Shifting the Paradigm: Antiracist Education for Advanced Practice Nursing Providers.

Introduction: Racism in the United States adversely impacts health outcomes. Achieving health equity will require an explicitly antiracist approach to the education of health care providers (HCPs). This article examines a required course that focuses on teaching advanced practice nursing students about the structural foundations of racism. This approach shifts significantly away from teaching race-based medicine (which assumes a biological basis for disparities) and the social determinants of health (which often blames individuals for disparities). Methods: A mixed methods evaluation was conducted to understand the change in learners' understanding of (1) structural racism and (2) the role that HCPs can play in addressing structural racism. Anonymous surveys asked the following: (1) What are three examples of structural racism in the context of health care? and (2) What is the HCP's role in addressing structural racism? Results: Statistically significant increases were observed. The percentage of students who could provide at least one example of structural racism increased from 41% to 70%. Significant increases were also found in students' abilities to identify structural and institutional antiracist interventions. Discussion: This project yields important data that can inform educational efforts focused on structural racism. The results strongly suggest that the course resulted in a change in student understanding of racism in health care and strategies to address it. Health Equity Implications: The development of a required course for advanced practice nurses focused on structural racism, including attention to social and institutional interventions, can significantly shift HCP understanding and is one strategy to move us toward health equity.

Success indicators for an accelerated masters entry nursing program: staff RN performance.

The purpose of this exploratory research study was to assess employment performance outcomes of students who completed the prelicensure segment of an accelerated graduate entry program, the Masters Entry Program in Nursing (MEPN) at the University of California, San Francisco. MEPN RNs and their managers at three study sites completed a survey constructed from staff RN performance criteria position descriptions and participated in focus groups. Data were used to evaluate staff RN employment performance and how well the educational program prepared students for the staff RN role. Findings indicate that MEPN RNs' self-assessment and their managers' performance evaluation were rated as very effective in their staff RN roles, regardless of years of nursing experience. Recommendations for further research are discussed, encouraging the use of employment performance criteria as an additional way to evaluate the quality of nursing educational programs.

Meeting the nursing faculty shortage challenge: an accelerated doctoral program in nursing.

In 2003, the Gordon and Betty Moore Foundation partnered with a major west coast school of nursing to create an accelerated doctoral program in nursing. The program's chief aim was to address the nursing shortage by increasing the number of nurse faculty by funding 42 doctoral students in five cohorts. Students accepted into the accelerated program receive a generous stipend and commit to earn their doctorate in 3 years and teach for 3 years after graduation at 1 of 17 area nursing programs. Two cohorts have graduated from the accelerated program and are currently in faculty positions. This article describes the accelerated doctoral program and the academic progression and postgraduation employment of the first two cohorts.

Water consumption beliefs and practices in a rural Latino community: implications for fluoridation.

OBJECTIVE: Adequate fluoride exposure is especially important for those experiencing disproportionately high prevalence of dental caries, such as rural Latino farm-workers and their children. Water is an important source of fluoride. This qualitative study examined water consumption beliefs and practices among Latino parents of young children in a rural community. METHODS: Focus groups and open-ended in-depth interviews explored parents beliefs about tap water, beverage preferences, and knowledge of fluoride. A questionnaire documented socio-demographic characteristics and water consumption practices. Qualitative analysis revealed how water-related beliefs, social and cultural context, and local environment shaped participants' water consumption. RESULTS: The vast majority of participants (n = 46) avoided drinking unfiltered tap water based on perceptions that it had poor taste, smell, and color, bolstered by a historically justified and collectively transmitted belief that the public water supply is unsafe. Water quality reports are not accessible to many community residents, all of whom use commercially bottled or filtered water for domestic consumption. Most participants had little knowledge of fluoride beyond a general sense it was beneficial. While most participants expressed willingness to drink fluoridated water, many emphatically stated that they would do so only if it tasted, looked, and smelled better and was demonstrated to be safe. CONCLUSIONS: Perceptions about water quality and safety have important implications for adequate fluoride exposure. For vulnerable populations, technical reports of water safety have not only to be believed and trusted but matched or superseded by experience before meaningful change will occur in people's water consumption habits.

Barriers to workers' compensation and medical care for injured Personal Assistance Services workers.

OBJECTIVES: We documented barriers to workers' compensation and injury-related medical care faced by homecare or Personal Assistance Services (PAS) workers. We explored differences between independent providers and agency-employed workers. METHODS: We conducted in-depth, semi-structured interviews with a diverse sample of 38 injured workers. Participants were primarily female and racial-ethnic minorities. RESULTS: Most participants (82%) were independent providers. Common barriers to reporting injury included commitments to clients and financial pressure. Unlike agency employees, many independent providers knew little about workers' compensation eligibility and injury reporting procedures, and frequently were given "the runaround" by the social service bureaucracy when they attempted to report injury and access injury-related medical care. Among independent providers, delays in filing a claim and receiving timely medical attention were common. CONCLUSIONS: The lack of a traditional employment infrastructure has important implications for vulnerable workers' health and the sustainability of consumer-directed PAS programs. We provide recommendations for improving workers' access to workers' compensation and injury-related medical care.

Associations between psychological demands, decision latitude, and job strain with smoking in female hotel room cleaners in Las Vegas.

BACKGROUND: Little is known of the impact of the work environment on smoking among women holding low-paid jobs in the service sector. PURPOSE: To study the associations between the components of the demand-control model with smoking in hotel room cleaners. METHODS: We conducted a survey on work and health among 776 female hotel room cleaners in Las Vegas. Associations between psychosocial work characteristics and smoking were analyzed with multivariate regression analyses. RESULTS: Psychosocial work characteristics were associated with smoking after adjustment for covariates. Effect estimates were substantially reduced by additional adjustment for ethnicity, but remained significant for high psychological demands and smoking prevalence (OR = 1.97, p = 0.02), high job strain and smoking prevalence (OR = 1.87, p = 0.04), and high job strain and smoking intensity (coefficient = 3.52, p = 0.03). When analyses were restricted to Hispanic workers and further adjusted for place of birth, low decision latitude (coefficient = 3.94, p = 0.04) and high job strain (coefficient = 4.57, p = 003) were associated with smoking intensity but not with smoking status. CONCLUSION: Workplace smoking cessation programs may benefit from a primary prevention component reducing job strain among service workers. More research is needed on perceived and objective differences in psychosocial work characteristics across ethnic, immigrant, and other social groups within the same occupation.

Women's perceptions of neighborhood resources and hazards related to diet, physical activity, and smoking: focus group results from economically distinct neighborhoods in a mid-sized U.S. city.

PURPOSE: To investigate women's perceptions of neighborhood resources and hazards associated with poor diet, physical inactivity, and cigarette smoking. DESIGN: After interviewing city officials and analyzing visual assessments, three economically distinct neighborhoods in a mid-sized city were selected. SETTING: Salinas, California, a predominantly Latino city. METHODS: Eight fobcus groups, conducted in Spanish or English in the three neighborhoods. Thematic coding of focus group transcripts identified key concepts. Women also mapped their perceived neighborhood boundaries. Participants. Women who had at least one child under age 18 living with them. RESULTS: Women identified food stores, parks, recreation areas, and schools as key resources in their neighborhoods. They identified fast food restaurants, convenience stores, violent crime, gangs, and drug-associated issues as "hazards". Distinctions between resources and hazards were not always clear cut. For example, parks were sometimes considered dangerous, and fast food restaurants were sometimes considered a convenient and inexpensive way to feed one's family. Women's perceptions of their neighborhood boundaries differed greatly by type of neighborhood-the perceived neighborhood area (in acres) drawn by women in the lower-income neighborhood was one-fourth the size of the area drawn by women in the higher-income neighborhood. CONCLUSION: This qualitative, exploratory study illustrates how resources and hazards in one's neighborhood cannot be viewed as having solely one dimension-each may influence health behaviors both positively and negatively.

Older adults' perspectives on key domains of childhood social and economic experiences and opportunities: a first step to creating a multidimensional measure.

OBJECTIVES: Although research has found that childhood socioeconomic status (SES) is associated with physical and mental health in mid- and later life, most of these studies used conventional, single dimension SES measures for the childhood period such as household income or educational attainment of parents. Life course and health disparities research would benefit from identification and measurement of a variety of childhood social and economic experiences and opportunities that might affect health in later life. DESIGN: This study utilized qualitative research methods to identify key dimensions of childhood experiences related to SES. We conducted in-depth interviews with 25 adults age 55 to 80 years from diverse economic and ethnic backgrounds. Topics included home, neighborhood, school, and work experiences during early childhood and adolescence. Interviews were audio-taped and transcripts were coded to identify thematic domains. RESULTS: We identified eight thematic domains, many of which had clear subdomains: home and family circumstances, neighborhood, work and money, potential for advancement through schooling, school quality and content, discrimination, influence and support of adults, and leisure activities. These domains highlight individual characteristics and experiences and also economic and educational opportunities. CONCLUSION: These domains of childhood social and economic circumstances add breadth and depth to conventional conceptualization of childhood SES. When the domains are translated into a measurement tool, it will allow for the possibility of classifying people along multiple dimensions, such as from a low economic circumstance with high levels of adult support.

Barriers to documenting occupational injuries among personal assistance services workers.

BACKGROUND: Personal Assistance Services (PAS) workers provide essential support to disabled and elderly individuals living at home rather than institutions. Occupational injury risks are known, but limitations in occupational injury surveillance prevent assessing injury prevalence. Changing employment arrangements adopted by publicly funded programs may complicate the classification of PAS workers. METHODS: We surveyed state workers' compensation agencies and Financial Management Services organizations used by state Medicaid programs. RESULTS: Changing employment arrangements pose further barriers to classifying and documenting injury, and accessing workers' compensation coverage. Workers' Compensation coverage varies according to employment arrangements of the PAS workers. Financial Management Services organizations vary in their roles for reporting injury. Most frequent activities were providing written information about injury reporting, and reporting injuries to appropriate agencies or insurance companies. CONCLUSIONS: Current limitations undercount the prevalence and consequences of PAS-related occupational injuries among agency workers and largely ignore independent providers. Policy and research recommendations are presented.

Financial management services in consumer-directed programs.

Shifting from an agency-based model of personal assistance services to consumer direction has important consequences for both recipients and workers. In consumer direction, recipients assume the responsibilities of employing their attendants--for both self-directing their supportive services and being responsible for numerous fiscal responsibilities. Many states have eased these fiscal responsibilities among recipients in publicly financed personal care programs by using Financial Management Services (also known as fiscal intermediaries). This article introduces the major types of Financial Management Services organizations used by Medicaid consumer-directed personal care programs, and examines the extent to which the varied approaches can and do serve the needs of both recipients and workers. Despite the expansion of consumer-directed programs and the accompanying emergence of Financial Management Services, these organizations have not been extensively studied or evaluated. The paper concludes with a discussion of the challenges, opportunities, and policy implications of the current practice; and suggests directions for future research.

Psychosocial work environment of hospital workers: validation of a comprehensive assessment scale.

BACKGROUND: Studies have shown that adverse workplace factors can increase the risk of ill-health in hospital workers, but more comprehensive measures of the psychosocial work environment are needed. OBJECTIVES: To test a comprehensive and theory-based psychosocial work environment questionnaire and analyze associations with mental health in a sample of Danish hospital workers. DESIGN AND PARTICIPANTS: Questionnaire-based cross-sectional study with 343 female employees from a large Danish hospital, including patient care workers (nurses, nurse assistants, midwives) and laboratory technicians. METHODS: The psychosocial work environment was measured with 14 scales from the Copenhagen psychosocial questionnaire, version I, covering three main areas: demands at work, work organization and interpersonal relations at work. We further measured self-rated mental health and sociodemographic and employment characteristics of the participants. Cronbach's alphas, analyses of covariance, one-sample t-tests, partial correlations and linear regression models were used to analyze data. RESULTS: Of the 14 work psychosocial workplace scales 12 showed a satisfactory internal consistency (alpha>0.70). Patient care workers had more quantitative, emotional and cognitive demands (all p-values <0.001), higher work pace (p<0.001) and more role conflicts (p=0.01) than laboratory technicians, but also better work organization, including more influence at work, better possibilities for development and a higher meaning of work (all p-values <0.001). Both patient care workers and laboratory technicians had substantially higher scores on the demand scales and lower scores on the influence at work scale than the general Danish working population. Further analyses showed that high levels of demands at work and low levels of work organization and problematic interpersonal relations at work were associated with lower self-rated mental health. CONCLUSION: The Copenhagen psychosocial questionnaire is a suitable instrument to measure the psychosocial work environment of hospital workers. The comprehensive assessment of the psychosocial work environment helps tailoring interventions to the specific needs of different occupational groups.

Physical workload, work intensification, and prevalence of pain in low wage workers: results from a participatory research project with hotel room cleaners in Las Vegas.

BACKGROUND: Occupational injury rates among hotel workers exceed the national service sector average. This study assesses the prevalence of back and neck pain, and its associations with physical workload, ergonomic problems, and increasing work demands. METHODS: Nine hundred forty-one unionized hotel room cleaners completed a survey about health and working conditions. Associations between job demands and pain were determined by logistic regression models adjusting for individual characteristics, cumulative work demands, care-taking responsibilities at home, and psychosocial job factors. RESULTS: The 1-month prevalence of severe bodily pain was 47% in general, 43% for neck, 59% for upper back, and 63% for low back pain. Workers in the highest exposure quartiles for physical workload and ergonomic problems were between 3.24 and 5.42 times more likely to report severe pain than workers in the lowest quartile. Adjusted odds ratios for work intensification ranged from 1.74 (upper back) to 2.33 (neck). CONCLUSIONS: Most room cleaners experience severe back or neck pain. Severe pain showed strong associations with physical workload, work intensification, and ergonomic problems.

Work-related pain and injury and barriers to workers' compensation among Las Vegas hotel room cleaners.

OBJECTIVES: We examined the prevalence of work-related pain and injury and explored barriers to and experiences of reporting among workers. METHODS: We surveyed 941 unionized hotel room cleaners about work-related pain, injury, disability, and reporting. RESULTS: During the past 12 months, 75% of workers in our study experienced work-related pain, and 31% reported it to management; 20% filed claims for workers' compensation as a result of work-related injury, and 35% of their claims were denied. Barriers to reporting injury included "It would be too much trouble" (43%), "I was afraid" (26%), and "I didn't know how" (18%). An estimated 69% of medical costs were shifted from employers to workers. CONCLUSIONS: The reasons for underreporting and the extent of claim denial warrant further investigation. Implications for worker health and the precise quantification of shifting costs to workers also should be addressed.

Violence and gender: reports from an urban high school.

This article reports on the survey component of a study examining urban high school students' experiences with violence. The survey's purpose was to collect information on students' experiences with violence, explore gender differences, and identify which factors are associated with the self-reported use of violence. Two prominent risk factors for the self-reported use of violence were found: having a close friend or family member injured by violence, and gun possession. Young men and women did not differ significantly in overall exposure, victimization, and perpetration. However, gender clearly informed the types of violence reported. The findings offer practical strategies for addressing adolescent violence, such as reducing gun availability and community-level violence, but future research must further examine the role of gender in order to structure more effective prevention and intervention approaches that target different kinds of violence.