The Dean’s Blog

Ebola Virus Disease and the Nursing Workforce

David Vlahov

The World Health Organization reported that as of August 11, 2014, the number of cases attributed to Ebola virus disease (EVD) in four West African countries stood at 1,848, with 1,013 deaths. More than 145 health care workers who have provided care to Ebola patients have also become infected, with 80 deaths so far.

Concern has spread to the United States, as two American health care workers who contracted the disease were flown here and are under care. Tom Frieden, director of the Centers for Disease Control and Prevention, has assured the public that the probability of EVD spreading within the US is remote. Nevertheless, both here and around the world, the virulence of the disease, some misunderstanding of how it is transmitted and a failure to have proper protections in place in some health care settings have caused alarm among those charged with treating EVD’s victims.

Those fears recall memories of when I was an infection control nurse in Baltimore, caring for patients with AIDS early in the HIV epidemic. I remember seeing an AIDS patient placed into full isolation, with nurses and physicians congregated outside the room expressing anxiety about whether they should go in at all. As the Health Resources and Services Administration’s Ryan White HIV/AIDS Program history project noted, some physicians and nursing staffs even refused to provide treatment to those with AIDS symptoms. As people died, stigma and willful ignorance kept many funeral homes from accepting bodies for burial. In 1987, the New York Times published an article titled “When Doctors Refuse to Treat AIDS.” Faced with a new and highly fatal disease, fear was palpable.

With today’s Ebola outbreak – just as with HIV and other viral outbreaks, such as SARS (severe acute respiratory syndrome) and H1N1 influenza (swine flu) – some health care workers have volunteered to be at the front lines, but others have been reluctant. Such reluctance is understandably highest in the earliest days, especially if the routes of transmission are not well understood, health care workers don’t know how best to protect themselves – and don’t trust their employers to provide them with all of the appropriate protections. That appears to be what’s behind reports of nurses going on strike in the affected West African nations.

Given the dire need for treating EVD patients and containing future outbreaks of the disease, we must:

  • Strengthen the global nursing workforce with increased clinical and public health training.
  • Establish an adequate inventory of equipment and supplies.
  • Provide a public health infrastructure for rapid and effective monitoring and response to emerging events.
  • Train governments to lead efforts in public health preparedness and response.

This is what we eventually did with HIV/AIDS and did more quickly with SARS and H1N1. Such preparedness builds a reservoir of trust and confidence that otherwise can be tested and undermined during emergencies such as the one we are currently witnessing.

Nurses play a crucial role in establishing that trust – not just by our presence at the bedside, but through use of our public health expertise to develop policies and lead and organize our communities. By addressing understandable concerns for our own safety and that of our colleagues and communities, we can help ensure patients receive the care they so desperately need.

 

Comments

Once again UCSF School of Nursing, this time Dean Vlahov, is on the front line to address a major health problem, i.e., ebola. Thank you.
Yes, good for UCSF with this timely message...I too recall the fear generated in the hearts of some nurses when it came to the early days of hospitalized HIV/AIDS patients...one staff nurse went so far as to sit on the floor, repeatedly pounding her feet/legs up and down as she cried out her refusal to take on a care assignment of an AIDS person. Let us hope your message goes beyond the UCSF connection for I hear a lot of misinformation over the radio and TV in regard to EBOLA...Thanks for the message...I shall forward it...
Thank you for sharing your experiences during the HIV early days. I was a young ICU nurse, witnessing one of the first cases of AIDs in our SF hospital late 1970s, early 1980s. Thankfully, for us, we had 2 tremendously informed and educated Infectious Disease Physicians who helped us set up a protected treatment plan of care. Yet, I also witnessed others who refused to care for patients because of their fears and lack of knowledge. Florence Nightingale was probably shaking her finger then and now at us for forgetting about the grass roots of Nursing. We are the compassionate workforce, which we should not forget these roots. Yet, we need to be informed about highly infectious disease and the best protection to avoid putting ourselves in harms way. When we do this, we should not walk away from those who are suffering and need the care we can deliver.
What are the appropriate safeguards and how is it transmitted?
The Centers for Disease Control and Prevention (CDC) is an excellent resource: http://www.cdc.gov/vhf/ebola/prevention/

Reducing the Impact of the Doctor Shortage in a Year

David Vlahov

With startling regularity, stories continue to appear in publication after publication in which the authors fret about how to respond to the growing demand for health care, particularly primary care, and the accompanying shortage of doctors. Typically, the writers call for more medical schools, more money for medical students to lower debt, and incentives for medical students to go into primary care.

