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Ep. 118 - Medicine: Color, Culture and Equity Pt. 4 (Bonnie Lunsford, RN,BSN)

episode 118

Ep. 118 - LiveWell Talk On...Medicine: Color, Culture and Equity Pt. 4

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Host: 
Dr. Dustin Arnold, chief medical officer, UnityPoint Health - St. Luke's Hospital

Guest: Bonnie Lunsford, RN, BSN, St. Luke's Emergency Department

Dr. Arnold:
This is LiveWell Talk on medicine color, culture, and equity. I'm Dr. Dustin Arnold, chief medical officer at UnityPoint Health - St. Luke's. Our guest today is Bonnie Lunsford, a nurse in the St Luke's emergency department, and also the first recipient of the Gail Stork emergency nurse award that was endowed by the medical staff. Bonnie is currently working on her Master of Communication in public health, and recently completed her graduate program, which identified and looked to improve inconsistencies and care for limited English-speaking populations. Her project has seen great success at St. Luke's and she's here today to share more about the project. Welcome Bonnie.

Bonnie Lunsford:
Thank you so much. I forgot I was the first one for that award. That was a nice reminder. Thank you.

Dr. Arnold:
Yeah. Yes, we're very proud of you. I was very happy that day. You know, when we talk about equity and equality, there is one, I think a language deficit, that is easy to overlook. And you and I have seen this in our career. We've changed from—it was okay to use the families, right? Some of that was specific, you know, we've changed that. I think we've changed that for the best, quite honestly. Can you give some background on what your project is and what prompted you to do it?

Bonnie Lunsford:
Yeah. Yeah. Thank you. When I started back for my master's at Allen College, I chose community and public health because I've always had a desire just to be a part of vulnerable populations. And I honestly thought I would probably be living overseas as a nurse at some point, haven't done that yet, but maybe that's in my future. And through that graduate program, I became aware of a population within our community that I had interacted with for years, because I've been in the emergency department for almost 16 years now, but never really understood that many of them come actually from refugee camps. And so I started working with the Catherine McAuley Center and their refugee resettlement, and began to realize that a lot of the disparity that those individuals experience. Number one, the language like you mentioned, but also just their lack of understanding for our healthcare system and preventative medicine. And I just felt like I was in a unique position to be able to help address some of those inequities by putting together something in the emergency department to help with that.

Dr. Arnold:
Yeah. A language deficit, not that it's a handicap, but it's like if you're deaf. It's like, the only handicap that people get mad at you for having right. They get frustrated with you. And then they start talking louder, like you'll understand loud English as opposed to normal English. Right? You know what I mean? Nobody gets, you see a blind person. You're like, wow, oh boy let's be helpful. But you encounter a patient that has a of language or hearing, and you find yourself kind of getting frustrated with them, you know? Which, that's not right, that's not good. And it's so easy to say, learn the language, learning English. Well that's fine, but that's not going to help take care of this patient. You know? And I think as clinicians, we have a patient we have to take care of. We have to understand that there's more to the continuum of care than just what we've seen in our own personal experiences and reach out to them. What were some of the inconsistencies that you observed with English? And the other thing, Bonnie, I always tell people: just imagine if you were in a foreign country. I don't speak any languages, you know. You're in, Hungary and you don't speak the language. You may not have someone who speaks English As Americans or as English speaking world, we're pretty blessed on a lot of things. But one of them is, most of the world speaks English, you know? So, I mean, that's not—not all of the world speaks Swahili.

Bonnie Lunsford:
Yep.

Dr. Arnold:
You know. So you have a little bit more flexibility, but what were some things that you noticed?

Bonnie Lunsford:
Like inconsistencies within my department, or just struggles with working with these individuals?

Dr. Arnold:
Both.

Bonnie Lunsford:
Okay. I really feel like there's a lack of understanding in the healthcare community about the reality of what these individuals face. And like you mentioned, sometimes our interactions can be really brief with them. And so we're frustrated, and we're not as patient because of that constant need to be quicker in what we're doing, but provide good care. So I think just hoping that individuals within the healthcare system can be a little bit more culturally sensitive and realize that, yes, there's a language barrier, but there's so much else that goes behind that. And this person is an individual on what was their path and their journey to coming here. And some of them may have been in our country for five years. Some of them may have been in here for three months, but still their understanding of our expectation of them in the healthcare system, might not be the same as ours. So really the inconsistency of what we would expect of our patients and really how they understand healthcare. So to them, many of the individuals that I work within and outside the hospital, healthcare is just the hospital. The hospital is one big word for: you go there when you get sick. So whether it's the clinic or urgent care or surgery or the hospital, it's all just going to the hospital. So I think that was something that was pretty eye-opening for me as well.

