The Nurse Practitioner

Wednesday, November 3, 2021

Embracing refugees from Afghanistan: What NPs should know

One of the authors of this post (Dr. Breckenridge) recently arrived at the airport to board her flight and was surprised to find it packed with people. It seemed strange, since she hadn't seen packed flights for several months due to the COVID-19 pandemic. As she oriented herself to her surroundings, she realized she was standing in line with hundreds of Afghan nationals. Images from the recent news about the Taliban overtaking the country flashed in her head. She felt an overwhelming desire to welcome these people to the US. She wanted to thank those who had assisted our troops; but as she started to speak to the people next to her in line, she quickly became aware of the language barrier. She found herself frustrated and emotional. She wanted to be able to communicate with them. Her thoughts caused her to reflect further. How would she care for these families in her clinic? She also realized that she needed to learn more about their culture. These thoughts prompted her to write this piece to help other NPs who may encounter patients newly resettled in the US from Afghanistan.

Over 95,000 Afghan refugees are expected due to the recent crisis, and many began their US resettlement process in September 2021. What does the influx of Afghan refugees mean to our healthcare system and communities? What do we need to know about the health needs of this group of refugees? How can we integrate cultural sensitivity into our care for these individuals? What health issues should NPs be aware of when caring for these families and individuals? These are just some of the questions we must ask ourselves as we prepare to support this people group.

Life in Afghanistan

Understanding the Afghan cultural environment is critical. Most of Afghanistan is rural countryside where farming is the primary source of income. It is a place where what you do as an occupation carries a lot of weight. A teacher is held in high regard whereas being a barber is considered less prestigious. It is a place of ethnic diversity. There are over 20 different ethnic groups living in Afghanistan. Most people are Muslim, both Sunni and Shia. Healthcare is sparse, especially for those who live in rural Afghanistan. The average lifespan is 51 to 54 years old, and the majority of the population is under the age of 15. Clean water is a privilege in much of the country. Land mines are not uncommon and frequently injure those not aware of their presence. Education in Afghanistan is different from the US. Public elementary school is available for children in urban areas but may or may not be available in rural settings. Middle and high schools are not common, so there is a high rate of illiteracy, though this does not reflect among refugees. Most refugees are educated and have worked with the U.S. Government as support staff and interpreters. The role of women in Afghanistan has changed over the years. Some are now allowed to work, but all women continue to be required to dress conservatively with head coverings (hijab) or other “typical" Islamic dress. Most men have a beard. At one time men were jailed if they trimmed or cut their beard. The Afghan families live intergenerationally, often caring for older parents in their home. Families are typically patriarchal. Entertainment includes kite flying, soccer, and television (if you are privileged to have electricity).

Transition to US healthcare

Because the medical system in the US is different, Afghan patients may be reluctant to seek medical care as they are unfamiliar with healthcare environments. Standard clinic routines we take for granted may need explanation. Language barriers, cultural differences, and lack of relationships with medical providers are additional obstacles. An example of cultural differences in medical care may be the presence of the husband at a woman's medical visit. The male will often do the talking for the woman. Providing proper interpretation services during a medical visit is essential. Although two primary languages (Pashto and Dari) are spoken in Afghanistan, many dialects exist. Additionally, lack of trust in the government is not uncommon. NPs must be sensitive to body language that could be misinterpreted such as a thumbs up sign and winking. Additionally, these families may struggle with punctuality since it is acceptable to show up unannounced or late in Afghanistan.

In the usual refugee resettlement process, refugees have a medical screening exam prior to leaving their home country and are screened upon arrival in the US with another special screening exam according to guidelines from the CDC and immigration services. Because of the urgency to leave Afghanistan, many of the new arrivals did not have the usual pre-departure medical screening. Each person receives a physical exam including mental health screening, communicable disease screening, immunization evaluation, and illicit drug use testing. Communicable disease screening includes but is not limited to evaluation for tuberculosis and sexually transmitted illnesses. All are treated for parasites. Communicable illnesses that are common in Afghanistan are measles, cholera, smallpox, and respiratory infections such as Covid-19.