As we have noted many times before – and in many settings – such measures are important, but they will not be enough and they will not get solutions in place as quickly as is necessary. Meanwhile, there is a more immediate, research-based solution right in front of us – if only state legislatures would listen objectively to the evidence.

Nurse practitioners (NPs) are RNs with at least a master’s degree who are nationally certified for a particular specialty area, such as family health care, midwifery or adult-geriatric care. Compared with physicians, NPs take less time to train, the programs are less expensive to run and the amount of student debt is less. Equally important, studies that the Institute of Medicine has characterized as valid have shown that NPs can safely and effectively deliver 90 percent of pediatric primary care services and 75 percent of general primary care services. Other studies have shown that each discipline sends patients to specialists when needed. Moreover, NPs are more likely than physicians to practice in underserved areas, both urban and rural, where the shortages are most severe.

Despite such findings, we still find articles in national publications in which the authors or their sources espouse relegating NPs to “performing vaccinations and strep tests.” That is a woeful underutilization of highly skilled practitioners. It reflects limited scope-of-practice rules and a narrow vision for addressing the desperate need for more high-quality primary care, which nearly every expert agrees is critical to improving people’s health – and reducing the exorbitant cost of care in this country.

The Bay Area Council Economic Institute recently issued a white paper that, among other things, noted that allowing nurse practitioners in California to practice to the full extent of their education and training could save the state $1.8 billion on preventative care visits alone over 10 years while increasing the number of those visits by 2 million per year. The lead author of the report notes: “While no single policy change will be a panacea for the critical cost and access issues facing California, this reform [allowing nurse practitioners to provide the health care services they were trained and licensed for] could be an important first step to bring down some of the barriers that are keeping healthcare costs artificially high.”

To be clear: having nurse practitioners practice to the full extent of their education and experience does not remove the need for more schools, more funding for the health professions and incentives to draw more professionals into primary care.

But those are longer-term concerns. To meet the shorter-term health needs of individuals and populations, there is a solution available now. It is time for legislatures to stop being distracted by false arguments and expensive lobbying efforts. They should act immediately to free nurse practitioners to practice to the full extent of their education, so NPs can help address the health care needs of the people our legislators serve. 

An Opportunity to Reduce Premature Births

David Vlahov

Premature birth is a major public health problem. According to Born Too Soon – a 2012 report co-produced by the March of Dimes, The Partnership for Maternal, Newborn & Child Health, Save the Children and the World Health Organization – worldwide, approximately 15 million babies are born prematurely each year. More than 1 million of these infants die due to complications of prematurity. Prematurity is the leading cause of death for babies in the first four weeks of life, and second behind pneumonia for all children less than 5 years old. Moreover, many survivors face a lifetime of disability, including learning disabilities, vision problems and hearing loss. Even more disturbing, trend data from 65 countries show rates of preterm birth rising in most countries around the world, rich and poor.

However, as the report notes in its executive summary, premature babies can be saved if one considers that, “Inequalities in survival rates around the world are stark: half of the babies born at 24 weeks (four months early) survive in high-income countries, but in low-income settings half the babies born at 32 weeks (two months early) continue to die due to a lack of feasible, cost-effective care, such as warmth, breastfeeding support, and basic care for infections and breathing difficulties. Over the last decade, some countries have halved deaths due to preterm birth by ensuring frontline workers were skilled in care of premature babies and improving supplies of life-saving commodities and equipment.”

UC San Francisco recently received a grant to address this global problem: a combined commitment of $100 million from Lynne and Marc Benioff and the Bill & Melinda Gates Foundation. The funding is to address prematurity risks, education, prevention and treatment in both the wealthy and less wealthy nations. We are proud to share that the School of Nursing played an important role in preparing the proposal and that we are now contributing interprofessional leadership for the planning year that has already begun. Linda Franck, chair and professor of Family Health Care Nursing, is one of the planning-year deputy directors, representing a department that includes nurse-midwives, neonatal intensive care clinical specialists and pediatric and family nurse practitioners. Professor Emerita Sally Rankin has been a key link between the School’s global health nursing program and UCSF Global Health Sciences. I am proud to serve on the project’s Internal Advisory Board.

