Nursesaida's Blog

Module 4 – Implications for Practice

A literature search was undertaken to obtain data that established a clear need for cultural competence among school nurses in urban centers, today. The search revealed that the United States has drastically changed as a result of an explosive influx of diverse ethnic and linguistic cultural groups as a first time phenomenon to most major American urban centers. However, despite the increased diversity, American healthcare practitioners have remained approximately 85% non-Hispanic whites; whose heritages and backgrounds have provided them with little if any of the knowledge, skills, and experiences that are necessary to effectively communicate with the vastly differing patient populations that make up this new culturally rich healthcare frontier (Tucker, Mirsu-Paun, A., van den Berg, & et al, 2007). Yet, despite the shifting trend in cultural and ethnic makeup, Pennsylvania’s nursing professionals have remained almost 95% White (Department of Health, 2008). Of the remaining ethnic groups that comprise the RN workforce in the state 2.9% are Black, 0.7% Hispanic and the remaining 1.6% are a combination of all other ethnic groups with Filipino Asian nurses making up the largest group for those remaining percentage points. As with most other states, the two major urban centers of Philadelphia and Pittsburgh employ the largest number of nurses with 84.5 percent of all RNs in the state working in urban counties (Department of Health, 2008). 

School health service programs affect the health and well-being of the Commonwealth of Pennsylvania’s school children attending public and non public schools. Public schools include 11 technical and over 100 Charter institutions while nonpublic schools cover those educational facilities in the private and parochial sectors. Pennsylvania’s Public School Code specifies that each school nurse may be assigned and held accountable to plan for and administer healthcare to a caseload of up to 1500 students spread out between 1 to 5 facilities (Ficca, 2006, p. 148, ¶ 1). Under Article XIV of that Code, all children enrolled in public and nonpublic schools must receive healthcare consisting of medical and dental examinations in conjunction with comprehensive nursing services. Certified School Nurses(CSN) and School Nurse Practitioners(CRNP/SNP) provide the Commonwealth’s 2.1 million children with a variety of nursing care including health promotion and disease prevention services in the form of health screenings (growth, vision, hearing, scoliosis, and tuberculosis) at specified intervals, immunization assessment, health counseling and health education; as well as health maintenance services delivered in the treatment of acute and chronic conditions, first aid, emergency care, medication administration and maintenance of student health records (Department of Health, 2008). 

Philadelphia County employs 316 full-time and 44 part-time CSNs. According to statistics from the Department of Health (2008), during the school term covering 2006-2007, the   largest number of nurses caring for children in the Commonwealth would be nurses that have the least multicultural experiences: 


(Department of Health, 2004). 

Why is that data significant? The National Association of School Nurses (NASN) states, “School nursing is a specialized practice of professional nursing that advances the well-being, academic success, and life-long achievement of students.  To that end, school nurses facilitate positive student responses to normal development; promote health and safety; intervene with actual and potential health problems; provide case management services; and actively collaborate with others to build student and family capacity for adaptation, self management, self advocacy, and learning (NASN, 1999).” Over the last decade, the cultural dynamics of Philadelphia public schools has changed drastically.  Today, the total K-12 student population enrolled in Philadelphia public schools is 163,064; and of that number, approximately 61% are from Black or African American decent and only 14% are Caucasian (School District of Philadelphia, 2009). No data was available on the racial makeup of private and parochial schools, but an additional 1000 students attend the 4 registered private Muslim academies. However, according to Dr. Ihsan Bagby (personal at the MANA Convention, Philadelphia PA, November, 2008) Philadelphia is recognized nationally as housing the fastest growing Muslim population of almost any urban center in America. The remaining 25% of public school students make up a variety of ethnic and cultural groups. 

A major concern for Philadelphia school nurses is health promotion and disease prevention, yet a 55-60% drop out rate reflects the underlying healthcare problems of epidemic teen pregnancy and inter-ethnic violence which are but two of the systemic health based concerns that have most Philadelphia Educational institutions struggling for solutions. Healthy People 2010 place these issues among the leading health indicators to be addressed towards meeting the goal of increasing the quality and quantity of the expected years of life of all Americans (Office of Disease Prevention and Health Promotion, 2008). School health services has a major role to play in reaching that end because children spend more of their waking hours in schools than in any other supervised setting. 

