the floor. This doctor was well known for being difficult to work with, and he always required the nurses to stand behind him in the room while he talked with his patients. Emily had one of Dr. G.’s patients today and was in the room, he asked her if the patient had ambulated. Emily told him they had not, but they planned to before and after lunch. The doctor made an audible sigh and while shaking his head at the patient said, “See…this is what I deal with every day. These nurses can’t get anything right. They’re all useless.” 

4: Personal relationship - involves a person who has an interpersonal relationship with the nurse, but no association with the nurse’s employer or the business. 

Example: Rebecca was walking to her car after work. Halfway to her car, she noticed an individual leaning against the trunk of her vehicle. Rebecca recognized this person as the someone her friend was currently dating. This person approached Rebecca aggressively and began yelling about gossiping and trying to break their relationship. Rebecca started back toward the building, hoping security was nearby, and was pursued by the female. Eventually, Rebecca made it to the building and got inside. Luckily, the door only opened with an employee badge, and Rebecca was safe. She went ahead to security.  

Currently, the customer/client type of workplace violence is the most prominent, especially in healthcare and toward nurses. The American Nurses Association (ANA) reports that OSHA does not require employers to implement workplace violence prevention programs, but it supplies voluntary guidelines and may cite employers for not supplying a workplace free from recognized serious hazards.  

Some states have legislated that employers develop a program while most states have advanced laws that amend existing statute for assaults of first responders by adding health care providers / nurses and/or increasing the penalty associated with such behavior. (3) 

It is worth noting that since there are, in most cases, no actual requirements for employers to provide safe work environments for nurses, preventing and dealing with WPV proves problematic. It falls on nurses to understand what constitutes WPV, how to manage it, how to cope with it, how to report it, and how to ensure action is taken and a resolution is reached when WPV occurs.  

Epidemiology 

Workplace violence can take many forms, and the possible varieties and scenarios are endless. Regardless of how it manifests, the effects of workplace violence are clear and widespread. It can affect productivity of employees, morale, attendance, turnover rates, quality of work, patient outcomes, and much more.  

Workplace violence can affect and involve workers, clients, customers, and visitors. WPV ranges from threats and verbal abuse to physical assaults and even homicide. In 2010, the Bureau of Labor Statistics (BLS) data reported healthcare and social aid workers were the victims of approximately 11,370 assaults by persons; a greater than 13% increase over the number of such assaults reported in 2009 (10). Almost 19% of these assaults occurred in nursing and residential care facilities alone. Unfortunately, many more incidents probably go unreported (5). 

Impact on Nurses Well-Being 

Workplace violence can take a heavy toll on nurses. These tolls can be emotional, mental, and physical as well as short-term or long-term. The seriousness of these injuries can vary widely ranging from minor upset to permanent injury and in worst cases, even death. (13) 

This harm doesn’t stop with the nurse. The effects of workplace violence may also include effects spanning the unit the nurse works on or even the entire facility. Low morale, reduced productivity, lack of trust in employers, and fear of going to work can be results of violent events occurring to even a single co-worker.  

Workplace violence can also have a financial effect on nurses and their employers related to lost time at work from injury or callouts, costs of care for treatment related to the incident (physical and/or psychological), or even legal fees. (13) 

Given that incidents of workplace violence are rapidly increasing, these impacts are expected to increase as well. It is easy to see how this harm is widespread and can potentially ripple outward into the nurse’s professional and personal life. The stress and harm do not stay at work, and can spread to the nurse’s family, social interactions, and more. 

Barriers to Reporting 

One way to combat workplace violence is knowledge of its existence, its nature, and its frequency. Unfortunately, there are many factors that either prevent or discourage nurses from coming forward with reports when they are the victims of WPV.  

A study presented in a Chinese nursing journal surveyed 325 nurses. Of these nurses, 266 were spread across 165 hospitals, and these hospitals were in 72 cities.   

A total of 172 nurses (64.7%) experienced violent incidents during the past year. Of these incidents, 45.5% were reported; and the reporting rate of physical assaults (69.0%) was higher than those of verbal abuse (36.9%), threatening behavior (51.7%), and sexual harassment (60.0%). Formal reporting accounted for 25.4% (15.4% in written form and 10.0% through a computer-assisted reporting system. 

 Almost half of the nurses (49.6%) said that the hospital had no reporting system, or they were uncertain about the reporting system. For reasons of not reporting, 51.9% of the nurses were unaware of how and what types of violence to report, and 50.6% of the nurses believed that the hospital paid greater attention to patients rather than staff. (7) 

Interestingly, almost fifty percent of the nurses surveyed had limited knowledge, if any, of a reporting system available to them, while fifty percent felt the hospital favored the patients over their own employees. Combined with an actual or perceived lack of supervisory support, this encourages an environment where nurses feel powerless to protect themselves or to take proper action when threatened or harmed. 

