The Dean’s Blog

Accepting and Understanding the Value of Gratitude

David Vlahov

Many years ago, while nursing in a coronary care unit, I had a patient who ran a kosher deli. Each day, his family would arrive with a heaping tray of pastrami and corned beef, the best deli treats I’d ever had. At first, I was uncomfortable with the family’s gifts; I was just doing my job. Eventually, though, I recognized both the family’s sincerity and the hurt I was inflicting by not accepting their gift. Their look of happiness when I did accept has always stayed with me.

Another time, at a busy mall, a middle-aged man approached me from a mass of shoppers and squinted intently at me. He seemed familiar, but I couldn’t place him. Then his squint evolved into elation. He waved his wife over, pointed at me and said in a possessive tone that I was his nurse. He spoke of being admitted to the coronary care unit, wondering if he would survive. After I wheeled him on a stretcher and transferred him into bed, I told him, “You got yourself in here. We’re going to get you out.” He said that he knew then he was in good hands. Yet once more I was embarrassed by the attention for merely doing my job. There was an awkward silence, and looking back, I realize I stifled his desire to give thanks.

This is a common experience for many nurses. Perhaps we take what we do for granted and find it difficult to accept our patients’ gratitude. Yet the older I get, the more I understand how important it is not just to accept their appreciation, but to use it as a way to build on the things we do well, just as constructive criticism is a way to correct our deficiencies. These situations are, in fact, opportunities to deepen our connections and grow as nurses – to speak with our patients and former patients about just how meaningful their gratitude can be.

And when the gratitude comes in the form of donations to our education, it is extraordinarily meaningful and valuable. After all, data show that better-educated nurses lead to better clinical outcomes – and schools of nursing are the only way to produce the teachers and leaders that assure quality nursing education across the country.

Now is an especially important time to support nursing education. The impending nursing shortage will be hard to address because we don’t have enough doctorally prepared teachers. The debt many who might seek such preparation will incur is a significant disincentive – and the means to get help with costs are shrinking. Government support has declined. Hospitals and clinics have tighter budgets, so they find it harder to support their nurses’ continuing education.

Thus, rather than shuffle uncomfortably when we are offered thanks, now is the time to encourage our grateful patients to support nursing education, so we can produce the next generation of highly skilled nurses, leaders and educators. That type of gratitude delivers huge returns for patients, families and society.

Launching Assistant Professors

David Vlahov

While attending a recent meeting of nursing faculty leaders from across the country, a small group of us from research-intensive schools met informally to compare notes. One of the topics was protected time for junior faculty on the tenure track: how much to provide and for how long to new assistant professors, and senior faculty’s expectations about how to accommodate such time.

There was no single shared vision across schools, but for me it is impossible to discuss this idea of protected time without looking at its role in an entire career arc.

For tenure-track junior faculty in research-intensive universities, progression through the academic ranks typically demands active research that advances knowledge, excellence in teaching and advising, and service to the academic institution, the profession and the community. Institutions vary in the proportion of effort devoted to each part of the academic mission, as well as the metric for productivity within each part, but many provide protected research time for the first year. The assumption is that new faculty members need time to become oriented to the culture of the institution and academia, write manuscripts that provide a foundation for a program of research and prepare and submit grant proposals that will fund work that advances knowledge.

The ideal is to recruit new faculty members who are already building on their dissertation and postdoctoral research topic to establish themselves as credible candidates to steward funding that produces new knowledge. Yet even for an ideal new faculty member, solid funding for research typically takes at least one and often two or three years to arrive, so providing time – and mentoring – to get proposals started is essential.

Doctoral programs prepare students in scholarship, but in many cases, doctoral work is a more solitary experience. Successful science involves collaborations across disciplines, so protected time does not mean isolated time. New faculty need to learn how to complete academic work in a more complex setting, one with a longer list of expectations and shorter deadlines. In this context, mentors are crucial resources who encourage, guide and connect new faculty members to people and programs that stimulate energy, creativity and productivity.

Protected time also implies a responsibility to the institution beyond one’s own research track – a time to learn to teach with an experienced professor and become engaged in the academic community. Senior faculty mentor on how to manage all of these challenges to succeed in the academic community.

The end of this initial period and promotion to associate professor is often an enormous relief. Yet unless the protected time and mentoring have been employed wisely, this next phase can also come as a shock. The workload in research, teaching and service actually increases. The metric for promotion to full professor is not only productivity in each area, but also evidence of leadership that includes mentoring new faculty, taking on more students and serving on committees that plan the future of the school.

Full professorship comes with even more responsibility. The expectation is to become a role model and transmitter for the culture of academia at one’s institution.

While this discussion is about faculty in the tenure track, the needs are the same for the clinical faculty – growing junior faculty to become the leaders for tomorrow.