In addition to healthcare needs, we must consider food insecurity among Afghan refugees. Refugee status provides 6 months of medical insurance and financial support from the US. Changes to immigration regulations have provided these benefits to refugees whose applications are in process (known as “parolees" - an immigration term for an individual whose application for refugee status is in process), but there may be delays in getting the benefits established. Despite support from the US government and refugee settlement organizations, refugees may find it difficult to overcome relocation barriers. Financial constraints, food preference, and anxiety are some of the concerns hindering food security. Reluctance to seek mental healthcare is a common problem. Many experience trauma prior to immigrating. Anxiety, depression, and PTSD are frequently encountered; yet NPs may find that refugees are reluctant to seek treatment due to cultural stigma.

As access and cost are two additional significant hurdles to immigrant health, NPs can play a very beneficial role in providing healthcare to this vulnerable population. Furthermore, immigrants report high satisfaction rates for those receiving care from NPs.

Important tips for the NP

Stay alert for symptoms and signs of illnesses not often seen in the US but that may be present in refugees, particularly tuberculosis, measles, mumps, rubella, rabies, typhoid, pertussis, diphtheria, cholera, polio, chicken pox, Hepatitis A, Hepatitis E, scabies, malaria, leishmaniasis, and lead poisoning.
Although an initial screening is completed in the immigration process, chronic diseases are not addressed and may have gone untreated for long periods of time.
Routine healthcare recommendations may be unfamiliar or met with hesitancy. Being patient with refugees and being willing to educate them is crucial.
All patients should be evaluated for malnutrition.
Dental assessments should be included in physical exams.
Female patients should only be seen by female practitioners. Males can be evaluated by either male or female.
If caring for these refugees, verify their vaccination status. Vaccines are part of immigration health services including COVID-19, flu, hepatitis, MMR, and Varicella vaccines.

NPs strive to provide patient-centered and family-centered care to each patient they encounter. To do this for Afghan refugees, they must understand their cultural environment. Due to poverty, an unstable environment, and a lack of resources in Afghanistan, many refugees are at risk for illnesses that are not commonly seen in the US. Many have endured trauma without access to mental healthcare resources. NPs should adjust differentials to include communicable diseases, malnutrition, exposure to lead, and the effects of trauma. As NPs seek to provide care to all members of an ever-changing community, this will include providing culturally sensitive care to Afghan families who have arrived in the US under the hardest of circumstances.

Tuesday, August 3, 2021

Trauma-informed care for homeless populations

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Trauma-informed care, harm reduction, and population-level advocacy. These are three topics essential to my work as a family nurse practitioner. I wish I had known about them thirty-five years ago when I began my first job after graduation from the Medical College of Virginia (Virginia Commonwealth University). I gained these essential skills through my work with people marginalized by poverty and homelessness. I now include all three topics in my health policy and health equity courses for DNP students at the University of Washington School of Nursing in Seattle.

That's what struck me the most when I recently re-read my article in The Nurse Practitioner Journal from July 1989 (under my then married name, Josephine Ensign Bowdler), “Health Problems of the Homeless in America." I wrote this article based on my work as a nurse practitioner at what became one of our nation's first Health Care for the Homeless (HCH) primary care clinics in my then hometown of Richmond, Virginia (Crossover Clinic, subcontracted with The Daily Planet, which then took over the HCH clinic). I cringed when I read my own words in which, in essence, I blamed people for their substance use disorders. I was heartened to see that I at least acknowledged the fact that the stress and trauma from the state of homelessness exacerbates mental health and addiction issues. In conclusion I stated, “Primary care providers need to examine their feelings about poverty and homelessness, and avoid the extremes of blaming the victim or attempting to rescue the victim. (…) It is important to remember that homeless persons are often using considerable energy to satisfy their basic physiologic and safety needs. Attention to proper health care can come only after these survival needs are addressed." (p. 51)