The Minnesota Nurses Association, in August of 2022, published a press release with the results of a nursing survey on the topic of workplace violence. In this survey, ninety-seven percent of the nurses surveyed observed WPV or harassment over the previous two years.  

The top reasons cited by nurses who did not report workplace violence were lack of time due to overwork and under-staffing, cited by fifty-eight percent of respondents, and lack of action by hospital management, cited by fifty-three percent of nurses in the survey. (4) 

It would appear from these studies that many nurses feel it is futile to report incidents of workplace violence they encounter, and even if they realized an incident was reportable, they may not be aware of a way to report it or have time to do it. This perceived powerlessness and sense of futility in the face of abuse and violence will only continue to worsen unless action is taken to remove barriers to reporting and for nurses to have access to aid and support for supervisory staff. 

Culture of Safety 

A commonly used phrase is “Culture of Safety”, but is there a standardized definition of what it is or could be? Many resources point to the safety of patients about medical errors, patient rights, and protecting the patient’s information, but few address the issue facing caregivers and especially nurses. However, there is no agreed-upon or standard definition of what exactly a “culture of safety” is or what it should look like.  

The American Nurses Association approaches the concept by saying, “Establishing a culture of safety in health care is essential to the security and well-being of your patients, staff, and organization. Effective nurse leaders embrace safety protocols that ensure their organization delivers a secure, protective environment that prioritizes patients and caregivers.” (12)  

Currently, there is only a single federal legislation in place about the issue. 

The only federal regulation currently in place is the General Duty Clause of the Occupational Safety and Health Act of 1970. This clause requires employers to supply a work environment free from recognized hazards that are causing or likely to cause death or serious physical harm. However, the general duty clause offers no specific recommendations about management of workplace violence.  

The Occupational Safety and Health Administration (OSHA) issued guidelines for workplace violence prevention for health care and social service workers. First issued in 1996 and later updated, the guidelines are only advisory. (1) 

It is paramount that nurses and other direct care providers accept the responsibility of creating policies and procedures within their organizations to define and enforce a work environment where violence is not tolerated and dealt with accordingly. 

There is currently a small body of research and work of the effects workplace violence has on nurses as human beings. Most of the evidence focuses on how workplace violence increases the risk nurses present to patients in the form of medical errors, staffing issues due to missed work, poor documentation, etc. 

The main body of evidence discussing how workplace violence affects nurses is noted in research around nurse burnout. A 2020 study published by the National Health Institute (10) states, “Workplace aggression is a source of extreme socio-emotional stress, which may lead to the experience of psychological strain.  

A large body of research shows that exposure to workplace aggression and violence may severely impair healthcare workers’ mental health, including symptoms of post-traumatic stress disorder, depression, and burnout.” 

This study also shows an important association with workplace aggression and violence targeting nurses and drastically increased levels of emotional exhaustion, depersonalization, and deep feelings of poor personal accomplishment. Over time, these feelings lead to complete burnout, and even worse, possibly psychological and/or physical conditions in the nurse affected.   

Even with this preliminary information and research, we still have a long way to go to show the full and far-reaching effects of workplace violence on nurses. Again, by being proactive and acting now, we as nurses can foster this research and bring to light the issues so they can be addressed. 

ANA Zero Tolerance Policy 

In 2019 the American Nurses Association (ANA) (2) release a brief titled “Reporting Incidents of Workplace Violence”. In it, they discussed several issues surrounding workplace violence, barriers to its reporting, and made recommendations to healthcare organizations on strategies relating to the issues of workplace violence.  

They also set forth a “Zero Tolerance Policy on Workplace Violence”, which provided some definitions and several recommendations on how to deal with WPV. 

The introduction to the “Culture of Safety” part of this brief is as follows:  

By prioritizing, developing, and sustaining an organizational culture focused on safety, we can drive the future of healthcare to a place where patients and those who care for them are free from harm. It is not only one of many priorities but is the overriding ethical imperatives for all leaders. (9) 

The ANA also suggested a three-level prevention strategy, each with a part for the employer and the employee. Essentially, the role of the employer is gathering data, providing a “safe” work environment, non-punitive reporting, and development of programs to provide a safe work environment for nurses. The employee’s role is to take part in the implementation and evaluation of said programs.  

Unfortunately, these are only suggestions and employers do not have to implement any programs or services to protect employees against workplace violence. Also, healthcare employers do not have to report any incidents to JCAHO who consider events of workplace violence to be “sentinel events”.  

In the end, it falls on the nurses and employees directly affected by WPV to assume the charge against workplace violence, hold employers accountable, communicate with local and state legislators, and effect change to protect themselves. 