This is timely, essential work. The research on factors associated with the incidence of prematurity, prevention methods and treatment is incomplete. Over the next decade, this project will frame and address key unanswered questions, taking advantage of a unique opportunity to generate ideas that are both transdisciplinary and transformative. We look forward to joining forces with colleagues from many disciplines to reduce the burden of preterm birth worldwide.

Five Reasons to Support a Commonsense Solution for the Primary Care Shortage

David Vlahov

Note: A version of this blog appeared as an op-ed piece in the Thursday, April 10, edition of the San Francisco Examiner.

Congress should reauthorize and fully fund nurse practitioner residencies in primary care clinics. Though relatively new, these programs can play a key role in addressing America’s burgeoning primary care crisis.

Here are five reasons why:

First, the country already lacks enough primary care physicians to meet our health care needs. The problem is especially dire in underserved communities, both rural and urban, where federally qualified health centers and nurse-managed health clinics deliver a huge portion of primary care.

Second, the primary care shortage is worsening due to the Affordable Care Act and the aging US population. According to the Association of American Medical Colleges, by 2025, there will be a shortage of 65,800 primary care physicians. Unless we make a full-bore effort to revitalize the provider pipeline – physicians, nurse practitioners and physician assistants – increasing numbers of needy Americans will be unable to receive the care they need, even if they are insured.

Third, a substantial body of research has shown that for the overwhelming majority of primary care concerns, nurse practitioners, or NPs, perform as well as physicians on clinical outcomes and patient satisfaction. Moreover, NPs can be trained faster and less expensively than physicians and have demonstrated a willingness and ability to work in underserved areas. This does not negate the need for more physicians, but we desperately need all hands on deck.

Fourth, despite the research showing NPs’ excellent clinical results, newly graduated NPs are often discouraged from joining federally qualified health centers because of the intensity and demands of providing service in these complex clinical settings. In fact, the Institute of Medicine’s landmark 2010 report, The Future of Nursing: Leading Change, Advancing Health, called for residency programs, partly in response to concerns that newly graduated NPs would not have had enough experience or training.

This leads to reason No. 5: Nurse practitioner residencies address these concerns. The residencies provide an extra year of hands-on training for newly graduated NPs, often including the opportunity to work in teams with physician colleagues, much as primary care physicians work with specialty colleagues. While it is too soon to rigorously gauge the value of the first wave of NP residency programs, residency is a proven model for training physicians, and the anecdotal evidence about NP residencies – including that from our own program in collaboration with Glide Health Services in San Francisco – is quite encouraging.

Inspired in part by Margaret Flinter, an advanced practice nurse who is the country’s leading advocate for NP residencies, Congress originally authorized a three-year pilot program (2011-2014) that established nurse practitioner residencies in federally qualified health centers and nurse-managed health clinics as part of the Affordable Care Act. Now, US Sen. Bernie Sanders, I-Vermont, has proposed that the NP residencies be reauthorized and funded at $75 million for the next five years.

On Wednesday, April 9, Flinter testified in front of the US Senate Committee on Health, Education, Labor and Pensions in support of that proposal. Hers is a voice the entire country – not just politicians and health care professionals – needs to hear.

After all, in the short term, reauthorizing and funding another five years for NP residencies is an effective, economical way to extend the primary care workforce in the clinics implementing these programs. Long-term, it gives researchers and policymakers an opportunity to rigorously gauge the value of the NP residency concept and establish best practices.

Given the urgent nature of the primary care crisis, the history of NPs delivering exemplary primary care and the low-risk, high-reward nature of this proposal, how can we afford not to support its reauthorization and funding?

I urge both the health care community and members of the general public to ask their representatives in Congress to support this desperately needed program.

