The Dean’s Blog

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.

As Viral Threats Expand, Nurses Must Continue to Step Up

David Vlahov

In her January 24, 2016, report to the Executive Board of the World Health Organization (WHO), Director-General Margaret Chan spoke about viral infections that are sowing fear and having deep, often lasting health effects around the globe.

In this report, she warned that even though the Ebola outbreak has been declared over in Liberia – the last country to report cases – the risk of further flare-ups would persist. Indeed, the next day, Sierra Leone confirmed its first new case since September 2015.

Dr. Chan told of new cases of the Middle East respiratory syndrome coronavirus appearing in Korea.

And she pointed to the increase of Zika virus cases in Latin America. Just over a week later, the WHO declared the Zika outbreak a global emergency.

Global warming, population growth, urbanization and air travel are among the reasons for the rapid, far-reaching spread of these infections. Yet regardless of the inciting cause, nursing’s essential and often central role in public health and prevention demands that we stay on top of emerging information about all of these global threats.

Zika, of course, is top of mind right now. We have known about the virus for decades, but in mid-2015, it exploded – most notably in Brazil, but also in 26 countries in the Americas. In the US, we’ve seen cases related to travel in affected regions and, as of this writing, two cases related to sexual transmission. We believe the infection lasts up to a few weeks and confers lasting immunity.

Prior to the current outbreak, we also believed the Zika virus typically causes asymptomatic infection, with reports of a rash and fever in about 20 percent of cases. Yet in cases throughout Latin America, though causality has not been established, the Zika virus is now associated with infected mothers giving birth to infants with microcephaly – a smaller-than-normal head that typically leads to abnormal brain function and shorter life span. Some have postulated potential links to Guillain-Barré syndrome. A recent JAMA article found a potential connection to blindness.

But at this point, it’s the increase in cases of microcephaly in Brazil that is most alarming. There have been 4,783 cases between October 2015 and February 2016, which dwarfs the average of 140 annual cases seen in previous years in the same country.

Mosquitoes of the Aedes genus spread Zika; they can breed in a pool of water as small as a bottle cap and usually bite during the day. The Aedes genus is found in tropical and warmer climates and in the US has appeared most frequently in Florida, the Gulf Coast and Hawaii. Yet it also has appeared as far north as Chicago during particularly hot weather.

Although much remains unknown, a number of ideas are emerging for how to prevent contracting the virus and putting infants at risk.

  • Some countries have recommended that women delay becoming pregnant for two years, in the hope that researchers might develop a vaccine in that time frame. Brazil recently reached an agreement with the University of Texas Medical Branch at Galveston to develop such a vaccine, hopefully within the next year.
  • Women intending to become pregnant should avoid travel to affected regions.
  • Men returning from affected areas should abstain from sex for a month or wear condoms.
  • For persons in affected areas, Aedes mosquitoes are more prevalent during the day, so many are advising wearing long-sleeve shirts, long pants and hats during the day and using insecticide at all times to avoid bites .
  • Those in affected regions should drain all standing water to minimize mosquito breeding.

By drawing on the best available information, nurses can help patients and clinical colleagues make the most informed decisions about how to prevent these infections. We can and should be scrupulous in screening, educating and referring patients, and also be prepared to educate the public in a wide variety of settings. Schools of nursing should review plans and procedures for infection prevention and response, especially schools that provide international experience or rotations; we have already begun our own review.

New information, however, arrives almost daily, and it is our responsibility to stay on top of it and incorporate it into what we do each day. 

How Did We Get to “More Is Always Better”? and Other Essential Questions on Aging

David Vlahov

Anthropologist Sharon Kaufman is one of the original members of the Institute for Health & Aging (IHA), which on November 9 celebrated its 30th anniversary. The event brought together scientists who had flourished in the Institute and made significant contributions to our understanding of health at the individual and societal level.

At the celebration, Kaufman drew on her recently released book, Ordinary Medicine: Extraordinary Treatments, Longer Lives, and Where to Draw the Line (Duke University Press, 2015), to speak about the struggle in health care between the desire to prolong life and the desire to avoid crossing the line to “too much” care. Exploring that dilemma led her to examine the larger engines of the biomedical economy: the research and insurance industries and their impact on what we do when life is at stake.

Kaufman spoke of “the hidden chain of connections among science, politics, industry and insurance that drives the US health care system,” noting especially that clinical trials sponsored by the multibillion-dollar biomedical research engine are at the heart of our increasing reliance on evidence-based care, which can be a good thing. But it’s important to remain aware that in the past 25 years, the number of trials that private and profit-driven pharma, device and biotech companies fund has more than doubled.

As these trials generate more evidence of therapeutic value, they also generate an ever-increasing number of standard – that is, difficult to refuse – treatment options. Our prioritizing of new therapies and technologies magnifies this effect, because it influences our collective perspective on the timing of death. Today in the US, says Kaufman, we consider most deaths premature, regardless of the age of the deceased.

As evidence of the phenomenon, she spoke of the implantable cardiac defibrillator (ICD). When clinical trials showed good survival rates and Medicare began to reimburse for its use, the ICD became a therapy that shifted from unthinkable a decade or so ago to routine and standard care for older persons with moderate to severe heart disease in the US. The floodgates were open.

Here’s the catch, notes Kaufman. In treating a potentially lethal arrhythmia, the ICD prevents sudden death (the silent heart attack in the night) – precisely the kind of death many say they actually want late in life. Yet the device is difficult to refuse, because doing so seems to go against medical progress and common sense.

Kaufman’s eloquent presentation distills the essence of a societal quandary nurses, physicians, patients and families must face together. It also exemplifies the value of our Institute for Health & Aging.

The IHA has been a vital incubator – not just for investigators, but also for work that has built models for improving health and, more fundamentally, how we think about health. Past work includes that of giants such as Carroll Estes, Bob Newcomer, Dorothy Rice and Patrick Fox, all of whom produced groundbreaking work on everything from Social Security and Medicare to long-term care, Alzheimer’s disease and the societal costs of tobacco, alcohol and drug use.

Today, in addition to Kaufman and IHA Director Wendy Max, the groundbreaking work emerges from other marvelous investigators, including a few the celebration highlighted: Marsha Michie on bioethics and genomics, Julene Johnson on arts and aging or Brooke Hollister on understanding the impact of reform on Medicare and Medicaid.

In each of these cases, the Institute’s investigators ask the absolutely essential questions about how scientific and medical advances change how we age and how we die. Their role and expertise have never been more important.

 

Harm Reduction

David Vlahov

A June 2015 report from the Trust for America’s Health and the Robert Wood Johnson Foundation found drug overdose is now the leading cause of deaths from injury in the United States. Rural Indiana recently found itself wrestling with an outbreak of HIV among drug users.

These findings and events represent human tragedies; what’s worse is that in many cases, the deaths and HIV transmissions were either preventable or, at least, ripe for mitigation. The problem is that as a country we are still trying to get comfortable with an approach to substance abuse known as “harm reduction.”

In this month’s Science of Caring, we ran a story about faculty at our School who are working to advance this strategy, which is based on minimizing risk through policies, programs and/or individual practices. It is an approach that meets people where they are rather than making judgments about where they should be in terms of their personal health or lifestyle.

Take the case of the illicit drug user who is vulnerable to or can transmit HIV infection but can’t stop his or her drug dependence. For many years, the approach to these individuals was often some combination of “just say no” and incarceration. Yet when the HIV epidemic came along, harm reduction emerged as an alternative strategy. The idea was to make drug abuse treatment accessible, but to also give illicit drug users access to sterile needles and bleach for syringe disinfection. To move in that direction, communities needed to learn and embrace what harm reduction strategies could offer, and legislators at various levels needed to change policies.

My own research and that of numerous others has found that harm reduction strategies are very effective in reducing the rate of new HIV infection among drug users. Yet before these data could be turned into policy, we needed to address politicians’ concerns. In my work, we responded to political concerns by conducting studies on the possible negative consequences of community-based access to sterile syringes. Our data from pilot projects showed that access to sterile needles in communities did not increase drug use, nor did it increase sharing of needles, reduce the rate of users going into drug treatment, leave contaminated needles on the street, encourage youth to start drug use or increase crime. That was a turning point. Communities came to see the value of harm reduction, and policies and programs changed. Outreach and education have now enabled these programs to become more widespread.

In short, harm reduction is highly effective in preventing death and containing harmful behaviors associated with using drugs. We know as well that harm reduction strategies – such as public education campaigns to safely store medications away from children, and the distribution of naloxone to police and medics to rapidly reverse the effects of opioid overdose – can be very effective in preventing drug overdose deaths.

Nevertheless, the acceptance of harm reduction remains incomplete, despite evidence of its success in many areas, including some that transcend the transmission of HIV or drug overdose. For example, to prevent automobile-related injuries and deaths, we’ve implemented multiple forms of harm reduction, from public information campaigns against drunk driving to engineering solutions such as the placement of taillights at the view level of the driver behind a braking car, crumple zones for crashes, air bags, and collapsible guardrails and streetlight poles. Such strategies have worked.

It’s likely and understandable that the reluctance to apply harm reduction strategies to illicit drug use comes from a complex social psychology tied to concerns that we are somehow sanctioning the use of these drugs. It is time, however, to recognize the evidence. We have had success in reducing needle transmission of HIV and complications related to drug overdose. We have faculty who are expanding this work, making progress on addressing challenges and creating promising strategies to reduce HIV risk related to binge drinking. It is time for health care professionals to incorporate harm reduction as an important, evidence-based public health tool that we should use whenever our clinical judgment deems it necessary.

 

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California Initiative Aims to Dramatically Reduce Preterm Birth, Improve Outcomes, Change the Approach to Persistent Public Health Challenges – Disturbed by stalled progress on reducing the incidence of preterm birth, an ambitious UCSF-led, Lynne and Marc Benioff-funded initiative aims to upend traditional approaches to researching and addressing an epidemic that affects 15 million families worldwide each year.
April 2016
Nursing in Prison – Doctoral student Douglas Long confronts the challenges of providing quality health care to inmates in San Quentin, one of America’s most famous prisons.
April 2016
Novel Doula Training for Incarcerated Women and Those at Risk Expands and Grows – A UCSF collaboration gives women at risk for incarceration hope for their futures. In return, they provide essential birthing services to incarcerated women and those in need in Alameda County.