Strategies to Prevent Workplace Violence 

To end nurse abuse for good, Boston-Leary says it takes every nurse speaking up and reporting abuse within an organizational culture that has an established process for allowing nurses to report abuse without fear of recrimination and then follows up with a resolution. (8) 

There are some suggested actions to help prevent and combat workplace violence in your practice setting. These actions include: 

Know the definition of abuse.  

The National Institute for Occupational Safety and Health (NIOSH) defines workplace violence as “the act or threat of violence, ranging from verbal abuse to physical assaults directed toward persons at work or on duty.” 

Agreeing on this definition is an important first step to achieving widespread acknowledgement of the distinct types of nurse abuse, particularly non-physical abuse, Boston-Leary explains. (8) 

Report Abuse 

Ask about how your workplace manages abuse reporting, whether it is in your current workplace or when you are applying for a position, Boston-Leary suggests. “Ask about how reporting abuse happens during any shift because there should be a reporting mechanism in place for everyone, even if it’s on a weekend or evening shift with no manager easily accessible to report to.” 
 
If (when) you do experience abuse, it’s essential that you speak up immediately and note any witnesses who could corroborate your description of the incident, she says. 
 
Even after you experience abuse and even if you didn’t report it, it’s important to share your past abuse with others to empower them to report abuse they experience. (8) 

Change Your Culture 

Join or meet a committee to build or strengthen zero-tolerance abuse policies. Based on ANA’s Zero Tolerance Policy on Workplace Violence, Boston-Leary suggests these crucial elements of a zero-tolerance abuse program: 

Stop violence before it starts through education to find risks and reduce vulnerabilities for workplace violence. 

Create an effective response to violence immediately after it occurs, including emergency care. 

Establish long-term responses that reduce the long-term negative effects of workplace abuse. (8)  

Communicate with your Legislator! 

Congress was considering legislation to #End Nurse Abuse by passing The Workplace Violence Prevention for Health Care and Social Service Workers Act (H.R 1195). If approved, this law would have required health care and social service industry employers to develop and implement a comprehensive workplace violence prevention plan that protects nurses and other healthcare professionals from on-the-job abuse. 
 
Boston-Leary believes legislators are very attuned to the trusted voice of nurses to share about what is happening in health care today (8). 

Nurse-led Strategies 

You can join these committees or work with your employer to create them. Collaborating with your supervisory staff and HR, you can create workflows, policies, reporting methods, and provide education on prevention of workplace violence and make a difference in your overall work environment.   

Regarding Your Legislators 

As mentioned before, 2021 Congress was considering federal legislation to end nurse abuse by passing The Workplace Violence Prevention for Health Care and Social Service Workers Act (H.R. 1195). The bill was passed by the House on April 16, 2021, but was never passed by the Senate.  

You can find your local and state legislator contact information very easily on the internet. A simple search for “how to find state legislator contact information” is a wonderful place to start. As a voting citizen, you have every right to contact them, and demand laws be created to protect you while you work.  

Below are some links to help you find elected officials: 

• https://www.usa.gov/elected-officials 
• https://www.usa.gov/state-governor 
• https://www.senate.gov/senators/senators-contact.htm 
• https://www.house.gov/representatives/find-your-representative 

Advocate for your own safety the same way you would for your patients!  

As nurses we aren’t afraid of stepping up to bat for our patients when they need something, but we are notorious for taking a hit and letting it slide, sometimes even to our own detriment.  

We owe it to ourselves to offer that same level of advocacy to ourselves and our co-workers.  

Resources 

The Joint Commission supplies resources available to report and learn about how to report workplace violence. The links included are for federal, state, professional, and other resources. The direct link to this page is: 

The Joint Commission: Workplace Violence Prevention Resources 

Local law enforcement  

As a private citizen, you are protected by laws about assault, battery, and other attacks on your person. You are within your rights to call the police on events of workplace violence, especially if your life or health are threatened, or you are physically attacked. It is likely your employer will not support you in this situation due to legal implications. It is best to ask your HR department and supervisory staff how these situations should be managed if they occur. 

Legal Counsel 

Consult with a lawyer about your legal rights in situations on workplace violence and how to best manage them. Be sure to bring scenarios, information on how your employer suggests dealing with these situations, and examples of violence you have seen or have experienced.  

Educate and Train Yourself 

Learn as much as you can about recognizing and managing workplace violence. Your employer may supply these courses, and if they don’t, it may be prudent to request them. Also, you can seek outside education and training on these topics including self-defense classes and crisis management courses. 

Practice Self-Awareness 

We all have inherent beliefs, perspectives, and feelings that can prevent us from acting in certain situations. Knowing yourself and understanding possible nuances within yourself that could be a detriment to you appropriately handling a situation of workplace violence could mean the difference between prevention and becoming a victim.   

