The Dean’s Blog

A Note on the Dean’s Blog

Sandra Weiss

Sandra Weiss, RN, PhD, FAAN, is interim dean of the UCSF School of Nursing while the School conducts a national search for a successor to former Dean David Vlahov. Dean Weiss has been a deeply respected professor at the School for many years and has held a number of administrative positions within the University of California. She is the Robert C. and Delphine Wentland Eschbach Chair in Mental Health, co-director of the UCSF Depression Center and a Fellow of the American Academy of Nursing.

In the months ahead, Dean Weiss expects to contribute her own blog posts as Science of Caring undergoes a redesign. We look forward to her thoughts.


Congratulation Dr. Weiss!!

Generating Evidence for Action

David Vlahov

While I will miss many aspects of serving this School as its dean, I am also excited to return to my research and other pursuits full-time. Among those pursuits is serving as co-director, along with UC San Francisco School of Medicine’s Nancy Adler, of Evidence for Action (E4A), a national program of the Robert Wood Johnson Foundation administered by UC San Francisco, which provides funding of investigator-initiated research to build a culture of health. I believe building that culture is one of the great, under-recognized needs in public health.

Consider that a visitor from Finland once commented about our country, “It’s amazing how little you are able to do with so much.” This is not a surprising critique coming from someone from Finland, where health care expenditures are significantly lower (9.6 percent of their gross domestic product [GDP], or $3,984 per capita) compared with the United States (16.9 percent of our GDP, or $9,451 per capita), while their life expectancies at birth are higher by 2.3 years (81.1 years in Finland compared with 78.8 years in the US).[i],[ii]

In fact, the US spends a much higher percentage of our GDP on health care than any other Organisation for Economic Co-operation and Development (OECD) nation (47 percent more than the next-highest spender), while we’re ranked only 27th of 38 OECD nations in life expectancy.[iii],[iv]  On average, our life expectancy is one year below the OECD average. In addition, according to the results of a U.S. News & World Report survey, we rank 14th of 60 countries evaluated for Quality of Life.[v]

So, what strategies are they using in Finland and the rest of the OECD countries that we aren’t?

One thing to consider is that while the US and Finland spend about the same percentage on health care and social spending combined (36.1 percent and 40.6 percent of GDP, respectively), Finland spends 31.0 percent of their GDP on social services, while we spend only 19.2 percent.[vi] This seems to support the premise that social spending could be a key factor in better health; and in fact, an analysis within the US by Bradley et al. (2011) found that a higher ratio of state “social expenditures to health expenditures was significantly associated with better outcomes in infant mortality, life expectancy and increased potential life years lost.”[vii],[viii] 

Moreover, the US is ranked ninth on the OECD Better Life Index, an aggregate scoring system based on 11 factors ranging from housing and income to work-life balance and life satisfaction that are all contributors to overall well-being. These aggregate values allow us to compare national well-being between the US and the other OECD nations. When we compare the US to the eight countries ranked ahead of us (which include Finland), we score significantly higher than average when it comes to housing and income, but below average when it comes to community, environment, life satisfaction, safety and work-life balance.  

Yet another consideration is that even though the US is ranked highest of the OECD nations when it comes to income, we’re ranked 33rd for social inequality within that category. The story is similar when we look at social and gender inequities in health, jobs, education, civic engagement and safety.

Given these numbers, one could deduce that improving US life expectancies and overall well-being depends at least in part on spending a higher portion of our GDP on social services and programs that reduce inequities and address social determinants upstream before they become health problems. That money could be put toward improving community building, environmental conditions, life satisfaction, safety and work-life balance for all Americans, with a particular focus on disadvantaged populations.

However, for the specifics, it’s not enough to look at strategies that work in Finland or any other country, because, of course, such strategies are not guaranteed to improve health outcomes in the US. The question then becomes: What investments in social services and other interventions that target social determinants will work to improve health outcomes of US populations?

Finding the answers to that question is one of the reasons I joined E4A. We’re funding research about the health outcomes of policies, programs and other types of interventions both within and outside of the health care sector, in order to build the evidence base to determine the best strategies to improve health equity, population health and well-being.  We’re particularly interested in evaluating the impact of interventions designed to address upstream social determinants of health. 

So far, we’ve funded 13 research projects with a wide range of foci – from food bank decentralization to a low-income housing redevelopment project and intervening on the economic determinants of health. You can learn more about our funded projects by visiting our Grantees Page.

What do you think are the most promising approaches to improving population health, well-being and equity? We’d like to hear your ideas. Apply for a grant today!




[i] OECD data: health spending. OECD website. Accessed August 24, 2016.

[ii] Health. OECD Better Life Index website. Accessed August 24, 2016.

[iii] OECD data: health spending. OECD website.

[iv] Health. OECD Better Life Index website.

[v] Best countries: quality of life rankings. U.S. News & World Report website. Accessed August 24, 2016.

[vi] OECD data: social spending. OECD website. Accessed August 24, 2016.

[vii] Bradley EH, Elkins BR, Herrin J, Elbel B. Health and social services expenditures: associations with health outcomes. BMJ Qual Saf. 2011;20(10):826-831. Published March 29, 2011. Accessed August 24, 2016.

[viii] Bradley EH, Taylor LA. Culture of health: how social spending affects health outcomes. Robert Wood Johnson Foundation website. Published August 17, 2016. Accessed August 24, 2016. 


Dear David. Bravo! This is spectacular, and necessary, work. Thanks for making me aware of it. Sharon Kaufman

How to Move the Conversation on the Public Health Crisis of Gun Violence

David Vlahov

Over the last weeks, the violence in Louisiana, Minnesota and Dallas shook the nation. Stark images of the shooting deaths of black men through streaming video escalated the issues of firearm fatalities, systemic racism and excessive police violence. The ambush and shooting deaths of the Dallas and Baton Rouge police officers stunned us. We mourn and express our condolences to the relatives and friends whose loss is personal and to communities whose trauma is collective.

However, as health care professionals, we cannot leave it at that; we cannot sit still while efforts to address these calamities continue to be frustrated. Nurses need to be among those helping the nation make sense of the conversation.

The issues are undeniably complex, involving guns, race, class and culture. Our focus in this piece is on guns, but we promise further conversation about race, class and culture in later installments of Science of Caring.

According to the Centers for Disease Control and Prevention (CDC), firearm-related fatalities are among the top five leading causes of injury-related death. Suicides account for 63 percent of fatal firearm violence, but are more common among whites, and the number has been increasing over the past decade. Homicide rates have been on the decline in the past decade, but are more concentrated among black males, where high rates have remained relatively unchanged over time. Mass shootings garner headlines, but they represent less than one percent of all gun-related deaths. 

Then there is the issue of mental illness and guns, which is widely misunderstood. As Dr. Jeffrey Swanson, a professor in psychiatry and behavioral sciences at Duke University School of Medicine, put it recently: “Mental illness is a strong risk factor for suicide. It’s not a strong risk factor for homicide,” though he made it clear that almost by definition, inflicting violence on large groups of people is a type of mental illness. All of these findings appear to have implications for possible interventions, but we need more data to intelligently inform the design of policy and practice.

Unfortunately, there have been no government-sponsored studies about how to prevent firearm deaths and injuries since 1997, when the Dickey amendment was added to a US House of Representatives bill. The amendment stated that the CDC may not conduct any studies that “advocate or promote gun control.” In 2012, that prohibition was expanded to the entire Department of Health and Human Services.

The restriction on research means that it’s difficult to objectively evaluate the potential efficacy of any proposed gun control laws. In 2003, when the Task Force on Community Preventive Services issued its first report evaluating the effectiveness of strategies to prevent violence, it concluded that there was insufficient evidence to make any determination.

In an effort to change the dynamic after the Sandy Hook Elementary School massacre, which took place in Newtown, Connecticut, in December 2012, Vice President Biden called for the Institute of Medicine to conduct a review and provide a report on firearm-related research. I served on the panel that released the report in June 2013, Priorities for Research to Reduce the Threat of Firearm-Related Violence. We highlighted significant gaps in knowledge to formulate prevention strategies and proposed a research agenda – designed to produce results in three to five years – which focuses on the characteristics of firearm violence, risk and protective factors, interventions and strategies, the impact of gun safety technology and the potential influence of video games and other media. Yet with Congress stalled on providing funding, the research has lagged, although some private foundations have stepped forward.

Nevertheless, even in the absence of all the necessary research, there are some commonsense approaches clinicians should be able to bring to their patient encounters. Last year, at least 265 children under 18 years old picked up a firearm and shot someone by accident; 83 of those incidents were fatal, and about half of the fatalities were the children themselves. Given the public health costs, we should be able to have conversations about gun safety with our patients, but legislators block that as well. When Florida legislators instituted a “physician gag law” that forbade even an assessment of gun safety, organized medicine took them to court, arguing that such laws interfere with their First Amendment rights. They lost on appeal and the gag order remains in effect. According to the Law Center to Prevent Gun Violence, similar legislation has been introduced in 14 states, and watered-down versions of Florida’s gag law have been enacted in Minnesota, Missouri and Montana.

Nurses, I’m proud to say, are standing up to these restrictions in many different ways. Recently, American Nurses Association President Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, declared after the recent tragedy at Pulse nightclub in Orlando, “Now is the time to enact meaningful gun control legislation at the state and federal level to protect society…. We all must join with other members of our community and at every level of civil society in dialogue and action to address the underlying issues that result in hate and motivate unspeakable acts of violence.”

The Emergency Nurses Association has also taken a strong position that as health care consumer advocates, nurses must educate the public about the risks of improperly stored firearms and support the creation and evaluation of community and school-based programs targeting the prevention of firearm injuries. They also support the establishment of a national database of reportable firearm injuries to make evidence-based decisions regarding patient care, safety and prevention. Moreover, they recognize that the most effective way to keep children from unintentional firearm injury is to limit access.

Quite appropriately, the ENA also points to where the literature is unclear. Despite the organization’s belief in education, they acknowledge that data are limited and mixed on the effectiveness of existing strategies for education of children. Which brings us back to the key point: Ill-advised restraints continue to hamper efforts to develop the evidence base we need for a public health approach to reducing firearm fatalities and injuries. I join with many others in calling for a national database and a robust research effort that can support public health clinicians in our efforts to stop the firearm-related deaths and injuries.

And on the subject of what clinicians can do, I know of a nurse who felt that discussions with patients about gun safety were better left to gun safety experts. I disagree. As nurses, we can’t pass off the responsibility. We are witnesses to the carnage and we see the aftermath. We have a moral responsibility to be actively engaged, both with our patients and in this national debate, bringing not just our clinical expertise and perspective but also our commitment to generating the data that underpins rational policy and advocacy. We should contribute and, at times, lead the conversation on how clinicians can help the cause of gun safety, and we should unabashedly advocate for the health and safety of our patients and our communities. 


David,With great interest I read your blog on gun control research. We have moral responsibility to educate our children to conduct themselves as law abiding citizen. Using gun is not the way to relieve frustration. People need jobs and our veterans need to be respected and welcome when they return and find job to make them feel part of the community. Mariamma
Yes, we can do what Yu have proposed and should.
David, thank you for your important commentary. As faculty, we need to better understand how to talk about gun protection with students in their training as clinicians and as future thought leaders. Carmen
Thank you so much for speaking out about this issue, Dean Vlahov.
Very well written. Thank you.
Thank you for speaking about this problem. I agree nurses are an important source of health care information, research has shown that nurses are a trusted source for information, we must become well informed and engage in conversations, especially with families with under age children. Thank you using your time and voice for this important issue. Gail Perin
Thank you, Dr Vlahov for your commentary on public health & gun violence. This is an unaddressed crisis which desperately needs attention. Political remedies have been almost impossible to come by, but nurses may be able to provide some remedy by broaching this subject with their patients. Glennda
The gag order is particularly disturbing, on several levels. Jizell Albright

Academic Nursing Advances Health Care Transformation

David Vlahov

The American Association of Colleges of Nursing (AACN) recently released a commissioned report titled Advancing Healthcare Transformation: A New Era for Academic Nursing. By building on the Future of Nursing report from the Institute of Medicine, Manatt Health examined the opportunities for schools of nursing within or aligned with academic health centers (AHCs) to become firmly integrated in advancing health care transformation.

The AHCs are hubs of innovation for developing and testing new models of care. Nurses, of course, are key to the success of transforming health care in this new environment, especially as the Affordable Care Act facilitates experiments that move away from fee-for-service and toward value-based payments tied to metrics for quality, safety and value in the context of population health.

Over the past few years, schools of nursing have already begun contributing to these important changes through all aspects of our tripartite mission of research, education and practice. Some schools have demonstrated fiscally responsible nurse-managed clinics for student health and medically underserved community settings. Mary Naylor, PhD, RN – our UCSF Presidential Chair – has provided ample evidence for fiscally prudent transitional care models for complex care management in acute to community settings. At the San Francisco VA Health Care System, we have ample experience with joint medicine and nursing faculty models, which provide nonhierarchical, team-based care using the lens and strength of each profession. In many of these clinical settings, we are both training students and conducting the research necessary to deliver evidence-based solutions.

The AACN-sponsored Manatt report advances this agenda by offering a number of critical observations and recommendations that derive from a process that was both thorough and inclusive. The authors interviewed a wide range of stakeholders, including deans of nursing and medical schools, chief nursing executives, health system CEOs and university presidents. Manatt drew on its stellar reputation to convene a summit with many of these stakeholders to sort through priorities, barriers and facilitators.

One key ingredient for the successful integration of schools of nursing with AHCs to transform health care is joint appointments for campus and health center leadership. For example, in some institutions the dean of nursing is an associate chief nurse executive (CNE) and the CNE is an associate dean in the school. In other institutions, the dean might be a full member on the health center’s board of directors.

There are a number of other recommendations that speak to the essential central theme: Schools of nursing and AHCs must work together to create an organizational climate that not only brings all players to the table, but gives them the confidence and structure to innovate together. That is the best way to plan and achieve a successful transition to a new era in health care. 

Nurses Play an Important, Perhaps Surprising Role in Prison Reform

David Vlahov

When President Obama commuted the sentences of 61 inmates in March 2016, it was the most visible element in a flurry of prison reform activities aimed at relieving overcrowded prisons and finding alternatives for nonviolent offenders.

Among those activities: The federal prison system has been releasing thousands of individuals who received long sentences for low-level, drug-related, nonviolent crimes. Sentencing reform bills are making their way through Congress. The Releasing Aging People in Prison (RAPP) project – an advocacy campaign aimed at helping older, low-level offenders – is gaining momentum.  

This is important and humane work, but achieving the desired goal will not be easy. Studies have shown that the greatest period of risk for inmates is soon after release, with high rates of drug overdose and rearrest. This should surprise no one. Releasing individuals who have spent years behind bars to a new and challenging environment with little or no preparation is bound to present many challenges.

Nurses can play an important role in helping to ease these transitions.

While community reintegration programs already exist to help former inmates, they have had mixed results. Those focused solely or mostly on employment have tended to have little effect on recidivism. In contrast, those that have provided a more holistic, multimodal approach (e.g., employment, education and health care) have tended to do better, not just in reducing rearrests, but also by showing improvements in other dimensions. Our alumna and faculty member Elizabeth Marlow, for example, has been on the leading edge of shaping a humanistic approach to re-entry, with a particular emphasis on education. Her work demonstrates one way that nurses can play a crucial role in supporting effective reintegration.

Especially as the prison population has aged, sending people back into the community who are relatively healthy and who have the skills to maintain their health is another key challenge. Our doctoral student Doug Long not only uses direct care and patient education to better prepare prisoners for their arrival in civilian life, but is also doing important research about aging in prison. He is a fine example of how nurses can deliver both critical observations and academic research to support policy change and transitional care programs.

Reversing the excesses of prison sentencing that came into being during the War on Drugs has become a bipartisan issue, one of the few on which there appears to be widespread agreement. As nurses, we have an obligation to bring our expertise to this critical issue and help build healthy transitions for individuals and the families and communities to which they return.

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Partnership with SFVA Creates Rare Residency for Psychiatric/Mental Health NPs – In an effort to better meet the mental health needs of Bay Area veterans, a new psychiatric/mental health NP residency creates opportunities for building important alliances between the San Francisco VA Health Care System and UC San Francisco School of Nursing.
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Addressing the Ethical Challenges of Noninvasive Prenatal Testing – In the first in a series of posts on bioethical issues in health care, Marsha Michie of the UCSF Bioethics team, explores some of the concerns raised by the emergence of noninvasive prenatal testing.
August 2016
“Nerds and Nurses” Race to Develop Super Alarm to Combat Alarm Fatigue – With alarm fatigue causing concerns across the country, an interdisciplinary research team races to create a super alarm that would make optimal use of the abundance of clinical data available today.