Whitney A. Nash and Rhonda D. Buchanan
This research describes the collaboration between the University of Louisville School of Nursing, the Latin and Latino Studies Program, and the Kentucky Racing Health and Welfare Fund to provide low to no cost comprehensive health care services to the backside workers (behind the scenes) in the thoroughbred horse racing industry. An integral part of this program is the Latin American and Latino Studies (LALS) internship, which provides students the opportunity to fulfill their requirement while providing a much- needed service to the racing industry’s primarily Hispanic population. Students complete a semester-long internship that enables them to refine their translation/interpretation skills in Spanish while developing a broader understanding of the impact of cultural determinants of health. Students have reported the experience to be professionally and personally rewarding and have identified it as “life-changing.”
On the first Saturday in May, the city of Louisville, Kentucky receives worldwide attention for hosting the most exciting two minutes in sports, the Kentucky Derby. What many don’t realize is the amount of work that takes place behind the scenes the other 364 days of the year on the backside of Churchill Downs to prepare for this world-class event.
The demographic make-up of individuals traditionally conducting the daily operation of the thoroughbred horse racing industry has changed over the past two decades. In the mid-twentieth century many of those who cleaned the stalls and fed and cared for the horses were African American.
At many racetracks today, Hispanics account for the majority of backside workers, an increase that reflects the growth in the Hispanic population in Jefferson County and the entire state over the past decade. This growth is a reflection of Hispanics becoming the fastest growing demographic segment in the United States. An unpublished report prepared for the Kentucky Governor’s Office of Minority Affairs by the director of Research and Statistics for the Kentucky Education and Workforce Development Cabinet states:
Between the 2000 and 2010 census, when broken down by race and Hispanic origin, Kentucky’s non-Hispanic white population grew by 137,642, or 3.8%, and accounted for 46.3%, or less than half, of the state’s population growth; our black population grew by 41,526, or 14%; and our “official” Hispanic population grew by 72,897, or 121.6% (Crouch, 2011, p. 1).
The 2010 census indicates that in Jefferson County the Hispanic population has increased from 12,370 in 2000 to 32,542, a 163% increase. According to Crouch, “official” census counts in Kentucky are much lower than the actual figure. Crouch believes the undocumented Hispanic population is significantly larger—probably, perhaps two to four time larger. While no statistics are kept on this silent community, those who are intimately involved in the horse racing industry would most likely agree that employees on the backside are now predominantly Hispanic.
Both African Americans and Hispanics are disproportionately impacted by diminished access to health care. At least one in three Hispanics and almost one in five African Americans are uninsured in the United States (Mead, Cartwright- Smith, Jones, Ramos, Siegel, and Woods, 2008). In fact, 2009 data show that in the United States, four in ten individuals from low-income families have no insurance coverage. This lack of coverage makes them six times less likely to receive care (Kaiser Family Foundation, 2009). Adding to this dilemma is the higher rates of disease within these groups. Hispanics and African Americans are more likely than Caucasians to suffer from diabetes (Mead et al., 2008), new HIV infections (Centers for Disease Control and Prevention, 2007), and many forms of cancer (American Cancer Society, 2007).
Historically, the Kentucky Racing Health and Welfare Fund provided health care coverage to qualified individuals through a variety of local providers. This organization receives its funding from the state. The revenue is generated from uncashed pari-mutuel tickets. When individuals have a winning ticket but fail to cash it in, this money is returned to the state. Part of this money is used to supply the Fund. Due to the backside workers’ inconsistent schedule and the hours providers were typically available, many clients would receive care from an unending variety of primary care providers. This resulted in lack of care coordination and the over utilization of diagnostic testing. The board of directors of the Fund felt a centralized location of care provision, as well as a coordinated effort between the Fund and care provider, was needed.
To address the need for health care services for backside workers, the University of Louisville School of Nursing and the Kentucky Racing Health and Welfare Fund established the Kentucky Racing Health Services Center (KRHSC) in 2005 to coordinate primary care services for backside workers. This partnership also provided the university a site for clinical preceptorships, initially for nursing and medical students. While this form of training is central to the professional preparation of nursing and medical students, this unique clinic also provides the University of Louisville with the opportunity to enhance its mission of service to the community. In fact, the University of Louisville is within walking distance to the KRHSC and Churchill Downs.