Conclusion

Being an agent of change can be intimidating, terrifying, and even force us to deal with feelings and beliefs we didn’t even realize were in our way. Incidents of WPV have been rising sharply over the past several years, and there is no sign of slowing. It’s up to us as front-line workers, nurses, and co-workers to take responsibility for our own safety and work environment.  

Through cooperation and consistency, we can create and bring solutions to the workplace and hopefully one day, aid in the creation of laws that make our jobs safer for us to supply the care and support our patients need. We owe it to ourselves to take the necessary steps to show our employers it’s time to address this issue. “Be the change you wish to see in the world.” ~Mahatma Gandhi – 

Telemetry Basics - Rhythm Recognition

Introduction   

To truly understand telemetry, nurses must have knowledge about the anatomy of the heart and how electricity passes through it, how the electrocardiograph (EKG) works to receive and record the electrical activity, and how this information is transmitted via telemetry to the appropriate receiving device.

Defined as the transmission of instrumental readings by various methods such as radio waves or wires, telemetry gathers and transmits EKG readings to a central or remote monitor for interpretation and storage (71). The ability to read EKG rhythms from a variety of monitors consists of more than looking at a rhythm strip and identifying the rhythm. It consists of knowing the anatomy of the heart, how electricity travels through it and translates into the EKG we know, and what changes can happen based on injury, electrolytes, or other causes.

Heart Anatomy 101

As we know, the heart consists of four chambers, two atria—right atria (RA) and left atria (LA)—and two ventricles—right ventricle (RV) and left ventricle (LV)—working in a cycle to ensure adequate blood flow occurs. The heart receives blood from the inferior and superior vena cava (IVC and SVC) and enters the RA, moves to the RV, passes through the pulmonary artery (PA) and lungs, returns to the LA, enters the LV, and exits the heart through the aorta.

Heart cells, known as myocytes, are negatively charged, or “polarized” at rest. When these muscle cells contract, they become “depolarized” or positively charged. But how do the myocytes know when to contract? Less than 1% of the cells in the heart have a special role and name. These are known as the pacemaker cells and their role is to ensure that the heart beats. This is done through the action potential that is spontaneously created by the pacemaker cells. Some of these pacemaker cells have different speeds in depolarization, meaning that the fastest pacemaker cells are the ones controlling the speed. This will make more sense later when discussing specific cardiac rhythms (69).

Starting in the right atria, the sinoatrial node (SA node) is the primary group of pacemaker cells that determines the heart rhythm. The SA node, as well as the other pacemaker cells within the heart, progress through a rapid depolarization and repolarization process (2).

Pacemaker cells do not have a true resting potential, this means they are always in an “unstable” state to create spontaneous action potential. The action potential is the brief reversal of polarity in the cell; polarity consists of potassium (K⁺) in the cell with a negative charge, while sodium (Na⁺) and calcium (Ca⁺⁺) are outside of the cell with a positive charge (2).

Starting at the beginning of the cardiac cycle the pacemaker cells always have a membrane potential or voltage—the voltage of the cellular membrane as a result of permeability and concentrations of ions inside and outside the cell—of -60 microvolts (mV). From -60mV to -50mV the channels within the cells open, leading to a slow influx of Na⁺ inside the cell and a slow depolarization of the cell. Once the membrane voltage has reached the minimum threshold of -50mV the Ca⁺⁺ channels open, causing Ca⁺⁺ to move into the cell. This is known as the rising depolarization phase. The membrane voltage reaches the peak and the next thing that happens is the falling repolarization phase. This is where the K⁺ channels open to return the cell to a repolarized state (2).

(20)

Once these steps have occurred, the energy is transferred to surrounding cells, and the cardiac cycle continues. However, the action potential in the other myocytes is slightly different. Myocytes have a resting potential, which is different from the pacemaker cells. The resting potential is around -90mV and these cells only start the depolarization process when stimulated by an external force. During the end of the pacemaker cell’s action potential phase, additional Ca⁺⁺ is passed into the neighboring myocytes through gap junctions. The introduction of Ca⁺⁺ into the cell causes a sharp rise in the membrane voltage that approaches the threshold which is -70mVs. Once that threshold has been reached, the NA⁺ fast channels open and a rapid depolarization occurs since Na⁺ is brought into the cell. The Ca⁺⁺ slow channels open at -40mVs, further causing depolarization with Ca⁺⁺ entering the cell (2).