We need to carefully manage our investment of protected research time and mentoring for new faculty. This is not solely a period for them to write and submit manuscripts and grants. It is also a support system that enables these talented individuals to grow into full citizens and leaders in the academic community – ones who attract high-caliber colleagues, bright students and the resources needed to tackle the questions that will lead to improved science.

Comments

Thank you for this thoughtful commentary on the growth and development, and expectations for faculty. I appreciate the attention to the multiple demands for faculty and on how support/mentoring is an important key to career advancement. Being in the clinical faculty series, there has been relatively little attention to the expectations and demands for faculty in this series. So, I am glad that clinical faculty were mentioned in this commentary. It would be great to have a conversation around "protected time" for new clinical faculty (assistant professors). Time is needed for developing the skills needed to be an exceptional clinical educator and scholar. It is also needed for enhancing academic leadership skills that assure the advancement of our clinical programs and making important contributions to health-related policies and more. I would be happy to enagage in such conversations. JoAnne M. Saxe, DNP, ANP-BC, Director, Adult-Gerontology Primary Care Nurse Practitioner Program
very insightful and appreciated, Dean Vlahov. We all struggle with this challenge, and find it is easier to conceptually support effective mentoring than it is to follow through in practice. Your observations on post-tenure let down are particularly astute. Dick Culbertson, Ph.D. '93; Dean, LSU School of Public Health; New Orleans, LA.
Excellent topic. I would appreciate learning from you what other research intensive universities are doing to launch research and clinical professors.
Your request is good and one that may best be answered by leaders in other Schools/Universities. I'm glad to have this blog serve as a forum for sharing information and building the conversation.

NPs, Expanded Scope and the Need for Team-Based Health Care

David Vlahov

My most recent blog post – which commented on an Academic Medicine article titled “Primary Care Workforce Shortages and Career Recommendations from Practicing Clinicians” – touched a nerve with some readers. People have responded in a number of ways. Some felt that the blog was “out of touch” and “tone-deaf” to the issues of concern for primary care nurse practitioners (PCNPs), in essence abandoning our shared commitment to the preparation, profession and position of nurse practitioners.

Nothing could be further from the truth! To be clear, in my earlier blog posts (e.g., “Reducing the Impact of the Doctor Shortage in a Year,” from July 2014), published articles (e.g., “Nurse Practitioners: Implementing the Affordable Care Act,” in San Francisco Medicine, April 2013) and numerous national presentations, I have consistently made the case for PCNPs being able to practice to the full extent of their education and license. The recent blog post is most definitely not a departure from that position.

The Institute of Medicine’s 2010 report on The Future of Nursing framed the future in the context of health care reform. In essence, the country needs a larger, stronger and more integrated health care workforce to meet the nation’s health care needs. To meet the real and growing challenge of providing quality care, the IOM stressed the development of educational standards for practice; the education of doctorally prepared nurses for leadership, education and research; and the need to address the scope of practice whereby nurses can fully practice to the level of their education.

In California, we have had some disappointment in making progress toward these goals. In 2013, Senate Bill 491, which would have allowed nurse practitioners to operate without physician supervision at certain medical facilities, did not pass. Among others, I was asked to and did provide research in support of independent practice. In addition to summarizing the research base that has found nurse practitioners provide high-quality and safe care, with outcomes and patient satisfaction comparable to primary care physicians, I also presented the case that it is much more cost-effective to train nurse practitioners and that they graduate with much lower debt compared to physicians. I argued for the importance of having expanded practice restrictions eased as a means to expand the health care workforce to meet the increasing needs associated with health care reform. The early version of this bill was discussed with the deans of all the UC schools of nursing, who similarly expressed support. Additionally, a letter in support of the bill came from the University of California, Office of the President.

There can be no doubt of where I stand on the issue of independent practice for nurse practitioners. And we will continue to fight for this becoming a reality in California as it already has in some states. Hopefully, the 2013 bill will be reintroduced and will pass in the next legislative session.

All of that said, a larger workforce – even one enhanced by making full use of NPs’ unique skill set – is not enough. Coordinated, team-based care is health care’s future. Thus, we need to do better in terms of training together, working together and supporting each other. Listening to and understanding the views and concerns of our professional colleagues moves us closer to these important goals.

David Vlahov, RN, PhD, FAAN

 

In Support of Primary Care Medicine

David Vlahov

Recently, an article in Academic Medicine described the results of a survey that found 66 percent of primary care physicians (PCPs) would recommend becoming a primary care nurse practitioner (PCNP) as a career choice, whereas only 56 percent of PCPs would recommend a career in their own profession. Conversely, 88 percent of primary care nurse practitioners would recommend their own career.

As one of many nurses who have argued long and loud that the challenges of health care reform demand that we expand the scope of practice for nurse practitioners, I might be expected to take some pleasure in such findings.

I do not; I find the survey results dispiriting. A shrinking pool of primary care physicians is unequivocal bad news for anyone who cares about creating a truly responsive and high-quality system of care.

Consider one key passage of the article:

It is possible that Primary Care Physicians’ greater willingness to recommend a career as a PCNP over a career in their own profession could reflect their pessimism about the future of primary care medicine. Dissatisfaction with factors not assessed in this survey – lower payments and incomes relative to specialists, long work hours, increasing bureaucracy and compliance oversight, devaluation of primary care among the academic medical community, the additional years of education, and high debt levels following the completion of medical education, particularly in relation to their salary as compared with physicians in other specialties – could weigh heavily enough to offset PCPs’ misgivings about PCNPs and thus explain their greater willingness to recommend that qualified students pursue careers as PCNPs.

If the authors’ speculations about the sources of primary care dissatisfaction are correct – and such thoughts are nothing new for those of us who count primary care physicians as friends and colleagues – then it is time for all of us to find ways to turn this train around. A strong primary care physician workforce is a non-negotiable necessity for quality care.

Therefore, we must build new incentives for primary care medicine into the evolving designs for health care delivery and academic medicine. We must work together with our primary care physician colleagues to create and sustain the conditions necessary to maintain and expand their vital practice. Even as PCNPs have sought a wider scope for their own practice, it has always been in the context of adding value to an essential partnership with primary care physicians and other health professionals to enhance health and well-being for all individuals.

To be clear: becoming a PCNP is a great career choice. Yet PCNPs do not exist to replace primary care physicians. We are not interchangeable. There may be overlap in our roles, but there is also important differentiation where each provides additive value to health care delivery and the health of our patients.

If nursing is dedicated to creating and being part of a comprehensive health system that meets the needs of disease prevention, management and health promotion, then we must advocate for a strong primary care physician workforce that feels truly energized about bringing its expertise and innovation to our shared mission.

Thoughts on World AIDS Day

David Vlahov

World AIDS Day (Dec. 1) is an opportunity to renew our commitment to creating a generation without this dreaded disease. This year’s theme – Focus, Partner, Achieve: An AIDS-Free Generation – is a perfect rallying cry for a fight that, unfortunately, is not yet over. Just this week, the US Centers for Disease Control and Prevention released a study which found that more than 1 million Americans have HIV, nearly 50,000 more become infected every year, and in 2011, fewer than 3 in 10 had the disease under control.

So a renewed commitment is essential – and some of us find the strength for that commitment in the inspiration of heroes. With HIV/AIDS there is no shortage of such heroes, from patients and families to researchers, clinicians, advocacy groups and policymakers.

Inevitably, though, I think of my nursing colleagues. In the early 1980s, when the disease first emerged as a virulent and mysterious killer and I saw my first patient with HIV/AIDS – when we didn’t know how to ease the suffering, and the stigma associated with this “gay disease” was more cruelly overt than it is today – nurses often took center stage.

No place was this more true than in San Francisco. In 1983, the San Francisco Department of Public Health and UCSF created the first outpatient clinic devoted to caring for people with AIDS and, led by Cliff Morrison – a nurse and clinical faculty member at UCSF School of Nursing – the first inpatient AIDS unit in the nation at San Francisco General Hospital.

Absent any known treatment or cures, Morrison and his colleagues focused on relieving the physical and emotional suffering of early AIDS patients. Symptom management – a major clinical responsibility for nurses in any setting and a major pursuit of nurse scientists – was crucial.

Morrison and his team also understood that easing suffering meant helping patients overcome the stigma of HIV/AIDS. Their early realization led to research by nurse scientists and others that has leant understanding to stigma’s role in all disease.

Community health nurses and researchers were among the first to understand that AIDS affected other communities, such as injection drug users and sex workers. Developing community health interventions was an important factor in stemming the epidemic.

As discoveries emerged, nurse educators at UCSF and other schools adapted our curricula, developing patient education techniques that helped individuals and communities reduce the risks of contracting HIV and helped patients adhere to treatment regimens. Over the years, nurse educators here have helped create a virtual army of HIV/AIDS-trained practitioners for the Bay Area and the world.

That’s important, because as HIV/AIDS has become more chronic illness than death sentence, nurses often are the clinical leads with patients. We work with physician colleagues to develop realistic treatment plans tailored to the context of our patients’ entire lives. We point patients to community resources and help them understand it is possible to live full and rewarding lives while managing the illness.

So, today, as the HIV/AIDS community renews its commitment to this fight, I feel enormous pride in my profession. We are only one among many groups whose heroic efforts inspire us today, but our work demonstrates the very best in nursing and health care – not just the compassion and kindness with which we are often associated, but our complex and essential role in many aspects and on many levels of patient care.

Still, there is much left to do. Let’s draw our strength for the continued fight from our heroes. 

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