The KRHSC provides student-facilitated services delivered under the direction of School of Nursing faculty. Basic health screenings, primary care, and referral coordination form the foundation of the health service center. When established, Spanish language translation and interpretation services were provided by a network of volunteers; however, as the client base grew, it became obvious that a more formal mechanism to deliver language services was needed.
The KRHSC was developed specifically to serve the backside, including Churchill Downs, Turfway Park, and Ellis Park. The workers are not employees of the racetrack but of the individual horse trainers. Because many of the trainers have only a few employees, it is cost-prohibitive for them to provide health care insurance.
A distinctive feature of the KRHSC is that its development and implementation is managed solely by certified nurse practitioners who are full-time faculty members of the nursing school. Fortunately, the nurse practitioners have a practice allocation in their workload and part of the funding for the KRHSC covers their practice time at the Center. Undergraduate and graduate students from multiple disciplines, including LALS, nursing, Spanish, biology, and other volunteers, provide all other services at the KRHSC, such as patient flow and clerical support. In an era when there are fewer primary care physicians, this model is becoming more widespread. Several studies suggest that care provided by nurse practitioners is not only of high quality, but is also cost-effective and results in high patient satisfaction (Elsom, Happell, & Manias, 2009; Horrocks, Anderson, & Salisbury, 2002; Laurant, Reeves, Hermens, Braspenning, Grol, & Sibbald, 2006).
The KRHSC operates 13 hours per week. Full primary care services are provided three days a week. After speaking with the workers and the trainers, we determined that Monday and Friday midday and Wednesday early evening would best accommodate the workers’ schedules.
The KRHSC is housed in the basement of a refurbished schoolhouse within walking distance of the state’s busiest and most recognizable horse racing track, Churchill Downs. Individuals currently working on the backside, as well as their spouses and dependents, are eligible for free care under the Fund’s guidelines. Clients must have an appointment and most can be seen the same day that they request care. During the peak season of May to November, it is common for the nurse practitioners to see 10–12 patients each, during a 5-hour clinic day. A list of area clinics that offer a sliding fee scale is provided to those individuals not meeting KRHSC eligibility criteria.
Each semester, various levels of nursing students spend a portion of their clinical rotation at the KRHSC. Student volunteers work with the nurse practitioner staff to evaluate and treat patients with a variety of medical conditions. Since 2005, there have been over 9,500 patient visits to the KRHSC. In addition more than 200 students in nursing, medicine, Spanish, and LALS have experienced primary delivery in this unique setting.
The program provides much needed support for the backside workers, and also provides training opportunities for University of Louisville students. However, an important element of this program is the level of civic mindedness students gain through their experiences while serving with this program. For example, they become more aware they are a part of a larger community and they participate in work that addresses inequities within the community (Colby, Ehrlich, & Beaumont, 2003). As the need for services grew, so did the learning opportunities for students. After the first year of service, it became clear that a more developed and formalized program for language services was needed at the KRHSC, and in the fall of 2006, the KRHSC began to partner with the LALS Program.
Service to the community, whether in Louisville or abroad, has been the foundation of the LALS Program since its inception in 2000. Internships are a requirement for undergraduate students who minor or major in the program and an elective for graduate students who pursue the graduate certificate. Volunteer interns put their Spanish linguistic skills to good use and give of their time, energy, knowledge, and talents to more than 20 local organizations that serve the Hispanic community, as well as foreign organizations in Argentina, Bolivia, Guatemala, Mexico, Panama, and Peru. After consulting with the LALS director, students are matched with an organization related to their personal career goals and interests. For example, pre-med students volunteer at the KRHSC, future teachers mentor Latino middle school students for Adelante Hispanic Achievers, (Hispanic youth development program) and those interested in careers in law may serve as interns to interpret the court system. Between fall 2006 and summer 2012, 20 LALS students had served as interns at the KRHSC.
The majority of the students who have completed internships at the KRHSC have been pre-med students with an advanced level of Spanish. Students who are native Spanish speakers and those who have lived or studied abroad in a Spanish-speaking country are best prepared for the opportunity. To aid in the standardization of student selection, the KRHSC implemented the Foreign Service Institute Language Proficiency Rating Scale. The range of proficiency is from elementary level to bilingual (Interagency Language Roundtable, 2011). Students complete this assessment and the KRHSC uses the results as a guide only. In addition to LALS students, selected Spanish language majors enrolled in the University of Louisville Honors Program also have the opportunity to intern at the KRHSC.