At the peak of cellular depolarization, the Na+ channels close, leading to a slight repolarization through some K⁺ entering the cell. This is minor as the Ca⁺⁺ channel is still open and continues to move K⁺ out of the cell. A plateau is created because of this and allows for the cell to go through two important phases. The first phase starts when the membrane voltage increases from the resting potential and continues until the plateau phase ends. This is known as the absolute refractory period and is where the myocytes relax before they can respond to additional stimuli. It prevents summation and tetanus which could lead to the heart not beating. The second phase is where additional Ca⁺⁺ is pulled out of the sarcoplasmic reticulum (SR) to further push K⁺ out of the cell (2).

The phase ends when the Ca⁺⁺ channel closes, extra Ca⁺⁺ is sent back to the SR, and K⁺ is allowed back into the cell. The sodium/potassium pump allows Na⁺ to exit the cell, returning the cell to its resting potential. This rapid process occurs in every myocyte for the life of the cell. Pacemaker cells are the only cells that can generate a heartbeat. Impulses from the nervous system can increase or decrease the heart rate, but they are influencing the pacemaker cell to generate more beats, not creating them (2).

It is important to note that there are several sets of pacemaker cells within the heart. The SA node starts the process, but there are a few others spaced out along the electricity’s path to ensure that the atria and ventricles of the heart have time to fill and properly contract. The second set of pacemaker cells is the atrioventricular node (AV node) where a slight delay of 0.01-0.05 meters per second (m/s) happens to make sure that the ventricles fill up adequately. The bundle of His takes the electric impulse to the left and right bundle branches and from there, the Purkinje Fibers are triggered. These fibers have a speed of 2-4 m/s to provide enough force to eject the blood from the ventricles (69).

Correlating all of this back to telemetry, scientific development within the medical profession has allowed us to visualize this electrical activity and translate it into an effective method of diagnosing cardiac conditions such as abnormal heart rates or cell death.

Types of Telemetry

EKG

There are many ways to view cardiac rhythms now, however, the oldest method is the EKG. During the late 1700s, the Italian physician Luigi Galvani was experimenting with electricity and animal tissue. His experiments spanned at least three decades and inspired other physicians during and after his time. Using legs removed from the bodies of frogs, Galvani theorized that “animal electric fluid” enabled the muscles within the legs to move when touched by metals; according to him, this was “natural” fluid and not created as static electricity or friction is. He went on to theorize that the brain is an essential part of creating the “electric fluid” with nerves as the conductors (6).

Jumping forward to 1842, Doctor Carlo Matteucci made a significant contribution to EKGs. During his time researching electrical detection in animals, he discovered the electrical currents within the heart that accompany each heartbeat. Thirty-five years after Matteucci, Augustus Waller was able to use a capillary electrometer and electrodes to perform the first human EKG. These electrodes were placed on the chest and back of the participant and were vital in demonstrating there was electrical activity that preceded the contraction of the ventricles. William Bayliss and Edward Starling improved upon Waller’s research by using improved capillary electrometers to demonstrate triphasic cardiac electrical activity (1).

The Dutch physician most noted for creating the EKG known today was Doctor Willem Einthoven. He was inspired by Waller and those before him to improve the capillary electrometer, successfully identifying five deflections that were initially named ABCDE. Having to factor for inertia, Einthoven implemented mathematic correlation, resulting in the traditional EKG rhythm strips we use today with the letters PQRST depicted in the image below. Einthoven is also responsible for coining the word electrocardiogram or electrokardiogram in Dutch. This is where providers get the “k” in EKG from (1).

While Waller’s EKG utilized ten electrodes, Einthoven was able to condense that number to three, eliminating the right leg and the mouth electrodes. These three leads created Einthoven’s triangle; an important concept still used today and that will be discussed later. All of Einthoven's work resulted in him being awarded the Nobel Prize in Physiology and Medicine in 1924 (1).

Bedside Monitor

Emergency departments (ED), intensive care units (ICU), and other specialized areas that require continuous monitoring of a patient’s EKG and vital signs utilize various bedside monitors to ensure they are receiving accurate, real-time information on the patient. Cords are used to connect the patient to the monitor. The electrodes to display and document cardiac rhythm and heart rate are applied to patients in the standard 5 lead placement displayed in the below image. The vitals displayed on the monitor can also be displayed outside the room on a screen with multiple patients. Nurses, paramedics, or trained telemetry monitor technicians can watch many of these monitors at a time.

(14)

The placement of the five leads consists of the following:

• RA: 2^nd intercostal space, anterior axillary on the right – some providers may put this lead higher on the chest or on the right arm
• LA: 2^nd intercostal space, anterior axillary on the left – some providers may put this lead higher on the chest or on the left arm
• RL: 8^th intercostal space, anterior axillary on the right – some providers may put this lead lower on the abdomen
• LL: 8^th intercostal space, anterior axillary on the left – some providers may put this lead lower on the abdomen
• V: 4^th intercostal space, right margin of the sternum

Note: Always follow the manufacturer’s instructions for specific lead placement.