Dr. Arnold:
Yeah. I had that same experience with the Mesquakie settlement when I practiced in Grinnell. To see these patients, discharge them home from the hospital, they were critically ill. And you needed to see them in a follow up and they wouldn't show up. So you call them and say, hey, how are you doing? You had an appointment today. They go, oh, I didn't know I should come to the doctor when I wasn't sick. Because they didn't go to the doctor unless they were sick. You know, they had the concept of follow-up and preventative care, and they just—it was kind of admirable in a way that they just weren't running to the doctor for everything. But on the other hand, we needed to see them. But you're absolutely right, it's that cultural deficit. And they don't know what we're expecting. You know, so they start with a deficit there. And it's not like they don't want to fulfill our expectations. They just don't know how.

Bonnie Lunsford:
Yeah. Yeah, I would agree with that. I think there's also a lack of bilingual district instructions. And that is a big gap that I think UnityPoint Health can do better in that, and I'm helping with a part of that project. But we discharge these individuals from the emergency department, we hand them a piece of paper that's all written in English. And even though we go over that with an interpreter, they go home and they can't remember. I mean, how many times have we gone somewhere ourselves and get home and remember the dose of the medication we're supposed to take or what day we're supposed to go back. So I think that was also a big gap that I was able to recognize was occurring within my department that prompted it to.

Dr. Arnold:
And what were the results of your project? I mean, what have you seen? What has been the outcome? You've talked about the language appropriate discharge instructions or language applicable might be the best term. What other results did you see?

Bonnie Lunsford:
Well the project itself, I standardized care coordination, which is kind of fancy words to say: any limited English proficient patient that came to the emergency department, would trigger a referral to our social workers or our nurse case managers. And those individuals would go in the bedside and they would have somewhat of a standardized questionnaire that they would go through to make sure these individuals had the resources they needed in the community: family doctors, pharmacies. And then also just to make sure that they did understand, okay, this is where, you know, if you do get medicine, this is where it will come from. Or if you need a referral to a family doc, we'll help you. And then they would all oftentimes call them the next day with an interpreter to make sure they understood. So just by standardizing that process, we were able to see a large increase in how many referrals this team was able to give and how many resources they were able to provide. I tracked the data two different ways. One, I compared how many presented to the emergency department that spoken language other than English. And then of those, how many were seen by care coordinators. And so we saw that referrals increased by at least 33% according to Epic. But my tracking method, I felt like was a little bit more accurate in that any time the care coordination team received a referral, how often they would go at the bedside and meet with these patients, and how often did they give resources? We had some pre-project data and I compared it to the post-product and those resources increased by 250%. Which I felt like was a pretty significant number to just show you that simply by getting the referral so that they knew that this patient was here, they could increase those resources 250%. So I think that showed that there's a big need for these individuals to get more resources and more support from us as healthcare.

Dr. Arnold:
Early on in the COVID pandemic, Dr. Edwards put together some data and we were about a hundred patients in admissions, 25% of them were English deficient. I mean, so as a clinician, you can come to work and say, well, that's something that happens in the big cities. And it's happening right here. Even back to Ebola in 2014. You know, we had people, employees up in Waterloo that were like, yeah, I'm going home. You know, Kenya and in flying out of these airports that there were episodic outbreaks of Ebola. So the world's a small place.

Bonnie Lunsford:
Yeah.

Dr. Arnold:
Did you learn anything else in this, I mean the culture—I don't want to say sensitive—culture competency as a clinician. I know I have that deficit. I don't recognize that there might be a cultural perception or expectation from healthcare that I'm not delivering on. What were some things that you discovered?

Bonnie Lunsford:
Oh, I agree. I think that I will probably never be culturally competent, but I would like to say I'm working towards that and that I'm trying to be more aware of differences in culture. One thing that was surprising to me is, some of them are illiterate, so even if we could provide them with written information, they might not be able to read it. And then the second thing, is that even that I feel like we also need to realize that anyone that doesn't speak English, we don't want to assume that what we're presenting to them is the only option for them. What we need to do as healthcare providers is present them with the information so they can make an informed decision and then respect the decision they make. Because I think that's a huge cultural difference. Not everybody wants to do recommended procedures or take medications, and that they have their right as a citizen in this country to make those decisions. And so that was pretty eye-opening this year too. Although I feel like—especially as a nurse—this is the best procedure for you, these are the best medications for you to take, we have to take that step and really respect their choices. Let them be autonomous in those choices.

Dr. Arnold:
Absolutely. And I've said this on a previous podcast, not only the cultural competency, but also their medical IQ in that second language. I mean, it's one thing to speak English. It's one thing to have a reasonable medical IQ, when even our own indigenous English speaking population probably reads at an eighth grade or lower level.

Bonnie Lunsford:
Yeah.

Dr. Arnold:
You know, you don't stop and remember that. And then there's the flip side of it, where you have people that live here that are just so loyal to physicians and respectful, that they don't ask questions. So then you have the other extreme, where they just, whatever you say, they never questioned it. Or, they never partner in that provision of health care. Which, that's not good either.

Bonnie Lunsford:
Yeah. At one of the studies that I based my project off, found that individuals that not only had limited English, but also low health literacy, were experiencing health problems twice as often as people that had knew those things. So you look at that and we have, you know, someone like myself that I feel like I pretty understand healthcare pretty well. And I speak English that I have the potential to be twice as healthy as someone who doesn't have those, just because of language barriers. So I'm hoping to just help with some of that along the way.

Dr. Arnold:
I mean, sometimes when you question a patient: what's hypertension? They can't, they know what high blood pressure is. You use that term, hypertension interchangeably, thinking, assuming that they know it and they might not.

Bonnie Lunsford:
Yeah, you're right.

Dr. Arnold:
And I think that's important. I'll just tell a little anecdote. You know, here at the hospital as you know, and just for people listening to the podcast, that we now use certified interpreter services. We don't rely on the family unless it's an emergency, you know, but we do rely on that. I remember one time I was putting a pacemaker in and it was a Vietnamese family and the grandson was translating for me and I would talk for like a minute and then he would say two words, and then the grandpa would just agree with him. And I'm like, there's no way you're explaining to him what I'm trying to explain to them. So I think it's a good idea not to use the families if you can't use the expertise. And I've been really impressed with some of the interpreters that come to the hospital, their medical knowledge and the ability to translate it for us, I think is a big accomplishment. But as you point out, Bonnie, it goes beyond the four walls of the hospital. You can hand it to them in their own language and they don't have reading skills, then that doesn't accomplish anything.

Bonnie Lunsford:
Yep. I would hope that sometime over the next half a year, we could get interpreters back in the hospital too. Right now are all dependent on the Stratus interpretation, thankful for that, that we have that as an option. But there's something that is definitely missed without that face-to-face translation piece. And I think they read the culture and the interpreters that we brought into the hospital are also familiar with the community and different cultural dynamics just present here, just simply because we're in Iowa, too.

Dr. Arnold:
Yeah. Well, there's a book called the 12 nations. And what it is about is how the United States is actually 12 separate cultures. And it talks about Midwest, Northeast, you know, the Appalachian culture. And here in Iowa, we're kind of combination of Northeast and Appalachia. You know, Southern Iowa culture is way different from Northern Iowa culture. And it is. And so we shouldn't assume that all people that from Germany are German and they have the same behaviors and beliefs, because that might not be true. But we tend to do that. We try to tend to oversimplify. And I guess my goal is, just for clinicians to stop and say, okay, there may be a language barrier here, and I need to be cognizant of that and work to overcome it. Rather than just blowing by it.

Bonnie Lunsford:
Yeah.

Dr. Arnold:
Bonnie, this is great information. I always like talking to Bonnie. And this project, I'm very proud of you, which it's easy to be proud of Bonnie. This was Bonnie Lunsford, a nurse in the St. Luke's emergency department. Be sure to join us next month for Medicine color, culture, and equity. Thank you for listening LiveWell Talk On. If you enjoyed this episode, don't forget to subscribe. And if you want to spread the word, please give us a five-star review and tell your family, friends, neighbors, strangers about our podcasts. We're available on Apple Podcast, Spotify, Pandora, or wherever you get your podcasts. Until next time, be well.