After an orientation period, LALS students work directly with the nurse practitioners to ascertain medical histories, interact with clients and families, and work as part of the interdisciplinary team. LALS students also have the opportunity to work collaboratively with health science students. Of the 20 LALS students, one is currently enrolled in medical school, two others have been accepted, and several others will be applying to medical or nursing school in the near future.
As part of the assessment and evaluation criteria, students enrolled in the LALS internship are required to submit a proposal, weekly email progress reports, a time sheet, and a critical reflection paper to the LALS and the KRHSC directors. The weekly progress reports and the final reflection paper offer students an opportunity to evaluate the experience and examine their personal and academic growth throughout the semester. Critical reflection is widely cited as a key element in supporting students’ learning and deep integration of knowledge (Ash & Clayton, 2009). Students submit weekly progress reports to the LALS and the KRHSC directors as part of their coursework requirements for this internship. The information aids the staff of the KRHSC in identifying areas for program development, expansion of student learning activities, and improved communication with patients. The site supervisor completes a final evaluation form and submits it to the LALS director as part of the evaluation process.
For the purpose of this study, critical reflection papers received from 15 LALS students were reviewed by the KRHSC director to improve the quality of student experiences and build on past successes in health care delivery, Spanish language interpretation, and program structure. In order to use content from the students’ journals, approval from the University’s Institutional Review Board was sought and obtained.
Reflection provides the critical opportunity for students to comprehend more fully how they construct meanings and also deepens their capacity to transfer knowledge (Eyler, 2000). During the required internship evaluation process conducted by the LALS and the KRHSC directors, complex thinking patterns emerged. Improved Spanish linguistic skills and confidence in translation and interpretation were obvious and expected student reported outcomes. In their final critical papers, all students remarked that the KRHSC internship allowed them to increase their knowledge of medical terminology and to improve their confidence level when conversing with native Spanish speakers. Interestingly, many students recognized that vocabulary they had learned in the classroom was helpful, but their ability to use context clues was even more critical in their role at the KRHSC. These context clues include physical gestures and descriptive words to aid in communication. These remarks suggest students drew on multiple sources of knowledge to make decisions and communicate with their patients. The integration of their learning is evident in some of the comments listed below. For example, one student remarked in the final critical paper:
When I began interning at the KRHSC, I did not fully understand what it meant to be a medical interpreter. As a nursing/Spanish double major, however, I realized that maintaining accuracy across languages would be crucial to ensure proper diagnoses. Right away, I began learning Spanish medical terminology. Beginning with characteristic words for common symptoms, I progressed to know the names of many internal organs, systems, and procedures. While interesting, it was a difficult process. Like other new interns, I felt confident enough in my conversational Spanish but when it came to more specialized medical jargon I felt at a disadvantage. However, the nurse practitioners were able to assist me greatly.
Beyond the improvement in language ability, particularly the expansion of vocabulary pertaining to the medical field, many students pointed to specific cultural experiences that were especially impactful. One student wrote in the reflection paper:
It was when I was left in the room after the [nurse practitioner] went to write a prescription that the patient would tell me where they came from. They would talk about the difficulty of learning English and express their gratitude and excitement that I could speak with them.
Another student wrote in a weekly progress report:
I enjoyed interpreting for an elderly Mexican gentleman who came in for a post-operation checkup. Before his examination I was able to converse with him and his Cuban friend. In addition, I interpreted for a man from Mexico, who was very friendly and talkative. As I reflect on my experience with these two individuals and their positive responses to my assistance, I realize that casually conversing with the patient before I have to interpret makes them feel more at ease, which facilitates the interpreting process.
A broader understanding of the emotional toll of being away from family was also recognized. One student expressed empathy in this way: “Many patients had to leave family in their home countries. They lived apart from their children for years and sent money home. This was heartbreaking.”
Part of the role of the LALS intern at the KRHSC is to assist with client intake, such as collecting demographic data and helping to complete a basic medical history. Students are not always prepared for this experience. For example, one of the interns wrote:
I had some humbling experiences early on with checking in patients. Many patients from rural parts of Guatemala and Mexico displayed varying levels of literacy. Some could read but not write …; others needed all of their information taken orally and transcribed…. It never occurred to me that people who lived permanently in the U.S. might not be able to read or write their own name (in Spanish or English).
Many of the students who intern at the KRHSC have an interest in health-related professions, Students have pointed to their internship at the KRHSC as a clarifying and defining experience. Pre-med and nursing students conducting the LALS internship are given the opportunity not only to use their Spanish skills, but also to assist the staff with patient care. One student wrote in the final paper: “I learned to take patient histories, measure their blood pressure and present to the (nurse practitioner).” Others gained a deeper understanding of clinical decision-making. For example, one student remarked that before he came to the KRHSC, “I never knew why one medication was prescribed over another…. I also learned how important it is to distinguish between bacterial and viral infections.”
By far the most common theme that emerged from the final critical reflection papers was the students’ evaluation of the experience as “life-changing,” which is a difficult assessment to quantify. A nursing student and LALS intern stated, “Being an intern has helped me solidify what I would like to do in the future. I would like to live abroad, working in a clinic in a medically underserved part of Central or South America.” Another referred to the internship as “one of the most important experiences in my undergraduate education.” An intern who decided to return to the university to complete a second degree in nursing stated:
I’ve also decided that for the rest of my life I will seek out opportunities like this one that will allow me to demonstrate the lessons I’ve learned here: How to give back without boasting, how to never stop asking, how to never stop looking for the good, and how to lend a hand without judging.
In the conclusion of the critical reflection paper, another student summed up the experience in the following way:
The clinic has helped me realize the importance of being a proactive person in life as well as in health care. If you want to see change, you must pursue actions that encourage that change. Proactive people challenge seemingly impossible goals and succeed. The clinic has done just this: provided a health care system for an impoverished community and has generated a reasonable level of health literacy in a minority population. Completing this internship at the clinic is just the beginning of my service to the Latin American community living in Louisville. I hope to continue learning and volunteering with Latinos living in the United States and abroad and eventually pursue public policy options that will serve to increase their assimilation and literacy so that they may live healthier and not as physically demanding lifestyles. Proactivity can accomplish the impossible.
Leasons Learned /Opportunities for Improvement
While lessons learned and possible improvements were numerous, they can be summarized as follows:
- Greater consideration for requirements of internship. Although the student experience at the KRHSC has generally been a positive one, there is always room for improvement. The hours of operation (13 hours per week) make it difficult to accommodate the internship requirement of 80 hours for three credit hours. Supplementary activities are occasionally used to augment this requirement. For example, some students have volunteered at the Klein Family Learning Center on the backside of Churchill Downs, helping with English as a second language and computer classes.
- Balancing competing priorities. At times, the KRHSC can see more than 20 clients in a five-hour time period, which can limit instructor-directed learning opportunities. Because the main objective of the KRHSC is to care for patients, it is possible that the students may not receive the level of attention they would prefer. Fortunately, this is not a common concern, and students very quickly embrace the clinic’s mission and become part of the team.
- Remembering students as individuals with diverse learning needs. The biggest challenge for the KRHSC and LALS directors was identifying the student’s personal learning needs and developing an individualized opportunity that meets those needs. The development of a more formalized approach to this issue is a goal for the KRHSC and will further enhance the collaboration between the School of Nursing and the LALS Program. In addition, the new B.A. degree in LALS that began in 2012 provides even more opportunities for University of Louisville students to volunteer at the KRHSC.
The program has been successful and garnered local and national attention. In fact, the director of the KRHSC received the 2010 Outstanding Faculty Practice Award from the National Organization of Nurse Practitioner Faculties and the 2010 President’s Community Engagement Award at the University of Louisville. The LALS director also received recognition, as the 2012 University of Louisville Distinguished Service Award for Service to the Community.
Other universities have sought our advice regarding replication of this model. For example, Turfway Park in Florence, Kentucky has developed a similar academic collaboration with the Kentucky Racing Health and Welfare Fund and the Northern Kentucky School of Nursing. This partnership is designed to deliver care to the backside workers located in the northern part of the state.
The University of Louisville School of Nursing faculty plans to continue this initiative and its collaboration with the LALS Program and is investigating opportunities within the university and the surrounding community to expand services while maintaining high quality and convenient primary care delivered with compassion to the culturally diverse population it serves.
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About the Authors
Whitney A. Nash is director of Practice and International Affairs, Adult Nurse Practitioner Coordinator, director of the Kentucky Racing Health Services Center, and associate professor at the University of Louisville.
Rhonda D. Buchanan is professor of Spanish and director of the Latin American and Latino Studies Program at the University of Louisville.