Helpful Tip: Many healthcare providers quickly remember lead placement based on color is smoke (black) over fire (red) and snow (white) over grass (green). This leaves brown (chocolate) in the middle.

These bedside monitors can monitor pulse oximetry, respiratory rate, temperature, capnography, blood pressure, and arterial pressure. Some devices may have other unique monitoring features. These monitors may be portable or have a way to transfer the cords to a transport monitor. They come with alarms that can be adjusted based on the patient’s unique vital signs or hospital policy.

First responders have similar devices they use when transporting patients with the added benefit of having a defibrillator and a real-time feedback device built in (91).

Remote Monitoring

Remote cardiac monitoring is similar to bedside monitoring; however, the EKG rhythm, heart rate, and pulse oximetry are not displayed at the bedside. Instead, they are displayed in a different location, sometimes a monitor room, where a trained professional is watching many patients. When they recognize an abnormal rhythm, they will contact the appropriate staff to assess the patient. They may call for the leads to be removed, a change in rhythm, or a low battery.

The EKG leads are placed the same way as the bedside monitor leads are placed (always be sure to consult the manufacturer’s instructions). The information is transmitted wirelessly via wireless medical telemetry service (WMTS) from the “tele box,” but the leads must be wired to the box. WMTS does not use Wi-Fi and protects transmissions from Wi-Fi interference (48).

Mobile Cardiac Monitor and Event Monitor

A mobile cardiac or event monitor is a device attached to the skin that can perform continuous or event-specific monitoring. This device is attached to the patient’s chest near the heart and records when activated. This device is smaller than other portable cardiac monitoring devices like the Holter Monitor which will be discussed later. Information can be transmitted to the monitoring center to be reviewed by trained staff and/or artificial intelligence. Abnormalities like tachycardia, bradycardia, atrial fibrillation, or cardiac pauses are reported to a physician. The patient may or may not know about the rhythm abnormalities occurring as some patients are asymptomatic (18).

Event monitoring consists of the following methods (23):

• Patch monitor: depending on the manufacturer, the device is stuck to the chest and left on for a designated period of time.
• Loop memory monitor: the sensors always stay on the patient and the patient activates the devices to begin recording when symptoms occur in addition to a few minutes before the event starts and after it ends. There is an implanted option as well.
• Symptom event monitor: Patients place the monitor on them and activate it like a patch monitor, but only when symptoms start.

Insertable Monitor

Insertable or implantable cardiac monitors are just like mobile and event monitors, but they are surgically inserted into the patient. They perform the same actions, but there is an added benefit to these devices. If the patient has worn an external device in the past and has known cardiac arrhythmias, they may have an implanted cardioverter-defibrillator (ICD) inserted to detect and treat the abnormal rhythm. These devices are connected to the heart via wires (they may be placed in the right atria, the right ventricle, or both) and are operated by batteries that do need to be changed per manufacture direction. Patients and providers should be aware of magnets, or electrical signals from other devices that can interfere with the insertable device (61).

Healthcare providers can “interrogate” ICDs or pacemakers with a device created by the monitor’s manufacturer. When interrogated, the device’s information is transmitted to a monitor center who calls the provider to give them a verbal report of what the device has recorded; a paper copy is often faxed to the provider as well. Some newer interrogation devices may display the information of the device on the screen.

Holter Monitor

As mentioned with mobile cardiac monitors, the Holter monitor is another wearable device that can be used to monitor and diagnose cardiac arrhythmias outside of the hospital setting. This device consists of five electrodes and a monitor that the patient can wear or carry on them. It is similar to the remote telemetry devices used in the inpatient hospital setting as shown in the next image. Patients wear this device for a short time, and information is not transmitted to a monitor technician. Instead, information collected is sent to a monitoring center where it is interpreted and sent to the physician (58).

As covered in this section, there are many options for cardiac telemetry monitoring, and providers may encounter many types of them. It is important to know these devices and how they operate.

Lead Placement

Now that we have discussed the types of telemetry monitoring devices that are available, it is time to discuss how to properly place the EKG leads on a 12 lead, 15 lead, right-sided EKG, and where to place the V₄R lead.