What I didn't write about in the article because it had not yet happened, was the fact that I was about to lose my job, home, and family, and spiral into and out of homelessness as a young adult. Like anyone who experiences homelessness, this was due to a myriad of factors, including a history of unaddressed childhood trauma. The majority of people who experience homelessness, especially teens and young adults, have a history of significant trauma. Decades later I would write about this time in my medical memoir, Catching Homelessness: A Nurse's Story of Falling Through the Safety Net (2016) and further (in terms of trauma-informed care and gender-based violence) in Soul Stories: Voices from the Margins (University of California Medical Humanities Press, 2018). The experience of homelessness changed how I view not only homelessness, but also our health and social care systems. And the drive to examine my own and our nation's feelings about and approaches to poverty and homelessness led to a 6-year-long research project culminating in my newest book, Skid Road: On the Frontier of Health and Homelessness in an American City (Johns Hopkins University Press, 2021). The research for this book took me from hands-on healthcare work precepting our students in downtown Seattle homeless shelters to dusty archives in Seattle, as well as in London and Edinburgh (for research on the Scottish and English Poor Laws that underlie our country's Poor Laws).

The topic of advocacy in nursing education—including nurse practitioner education—if taught at all, typically focuses solely on individual patient advocacy. It often takes the stance that patient advocacy is a characteristic and virtue exclusively of nurses and not any other healthcare professionals on the healthcare team. This is untrue and unhelpful to the provision of quality patient care. Oftentimes, as in my own nursing education so many decades ago, the overly deified and uncritically examined historical figure and example of Florence Nightingale is invoked. Policy-level and political advocacy, especially for populations marginalized by race, ethnicity, sexual identity, socio-economic level, disability, national origin, or living situation are too rarely taught or modeled. However, I see that changing, mainly because our students advocate for these important changes. They give me hope, not only for the future of the profession of nursing and of the role of nurse practitioners, but also for the future of our healthcare system.

Josephine Ensign, DrPH, MPH, ARNP is a professor in the Department of Child, Family, and Population Health Nursing at the University of Washington, Seattle, Wash.

Friday, June 25, 2021

CDC issues guidance for post-COVID conditions

Last week, the CDC issued guidelines on diagnosis, treatment, and management of “Post-COVID Conditions."

Post-COVID conditions span a number of ailments—both physical and mental—that affect some patients infected by COVID-19. These can include headache, dizziness upon standing, tiredness or fatigue, joint or muscle pain, difficulty thinking or concentrating, loss of smell or taste, heart palpitations, chest pain, shortness of breath, cough, depression or anxiety, and fever, as well as symptoms that get worse after physical or mental activities.

The symptoms present after 4 weeks or more after the individual has been infected by the SARS-CoV-2 virus. This range of conditions can present in patients with initial severe manifestation of the infection as well as those with initial mild or even asymptomatic presentation.

Primary care providers can manage most post-COVID conditions according to the CDC, which advises the use of patient-centric methods and strategies to help patients attain better quality of life and function, and improvement of physical, mental, and social wellbeing. The emphasis should be on shared decision-making between providers and patients with a focus on specific symptoms.

The CDC cautions against reliance on lab or imaging findings as the only method to evaluate a patient's well-being, since the absence of relevant results via imaging does not necessarily give an indicator of the existence of post-COVID symptoms in a patient or its severity. Healthcare professionals should also be aware that we lack a thorough understanding of post-COVID conditions at this time and the guidelines are bound to change as we acquire more evidence and data.

Read the full guidance here.

Photo credit: Liza Summer, Pexels

Friday, June 18, 2021

Highly contagious Delta variant of coronavirus rising in the US

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The Delta variant, first known for ravaging the subcontinent of India is fast rising in the US.

The strain, which blindsided India, after the country had seemingly gotten the COVID-19 crisis under control, is now making its way around the world. It is hard to say how the Delta variant, which is said to be 40 percent more transmissible than the original Alpha variant, will affect the pandemic in the US. It may also cause more severe disease and higher risk of hospitalization.

At this point, the strain is responsible for 10 percent of infections in the US. The strain can infect people who have only had one dose of vaccine, though full vaccination appears to offer protection against the strain. This varies, of course, by type of vaccine, but it appears that most of the vaccines offer protection against the Delta strain, albeit at lower levels than that against the Alpha strain.

Early studies suggest that the Pfizer vaccine, which is 92 percent effective against the Alpha strain, can offer 79 percent protection against the Delta variant. The AstraZeneca vaccine, which is not approved for use in the US currently, but used in other parts of the world, was seen to offer 60 percent protection against the Delta variant; the vaccine's effectiveness against the Alpha variant is 73 percent.