Comments

I would add that the Veterans Administration has been actively recruiting and funding NP residencies for over 3 years at 5 VA medical centers, including our own affiliate the San Francisco VA Medical Center. In addition, the VA Medical Centers employ more nurse practitioners in ambulatory primary care clinics than any other healthcare system. The NP residents who complete these residencies easily secure post-residency employment in a variety of settings and report much higher professional confidence scores than new NPs who did not complete residencies. Susan Janson, PhD, ANP-BC, CNS, FAAN Professor Emeritus

How Nursing Can Meet the Needs of an Aging Population

David Vlahov

To address the complex health needs of an aging society, schools of nursing have a moral and professional obligation to generate a well-prepared workforce and produce high-quality research that advances health and health care for the elderly. Research efforts must be ambitious but focused, with attention to (1) building evidence-based health promotion and patient care strategies, (2) advancing the science of symptom assessment and management, (3) providing care for the family caregiver, (4) designing community-level interventions to promote safe and healthy environments and (5) analyzing health policy to promote an effective workforce and payment for care.

To achieve these aims at UC San Francisco School of Nursing, we have systematically drawn together faculty across three academic departments, our organized research unit and the rich and enthusiastic array of faculty in geriatric medicine at UCSF School of Medicine. The effort cross-fertilizes with organized and interprofessional faculty activities in our areas of excellence in symptom science and palliative care. The idea is to leverage the work of individuals by fostering creative collaborations that can accelerate and enhance our ability to meet a rapidly growing need. This past week we saw some of the first fruits of our efforts.

On March 17, the John A. Hartford Center of Gerontological Nursing Excellence, led by Meg Wallhagen, PhD, GNP-BC, held a conference on “Innovations in Geriatric Nursing Care.” Organized by Laura Wagner, PhD, RN, the day included talks on new research from our guest presenter, Elizabeth Capezuti, PhD, RN, who is the William Randolph Hearst Foundation Chair in Gerontology at Hunter College of the City University of New York, as well as from several of our junior nursing faculty, to a large audience of academics and clinicians from nursing and geriatric medicine. The conference ended with a discussion between our lead in nursing administration and leadership, Mary Louise Fleming, RN, PhD, and renowned geriatrician John Rowe, MD, from Columbia University’s Mailman School of Public Health, on how nurses and geriatricians can better work together to advance health among the elderly. (Coverage of the conference and other aging-related issues will appear in our April posting of Science of Caring, as well as in subsequent posts.)

And because we are fully on board with the UCSF mission of “advancing health worldwide,” earlier in March, the School held a Sino-American Summit on Geriatric Nursing with Dean Diana Lee and faculty from the Nethersole School of Nursing at the Chinese University of Hong Kong. The summit highlighted the unique challenges in a society where care for the elderly intersects with rapid urbanization and the one child rule; not only are there fewer young people available to care for their elders, but as young people migrate to cities for economic reasons, social relationships within families undergo significant change. The Nethersole School of Nursing faculty has stepped up its efforts to prepare nurses to meet these challenges. Later this year, we anticipate a visit with the dean and faculty from the Hong Kong Polytechnic University, known for its cutting-edge research and education. The goal is to foster a collaboration between our two schools to advance nursing science. Both of these efforts build on our recent trip to China and are a centerpiece of our far-flung efforts to engage in global geriatric nursing care.

All of which speaks to the type of institutional commitment required if nursing is to mount a credible response to the growing health needs of an aging population. The response must go beyond recruiting the best faculty and students and fostering a supportive environment that nurtures excellence in research, education and service. We must prepare geriatric clinicians, while simultaneously generating and integrating knowledge into the curricula for both adult and family care nurse practitioners and clinical specialists. We must focus on individual-level health promotion and nursing care for the elderly, but also address the needs of family caregivers and create a policy climate that encourages independent living. At a school of nursing, all of these things demand enriched mentoring and support of junior faculty, organizing and developing a community of scholars dedicated to this effort, and advancing partnerships with other professions and disciplines.

In a recent UCSF-wide exercise, a broad cross section of faculty, students, alumni and community stakeholders combined to develop a vision for the future of UCSF. The most prolific group on campus was “Team Aging,” an interest group from different professions and disciplines that sees UCSF leading the way in promoting a society that honors and cares for its aging members, whose numbers are increasing rapidly. This group reflects the depth of commitment and the breadth of enthusiasm to make UCSF responsive to one of society’s most pressing health care needs. The vision is inspiring and the promise is great: UCSF can serve as a model for health sciences institutions and schools of nursing around the country. Now, however, we must act on this promise and turn vision into reality.

 

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