12 Lead EKG

For the 12 lead EKG, providers should start with the four limb leads (14):

• RA: On the upper or lower right arm
• LA: On the upper or lower left arm
• RL: on the upper or lower right leg
• LL: on the upper or lower left leg

From there, the six pericardial leads are placed strategically around the chest to create a partial circle around the heart (14):

• V1: 4^th intercostal space, right margin of the sternum (this is lead V on the 5 lead EKG)
• V2: 4^th intercostal space, left margin of the sternum
• V3: sits midway between leads V2 and V4 on the left
• V4: 5^th intercostal space, mid-clavicular line on the left
• V5: 5^th intercostal space, anterior axillary line on the left (aligned horizontally with V4, between V4 and V6) on the left
• V6: 5^th intercostal space, mid-axillary line on the left (aligned horizontally with V4)

15 Lead EKG

The 15 lead EKG uses the same leads as the 12 lead EKG, but it adds V7, V8, and V9, known as the posterior leads, to encompass the posterior angles of the heart (14):

• V7: left posterior axillary line (aligned horizontally with V6, across from V5)
• V8: tip of the left scapula (aligned horizontally with V6, across from V4)
• V9: left of the spinal column (aligned horizontally with V6, across from V3)

Right Sided EKG

The right-sided EKG is important to rule out the diagnosis of a right-sided myocardial infarction (MI) or ischemia in or out while treating a patient. Lead placement is the same for the four limb leads, but the 6 precordial leads are flipped (14):

• V1: 4^th intercostal space, left margin of the sternum
• V2: 4^th intercostal space, right margin of the sternum (this is lead V on the 5 lead EKG)
• V3: sits midway between leads V2 and V4
• V4: 5^th intercostal space, mid-clavicular line on the right
• V5: 5^th intercostal space, anterior axillary line on the right (aligned horizontally with V4, between V4 and V6)
• V6: 5^th intercostal space, mid-axillary line on the right (aligned horizontally with V4)

V4R Lead Placement

A full right-sided EKG is not always needed. Lead V4 on the right side of the heart is the most important lead when it comes to determining an MI on the right side of the heart (14):

• V1, V2, V3, V5, V6: same placement as the 12 and 15 lead EKGs.
  • V4 is removed and placed on the right side of the chest
• V₄R: 5^th intercostal space, mid-clavicular line on the right (Where it is located on a complete right sided EKG)
  • The “R” stands for right to ensure that those reading the EKG are aware that lead is on the right while the rest are located on the left side of the chest.

Limb Leads

Now that lead placement has been covered, we can now discuss how lead placement shows different parts of the heart.

Leads I, II, III, AVR, AVL, and AVF are considered limb leads when reading the EKG. It is important to note that the right leg lead is the grounding electrode and does not affect the EKG (83). Leads I, II, and III leads form a triangle over the chest known as Einthoven’s Triangle as reflected in the below image. Lead I always has negative polarity while lead III always has positive polarity. Lead II’s polarity depends on what side of the triangle is being discussed. If we are looking at lead I on the EKG, then lead II is positive, but if we are looking at lead III, then lead II is negative (82).

The importance of what leads are negative and positive comes from how electricity travels through the heart. It starts on the right side and moves to the left, so it would make sense for lead I to have negative polarity while leads II and III are positively charged (82). This is also why the height of a PQRST complex changes based on what lead is being looked at on an EKG as reflected below.

Augmented or unipolar leads AVR, AVL, and AVF have the heart as the negative electrode and the limb leads are the positive electrodes. AVR goes from the heart to the right arm lead, AVL goes from the heart to the left arm lead, and AVF goes from the heart to the left leg lead. Just as discussed with leads I, II, and III, the path of the electricity in the heart determines how the PQRST complex appears on the rhythm strip (82). Lead II is the preferred strip to read by providers due to the best view of the rhythm due to the way electricity travels through the heart and how lead II follows that path by starting at the right shoulder and going to the left leg.

The chest leads, V1 – V9, create a circle around the heart on a horizontal plane. These leads are unipolar as well, with the heart being the negative electrode. Multiple views of the heart are captured because of the many leads placed along the patient’s body. This can give providers valuable knowledge on what areas of the heart may be affected. The next image gives a visual depiction of how the leads display their view of the heart.

Reading EKGs: EKG Components

To be able to interpret EKGs successfully, nurses must first have knowledge about the EKG components displayed on the EKG strips and how each part correlates to a part of a single heartbeat.

P wave

The P wave is the first deflection from the isoelectric line or baseline. Correlating this to the heart, this is where the atria depolarize or contract. The contraction of the right atria starts at the beginning of the P wave while the contraction of the left atria begins in the middle and end of it. Normal P waves are apparent between 120 and 200 milliseconds (msec) before the upward deflection of the QRS complex (44)

PR Interval

The next part of the PQRST complex is the PR interval. The interval symbolized the time between the depolarization of the atria and the depolarization of the ventricle. The normal speed is 120 to 200 msec (44).