Hence, public health officials are urging people to get vaccinated. Over half of Americans have received at least one dose of vaccine and over 40 percent are fully vaccinated. It is imperative that we speed up the rate of vaccinations to fully control the pandemic.

Photo by Miguel Á. Padriñán from Pexels

Wednesday, June 2, 2021

Nurse Practitioners as Gatekeepers for Suicidality: Asking Can Save a Life

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According to the Centers for Disease Control and Prevention (CDC), death by suicide is the 10^th leading cause of death in the United States when viewed across the lifespan. Additionally, while the impact of the COVID-19 pandemic on suicidality rates has not been fully ascertained, an early report in EClinicalMedicine, published by The Lancet, suggests that the prevalence of suicidality may be increasing in racial and ethnic minority populations disproportionately driving rates.

The growing issue of suicidality is further compounded by the maldistributed access to psychiatric care in many communities. This is largely due to the increase in demand for specialty psychiatric services combined with a shrinking psychiatric workforce. Inadequate numbers of practitioners are being trained to replace those leaving/retiring from community practices. This workforce shortage is being partially mitigated by the increased number of Psychiatric Mental Health Nurse Practitioners (PMHNP) in the field, less restrictive advanced nursing practice regulations nationally, and the use of innovative patient access modalities to psychiatric care, such as telehealth. Despite these best efforts, there remains a shortage of available providers to meet the growing need of people for psychiatric services.

Advanced Practice Registered Nurses (APRNs) in primary care and other community-based practice settings have the potential to be effective stop-gaps to meet this disparity in psychiatric access. While it would not be wholly advisable to shift all psychiatric care to non-psychiatric providers, it is feasible to provide non-psychiatric providers the skills to identify and treat low or moderate acuity mental health conditions.

While mild depression and anxiety symptoms are already widely treated outside of the traditional psychiatric specialty care, is suicidality a condition that can be managed without immediate access to acute psychiatry? A recent analysis from Vanderbilt University Medical Center (VUMC) written by Ketel, et al. (April, 2021) may suggest that it can. In 2018, a nurse practitioner-led, interprofessional primary care practice implemented universal suicidality screening at every patient visit. After analyzing 2 years of quality improvement data, they found that, out of 1,733 unique patients, 149 patients (8.6%) had some level of suicidality. Remarkably, a majority (62%) of patients that screened positive for suicidal ideation came into the practice for only medical complaints.

VUMC practice was able to effectively manage 112 patients (75%) without elevating the patient to specialty psychiatry. They accomplished this through the use of standardized, evidence-based screening and triage tools accompanied by regular follow-up and counseling by an embedded licensed master social worker (LMSW). In fact, out of the 149 patients screened, only 8 patients (5%) required referral/elevation to acute specialty psychiatry settings. On the downside, 29 patients (20%) who initially screened positive for suicidality were “lost to follow-up” or refused to accept care. In general, however, of the 112 patients that engaged with care, there were no suicide attempts or deaths. Additionally, the practice achieved complete resolution in suicidality in 84 patients (75%).

How was this possible? Suicidality, like most other physical and mental health conditions, has a range of acuities and is associated with both protective factors (factors that decrease acuity or prevalence) and risk factors (factors that increase acuity or prevalence). Both protective and risk factors can generally be quantifiably accessed and stratified. Protective factors that work preventatively against suicide or self-harm include a strong social support network, responsibility for the well-being of another person/animal (i.e. child/pet), and religious beliefs that prohibit suicide. On the other hand, risk factors are traits or situations that increase a person’s likelihood to complete suicide or self-harm. They may include being unemployed, experiencing a recent loss, experiencing psychological or physical trauma, and having immediate access to deadly means (i.e. firearms or medications).

While considering these protective and risk factors in individual patients can appear intimidating at first glance, it aligns with the course of care for most other clinical conditions encountered within the scope of primary care or community-based care.

As with other conditions, suicidal ideations present on a wide continuum of acuity. Suicidal thoughts can range from infrequent, passive thoughts of suicide, to constant, active attempts to do self-harm or kill oneself. The most widely accepted tool to measure suicidal ideation severity is Beck’s Suicidal Ideation Scale. In general, most patients presenting to non-psychiatric settings are not in this latter state of suicidality. When they do, it is obviously a time to engage the most immediate and intense emergency systems available. This would be akin to a patient presenting to a practice with acute chest pain or a person found unresponsive. Another example may be a patient with diabetes with an acute and severe episode of hyperglycemia. The appropriate response in this case would also be to immediately elevate the patient to a higher level of specialty care or emergency setting.

However, in both of these examples, possible cardiac event or severe diabetic hyperglycemia, the better alternative would have been for the APRN to detect and intervene well before the acute event occurred. This is done through detection and management of the patient’s unique set of risk factors and clinical indicators in early stages of disease progression. In the cases of cardiac disease and diabetes, regular and consistent use of evidence-based clinical detection and treatment modalities in the early stages of the disease progression can prevent or postpone the need for higher levels of acute or emergent care.

Early detection and treatment of suicidal ideation can be seen in this same light. If detected early, initial management of suicidal ideation is absolutely possible and appropriate in non-psychiatric settings. This does not imply that patients with persistent suicidal ideations do not require eventual elevation to specialty psychiatric care, but it does allow primary care and other ambulatory clinical settings to intervene at lower acuity levels. This will help shift at least some of the demand for acute psychiatry services and allow greater access to patients in truly acute psychiatric distress.

At minimum, most primary care practices can act as community “gatekeepers” for suicidal detection. A community suicide gatekeeper is a person or organization that is capable of identifying, approaching, discussing, and referring individuals in psychiatric distress to the appropriate level of care. Generally, gatekeepers have ongoing access to a community or have regular interactions with the public as a part of their normal routine. It is not a new concept. Originally it was developed in the early 1990’s as a way to engage school age children, adolescents, and young adults in school-based settings. A more updated article in RAND Health Quarterly by Burnette, et al. (2015) provides an excellent description of the scientific underpinnings for community gatekeeping.

Over the past 30 years, gatekeeping has expanded from just schools to include many social service and community organizations. In 2021 and in partnership with the National Action Alliance for Suicide Prevention and the United States Federal Government, the US Surgeon General released a “Call to Action” for the prevention of suicidality in the United States. This call to action is a “broadening of the vision” initiated in the 90’s. This is an expansive call that outlines six actions to decrease the impact of suicidality. It is an excellent plan and worth reading in its entirety, and this brief article could not do it complete justice. With that said, the first action in the statement seeks to encourage and empower every individual and organization to play a role in suicide prevention. That includes primary care practices and the APRN community of providers.

How do you get started addressing suicidality in primary care or as an APRN provider in the community? The first step is to identify partners and resources within your community that can help support your practice once patients are identified with suicidal ideation. This obviously includes traditional mental health service organizations in the community, but it also includes other community organizations who interact frequently with your population. Having a robust community network allows for close collaboration and sense of community togetherness around suicide prevention. An excellent evidence-based model for building community connectedness around suicidality is the CDC’s “Preventing Suicide: A Technical Package of Policy, Programs, and Practices.” The next step is to officially engage with your individual state’s suicide prevention program. A list of contacts by state can be found at the Suicide Prevention Resource Center. At this site, you will also find access to free online and in-person training to get your entire practice prepared to assist patients with suicidality. Other excellent resources to consider would be the American Foundation for Suicide Prevention and SAMHSA. Both of these organizations have copious amounts of resources for overall mental health, as well as the screening tools needed to fully implement suicidality screening effectively. Once your practice has accessed all of its available resources, it is time to take the next step and start confidently asking your patients about suicidal ideations.

Christian Ketel, DNP, RN-BC (He/Him/His)

Assistant Professor of Nursing

Director Vanderbilt Primary Care-West End

Co-Director of the Meharry-Vanderbilt Alliance Inter-Institutional Interprofessional Student Program

LEAN for Health Care Trainer and Facilitator

Tennessee ACEs Building Stronger Brains Initiative Trainer

Vanderbilt University School of Nursing

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