Looking at the demographic data on Pennsylvania’s professional nursing population might shed some light on at least one aspect of the problem.  A huge cultural discrepancy exists between the population being served and the providers of care. Across the state, 3, 054 Certified School Nurses are Caucasians and by comparison 82 are Black, 4 Asian and 12 classified as other. See the below data table on race by specialty for the state: 

(Department of Health, 2004) 

In rural counties those numbers would not be problematic. However, Pennsylvania’ urban centers are no different from other American cities in that the majority of the population represents a diverse mix of minorities with African-Americans being the largest group and Muslims rising quickly among all races and ethnicities. Most American cities are home to a Muslim community that is a microcosm of the entire Muslim world. That uniquely American Muslim culture has developed as a result of only 36% of American Muslims being born in the United States and the remaining 64% being born in 80 different countries around the world: 

This mixture represents every religious schools of thought, intellectual trend, political ideology and Islamic movement in the world. The three major ethnic groups of the American Muslims are South Asians (32%), Arabs (26%) and African-Americans (20%). Muslims from various African countries constitute seven percent of most Muslim communities, but more Muslims originated from Pakistan (17%) than from any other country. The remaining 5% of Muslims represent every other race and ethnicity including Asians from the Orient, Hispanics and non Hispanic American whites including Jews, and Native American Indians Bukhari, 2003, p. 7). The skills level that would be required to traverse such a diverse culture might try the wisdom and acquired skill sets a culturally experienced nurse. See the below table for American Muslim culture by ethnicity below: 

(Mujahid, 2009) 


On a final note about cultural and school nursing, Julia Graham Lear, PhD (2003), the Director of the Center for Health and Healthcare in Schools at George Washington University, argues that despite the success of school health programs and the support of parents, the majority of school health centers are losing funding and function with severe staffing shortages just as the need for this extra layer of support is rising. She postulates that the vision of a school’s academic education leader is inadequate for strategic planning and allocation of resources to meet the healthcare needs of a highly diverse and constantly changing student mix, which is typical for most urban schools (Lear, 2009). The inadequacies of this organizational structure for healthcare decision-making are further compromised when the consultative body charged with providing qualified input originates from nurses who neither understand nor share the heritage of the dominant ethnic, racial and cultural groups of the students that they serve. Finally, in acknowledgment of the shifting worldwide trend towards diversity, the American Nurses Association (ANA) published a statement recommending that each nurse achieve the ability to “practice with compassion and respect for the inherent dignity, worth, and uniqueness of every individual” (Flowers, 2004). The above data establishes a prima facie case for the need to develop culturally competent school nurse professionals in Pennsylvania. 

Vitamin D deficiency as a Serious Health Threat to the Muslim Community 

Why the rush to diagnose and treat vitamin D deficiency in children especially in Black Muslim female students living in urban centers?  The goal of public health nursing is the prevention of disease and disability for all people through the creation of conditions in which people can be healthy…[by designing]… interventions to mobilize resources for action, and promote equal opportunity for health” (DeSantis, 2001, p.311, ¶ 6; Quad Council, 1999, p. 2). Medical experts estimate about 50% of an individual’s “peak bone mass develops during adolescence, and the concern is that missing out on the strongest possible bones in childhood could haunt people decades later” (Neergard, 2007). Muslim students females are the working mothers of the next generation and through their health practices greatly influence the health of the next generation. 

Using the Philadelphia, PA public school system as ground zero for examining the potential gravity of the problem may illuminate the benefits that could be realized if school nurses and public health nurses spearheaded national research and prevention efforts aimed at screening, educating and referring students observed to be most at risk for developing vitamin D deficiency for appropriate treatment. If 61% of the public school students in Philadelphia are from Black or African American decent (School District of Philadelphia, 2009) then based on the prevailing data regarding the number of Muslims in urban centers at least 20, 000 families would be Muslim not counting approximately 1000 known students attending nonpublic Muslim schools and thousands more being home schooled through the many Cyber online schools. Although no statistics could be located specifying public school enrollment by gender, Philadelphia schools are no different from schools in other major urban cities in the nation where the largest populations of all Muslims dwell, but especially Muslims of color who comprise the greatest risk group (US Census, 2001). With similar or greater numbers of black covered Muslim students being at-risk in every major city in country, the potential long-term suffering, morbidity economic loss is staggering. Additionally, American Muslims tend to cover at much earlier age and are therefore covered for far longer years than their counterparts in most Muslim countries. Without early intervention, these young women face an increased risk for developing obesity, multiple sclerosis, diabetes and hypertension and chronic pain and mental health problems in disproportionate numbers to other black people. The simple addition of a self assessment questionnaire to the annual mandatory screenings of students can help identify those with the highest risk level for the disorder. 

In the 2008 study, Use of a Questionnaire to Assess Vitamin D Status in Young Adults, Bolek-Berquist, et al hypothesized that a simple questionnaire could identify young adults with a high and low likelihood of vitamin D deficiency. They created a series of questions to identify vitamin D intake. The authors found that subjects who received a suntan, used of a tanning booth or drank at least two servings of milk daily were significantly less likely to be vitamin D deficient than those who had not. More definitively, they found that responding in the negative to any two of the three questions from those aforementioned categories yielded a sensitivity of 79% and specificity of 78% for predicting vitamin D deficiency. Though there was obvious room for improvement, their screening tool can serve as a good indicator of the need for laboratory testing confirm suspicions, especially in the presence of dominant risk factors such as wearing concealing clothing and having dark skin. 

After accounting for all the cultural and biologic aspects of risk, the school nurses should seek to employee the following strategies in establishing evidence based practice in provide care based on this unique and critical subcultural need: 

  1. Individual Cultural Needs Assessment Cultural Needs Assessment
  2. Podcast: courtesy of Coca Cola Company’s Beverage Institute Ctrl and left click  to open podcast from an expert
  3. Test your knowledge  courtesy of the Coca Cola Company’s Beverage Institute Ctrl and left click to open quiz and test your knowledge
  4. Use the algorithm in clinical decision-making Ctrl and left click to open algorithm for Vitamin D
  5. Identify screen your students and educate or refer courtesy of Bolek-Berquist, J., et al Ctrl and left click to open Vitamin D Questionnaire 1.1


Both qualitative and quantitative research support the premise that female covered female Muslim are from a unique subculture and that they suffer from the most serious levels of vitamin D deficiency. Evidence strongly suggests that “inadequate vitamin D may be involved in the pathogenesis and or progression of several disorders including cancer; hypertension; cardiovascular disease; neuromuscular diseases; osteoarthritis; diabetes; and other autoimmune diseases” (Goldstein, 2009, p. 345; Holick, 2006) as well as “mood disturbances and impaired neuropsychiatric function” (Reed, et al 2007). However, despite a preponderance of evidence to support the critical importance of vitamin D to human health, hypovitaminosis D remains poorly diagnosed and rarely treated before the onset of serious illness. Several factors increase a person’s chance of developing vitamin D deficiency, but none contribute more to increasing the risk than having dark skin, wearing clothing that covers all body surfaces and “living at latitudes [above 37°N or below 37°S] where sunlight during winter months is known to be insufficient to promote vitamin D synthesis through the skin” (Holick, p. 356, ¶ 4). Because dark-skinned Muslim women continue to face barriers to accessing quality healthcare, their long-term poor health outcomes will be far more pronounced. A complex interplay of factors exists that influence perceived susceptibility of vitamin D deficiency among dark-skinned and veiled American Muslim women. To succeed in helping these young women reduce their risk of developing any of a number of crippling and life-altering diseases that accompany chronic vitamin D deficiency, the nurse, family and community will have to join forces to institute the required lifestyle changes and/ or supplementation with vitamin D to reduce risk and eliminate the threat to the long-term health of the community in their unborn children.


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