PR Segment

Next is the PR segment. This is similar to the PR interval but starts at the end of the P wave and ends at the start of the Q wave. This line is important because if there is a deviation from the isoelectric line, it could indicate a cardiac rhythm abnormality like Wolff-Parkinson-White syndrome which will be discussed later. The EKG may have a “slurred” upstroke from the P to R points on the EKG, making the Q wave appear to be on the isoelectric line. This is because the ventricles were stimulated or excited early, leading to a shortened PR interval. The “slurred” area is known as a delta wave (13).

QRS Complex

The QRS complex is where the ventricles depolarize and contract. The first downward deflection of the beat is the Q wave that lasts for < 0.05 seconds. It is present in all leads save for V1 and V3 due to the angle of the vector. The R wave is the upward deflection of the complex. R waves do not have a set height, but severely elevated R waves can be an indicator of ventricular hypertrophy. The second downward deflection is the S wave. Overall, the QRS complex is 0.07 to 0.10 seconds long and variations to this time can be an indicator of abnormal heart rhythms (17).

ST Segment

The ST segment starts when the S wave ends by returning to the isoelectric line and ends when the T wave begins. This period represented the completion of ventricular depolarization (17). The ST segment lasts 0.08 seconds to 0.12 seconds (51).

T Wave

The final wave in the standard EKG components is the T wave. This wave symbolizes the ventricles repolarizing. Inverted T waves can be an indication of past or current infections. A peaked T wave—as opposed to the normal curved T wave—can be caused by hypocalcemia, hyperkalemia, and left ventricular hypertrophy (17). The T wave runs from 0.01 seconds to 0.25 seconds (51).

The image below depicts the components of an EKG with labels to assist with understanding how the waves appear.

(4)

Reading EKGs: EKG Paper

The EKG paper has sets of squares, 25 little squares within one larger square. The smaller squares symbolize 0.04 seconds making the larger square 0.20 seconds. A single small square is 1mm while the large square is 5mm, this is because the larger square is five small squares tall.

(15)

Some EKG strips are presented in a six second format. To determine if the strip is a six-second, you must count the larger boxes. 30 larger boxes are required for the strip to be six seconds. Some may even have second markers that symbolize one second of time passed.

The 12 lead EKG can be more challenging to read and is often used to make an overall observation about the patient’s heart rate and rhythm. It can provide more information to providers than a single lead strip can. 

As discussed previously, the leads are placed along the path of the heart, and providers can determine what part of the heart may be affected by knowing what leads are placed where.

(51)

Now that we have discussed leads, lead placement, the PQRST complex, and EKG paper, it is time to cover different cardiac rhythms that you may encounter.

Rhythm Recognition

Normal Sinus (41):

• Rate: 60-100 beats per minute (bpm)
• Conduction:
  • PR interval 120-200ms
  • QRS width 60-100ms
• P wave morphology:
  • The maximum height of the P wave is:
    • Lead II and III: 2.5 mm
  • The P wave is:
    • Positive or above the isoelectric line in II and AVF
    • Biphasic (curves above and then dips below the isoelectric line) in V1
  • Duration:
    • Less than 0.12 seconds
  • Rhythm Strip:

(29)

Sinus Bradycardia (87):

• Rate: less than 60bpm
• Conduction:
  • PR interval 120-200ms
  • QRS width 60-100ms
• P wave morphology:
  • The maximum height of the P wave is:
    • Lead II and III: 2.5 mm
  • The P wave is:
    • Positive or above the isoelectric line in II and AVF
    • Biphasic in V1
  • Rhythm Strip:
    

(87)

• Signs and Symptoms:
  • None – depending on the patient
  • Cyanosis
  • Peripheral edema
  • Shortness of breath
  • Dizziness
  • Fatigue
  • Syncope or near syncope
  • Lightheadedness
• Causes (not limited to):
  • Normal physiology in an athlete
  • Medications like beta-blockers
  • Ischemia
  • Heart diseases
  • Sick sinus syndrome
  • Hypothermia
  • Hypothyroidism
  • Neuro-mediated bradycardia as caused by a vasovagal reaction
  • Pericarditis
  • Hypoxia

• Electrolyte imbalances

• Treatment:
  • None if asymptomatic, admission for observation may be indicated
  • Medications:
    • Atropine 0.5mg every 3 to 5 minutes for a maximum dose of 3mg
    • Antidotes or reversal agents
  • Transcutaneous cardiac pacing or pacemaker
  • Return patient to a normothermic state if hypothermic

Sinus Tachycardia (55):

• Rate: greater than 100bpm but less than 150bpm
• Conduction:
  • PR interval 120-200ms
  • QRS width 60-100ms
• P wave morphology:
  • The maximum height of the P wave is:
    • Lead II and III: 2.5 mm
  • The P wave is:
    • Positive or above the isoelectric line in II and AVF
    • Biphasic in V1
  • Rhythm Strip: