For many African Americans and other racial and ethnic minorities, the intensive care unit is the end of the line. According to a 2006 study by researchers at the University of Pittsburgh, a greater proportion of African Americans in particular receive treatment in the ICU at the end of their lives compared to Caucasian Americans. And overall, critical care patients in general are so seriously ill that one in five will die in the ICU or shortly thereafter.
Critical care nurses need to pay particular attention to the care of minority patients, especially African Americans, because many of these patients have seen a world of health troubles by the time they arrive in the ICU, says Alvin Thomas, MD, a critical care physician at Howard University Hospital in Washington, D.C.
Speaking at an education session at the American Association of Critical-Care Nurses’ 2008 National Teaching Institute last May in Chicago, Thomas noted that in the case of several critical conditions found in the ICU, such as severe sepsis and organ failure, African American patients are often more seriously ill than whites—no matter how high the quality of care the ICU provides. The problem, he emphasized, is not that black patients receive inferior care in the ICU compared to whites; rather, it’s that they have had less access to quality health care and have had poorer health outcomes throughout their lives, before they are even admitted to the ICU.
For example, many Americans of color are less likely than whites to have health insurance, a primary care physician or access to a specialist, Thomas pointed out. They are also more likely to have put off receiving care and to have higher rates of risk factors such as smoking, obesity and lack of exercise. As a result, when they are admitted to the ICU, they are much sicker than their white counterparts.
Thomas urges critical care nurses to become “champions” of population health for their patients. That means looking beyond the medical care given in the ICU and understanding the big picture of how these patients live in the outside world. How easy is it for them to purchase medications, get transportation to the doctor’s office, or even find a doctor in their neighborhood? How can their families be enlisted to help?
As an example, Thomas cited the recent case of a 37-year-old woman of color who lives in southeastern Washington, D.C., where primary care doctors are few and far between. She had labile, poorly controlled asthma but was reluctant to go to the hospital or call an ambulance. When her condition became unbearable, she took two buses to Howard University Hospital, walked into the ED, barely able to speak, and collapsed. She was sent to the medical ICU. Discharged after seven days in the hospital, she did not keep any appointments for follow-up visits in the pulmonary clinic and disappeared from the radar screen.
For Beverly George-Gay, MSN, RN, a veteran ICU nurse who is now a full-time assistant professor at Virginia Commonwealth University (VCU) School of Nursing in Richmond, Va., this story is all too familiar. “Many African Americans will wait before they seek care,” she agrees. Like the young black woman who came to VCU’s medical center with a large lump in her breast and was admitted to the ICU in an advanced stage of cancer. “She had tried a lot of home remedies before coming in,” George-Gay says.
Recent research studies confirm that minority patients, and African Americans in particular, tend to arrive in the ICU with more complicated conditions than their white counterparts. Blacks have higher rates of sepsis and severe sepsis than whites, a higher incidence of organ failure, and are signiﬁcantly more likely to develop post-operative complications that land them in intensive care. Black men have the highest adjusted in-hospital mortality rate from acute respiratory distress syndrome (ARDS) and elderly black women have the highest mortality from myocardial infarction.
Again, it must be emphasized that in most cases black patients develop these serious conditions before they are admitted to the ICU, not afterwards. Extensive research for this article failed to find any evidence that minority patients are treated differently than whites once they actually arrive in the ICU. One 2008 study, led by J. Daryl Thornton, MD, MPH, of the Case Western Reserve University Center for Reducing Health Disparities, suggests that black patients have a shorter length of stay in the ICU than whites and are less likely to be told about end-of-life issues, receive coronary artery bypass procedures or get pain medication. However, the researchers acknowledge that their study was based on analysis of less-than-recent data (from 1989-1994) and that additional research is needed before any conclusions can be drawn.
George-Gay certainly doesn’t think that African American patients receive unequal treatment in ICUs—at least not in her ICU. “Yes, some African Americans don’t get preventive care and are not [always] offered some of the cutting-edge technology,” she says. “But once they are in the ICU, I always thought we took care of all ICU patients in a colorblind fashion.”
But even though minority critical care patients are unlikely to experience overt racial discrimination in the ICU, they may still encounter unconscious bias, such as stereotyping, that can result in culturally insensitive care. George-Gay says her white colleagues sometimes surprise her with misguided conclusions about their African American patients. For example, when a black patient recently admitted to the ICU was found to have lice, George-Gay overheard a nurse commenting, “I think [black people] put something in their hair that causes lice.”
“I said, ‘WHAT?!’” George-Gay recalls. “[This nurse needed to be taught that] lice are a socio-economic phenomenon.”
The Institute of Medicine (IOM)’s landmark 2002 report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care notes that “although myriad sources contribute to these disparities, some evidence suggests that bias, prejudice and stereotyping on the part of health care providers may contribute to differences in care.”
Of course, most health care professionals do not think they are treating minority patients any differently. In a 2004 study by Joseph Betancourt, MD, MPH, and Owusu Ananeh-Firempong II, BS, entitled “Not Me! Doctors, Decisions and Disparities in Health Care,” doctors were asked if some patients were treated unfairly based on race or ethnicity; 14% said “never” and 55% said “rarely.” However, the Unequal Treatment report cites a 2000 study, “The Effect of Patient Race and Socio-Economic Status on Physicians’ Perceptions of Patients,” which found that many white doctors actually believed many common negative stereotypes about black patients—e.g., that they were more likely to abuse drugs and alcohol, were less educated and even that they were less intelligent—regardless of the patient’s income, education or personality characteristics.
The IOM report suggests that care providers tend to latch on to racial stereotypes when they cannot come up with a logical explanation for a minority patient’s health problem. “If the provider has difficulty understanding the symptoms, then he/she will operate with prior beliefs about the likelihood of patients’ conditions,” the report states.
For critical care nurses, the first step in providing culturally sensitive care to patients of color, especially low-income and immigrant patients, is becoming thoroughly knowledgeable about how health disparities and cultural issues may have contributed to the patient’s critical condition. For example, consider the impact of factors such as:
• Lack of primary care physicians. The IOM report cites a study that found a huge gap in the ratio of physicians to population between wealthy and impoverished communities—respectively, one physician per 300 residents versus one physician per 10,000 or even 15,000 residents.
• Lack of health insurance. Currently, some 47 million Americans do not have health coverage. Latinos are the hardest hit: 25.8% of this population is uninsured.
• Language barriers. Patients who speak little or no English are less likely to understand their diagnosis, prescribed medications, discharge instructions and plans for follow-up care.
• Behavioral and cultural risk factors. These can include not seeking preventive or routine care, not keeping follow-up appointments, obesity and smoking.
Minority critical care nurses interviewed for this article agree that cultural attitudes are often to blame for some of the poor health conditions they see in patients of color once they arrive in the ICU.
“Many African Americans don’t like being in the hospital; they just can’t stand it,” says Kim Staten, RN, an ICU nurse at Saint Barnabas Medical Center in Livingston, N.J. Consequently, they may put off seeking care for a medical problem until it becomes a crisis. “The thinking goes: ‘If I can walk, talk, breathe and go to my job, there’s nothing wrong with me,’” Staten explains.
A variety of factors lie behind this reluctance to seek routine care, including lack of financial resources and lack of convenient access to affordable health care services. In addition, this attitude suggests a great deal of mistrust of the medical system. A recent survey by the Kaiser Family Foundation found that 65% of African Americans and 58% of Hispanics—compared to only 22% of whites—were afraid of being treated unfairly when accessing health care services.
Unfortunately, the longer these patients postpone getting routine care, the bigger their problems will be when they finally have to be brought to the ICU, says Melissa Douglas, BSN, RN, a critical care nurse who works in the medical ICU at Georgetown University Hospital in Washington, D.C. They will be much sicker and the costs of their care will be far higher, she notes. Recently an African American woman was admitted to Georgetown’s ICU with kidney failure because she didn’t have a car to get to the dialysis unit. “She could have gotten a ride,” Douglas says, “but she didn’t think it was a priority.”
Once the immediate symptoms go away, she continues, many black patients stop taking their medications and have to be readmitted to the ICU. Douglas says this is a particularly common problem with heart failure meds, because they are expensive and the patient may not understand the need for constant medication to control their condition.
Traditional cultural beliefs and misperceptions about health and illness can also create barriers to seeking care, particularly among older persons of color, and even some younger African Americans in parts of the rural South. When Joyce Walker, RN, an ICU nurse at Gottlieb Memorial Hospital in Melrose Park, Ill., visits relatives in Shaw, Miss., she hears many examples of folk beliefs that are also kept alive among older generations of black Americans in her Chicago suburb. For example, some older patients resist surgery for cancer because they believe it will spread the tumor, or because they believe that they can control the disease through faith or will power.
In addition to being particularly vigilant when caring for minority patients in the ICU, critical care nurses also need to be knowledgeable about the cultural needs of patients’ families, especially if the patient is at the end of life. For example, different cultures have different ways of making family decisions about the care of a relative who is critically ill. Nurses also need to be sensitive to traditional cultural beliefs and customs about death and dying, such as a family’s wish to perform prayers or rituals they believe will help guide the patient to a more peaceful death.
Cynthia L. Russell, PhD, RN, an ICU nurse at the University of Missouri-Columbia’s Sinclair School of Nursing, believes nurses should encourage family members to give support and comfort to the patient. Some hospitals, such as the Medical College of Virginia Hospital, have opened up some of their ICUs to families 24 hours a day, seven days a week, George-Gay adds. Family members may be asked to rub lotion onto the patient or pull a pneumatic stocking onto the patient’s foot.
“Patients’ families need to stay involved,” says Walker. “If the family doesn’t visit, the patient’s health deteriorates.”
Cultural attitudes can sometimes impede patient care, such as when a patient’s family refuses to approve a do-not-resuscitate (DNR) order or an amputation. “They’ll reject DNR and say, ‘We’re going to leave it in God’s hands,’” Staten says. “They want to do everything possible for the patient who is a frail old lady or little old man.” So she paints them a picture of what it would be like for their loved one. “I tell them it means pounding on his chest, which is going to give him a lot of pain,” she says.
There are many tools and resources available to help critical care nurses increase their knowledge of minority health and cultural competency issues. For example, the Culturally Competent Nursing Modules (CCNMs), developed with support from the Office of Minority Health, are a popular online continuing education course designed to help nurses understand issues related to cultural competency in nursing practice, become more self-aware about biases and beliefs that may influence the care they provide, and enhance their skills in providing care to patients from diverse cultures.
To learn more about this course, visit the Web site www.thinkculturalhealth.org.