The Dean’s Blog

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.

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.

 

Thank You, Dr. Relman

David Vlahov

Dr. Arnold Relman has been a highly influential medical educator and is a former editor of a prestigious medical journal. In the February 6 issue of the New York Review of Books, he wrote of an experience this past summer when, at age 90, he fell down the stairs at home. He suffered a cracked skull, broken vertebrae in his neck and broken bones in his face. He received emergency treatment to check bleeding from his brain and restore his breathing. Resuscitation saved his life, and over 10 weeks, he underwent numerous medical procedures and experienced a number of complications. Almost miraculously, he not only survived, but with rehabilitation, is mostly recovered. His survival is a testament to the emergency care and rehabilitation services he received, as well as to his strong will to live.

His essay is a firsthand account of his hospital experience, combined with some insightful observations about the health care system. In one passage, he points out that “What personal care hospitalized patients now get is mostly from nurses” and confesses that he “had never before understood how much good nursing care contributes to patients’ safety and comfort, especially when they are very sick or disabled. This is a lesson all physicians and hospital administrators should learn. When nursing is not optimal, patient care is never good.”

Just as Dr. Relman is grateful for the nurses’ role in patient recovery, we are grateful for his recognition of that role – though, of course, deeply sorry that he had to suffer this personal trauma to come to a realization that speaks to an often hidden insight about how to improve care.

In short, despite years of advocacy from powerful voices in nursing and medicine, a widely publicized Institute of Medicine report and various nationwide initiatives such as the Magnet program, the role of nursing remains underappreciated and, often, poorly understood in many clinical settings. This lack of understanding can create a culture where low expectations erode the contribution highly trained nurses are capable of making and, at worst, can diminish nurses’ willingness to do their best work.

It’s a culture that most schools of nursing across the country are fighting hard to combat, and as Dr. Relman’s insight makes clear, we are making some progress. We are proud of the training our graduates receive in the technical aspects of care, role differentiation that readies them for working in teams, and communication skills needed to work effectively with patients and families. And we are constantly seeking ways to up the ante, to demand more of our graduates so their patients can reap the benefits.

Thank you, Dr. Relman, for helping us advance understanding.

Comments

Well said David. It is regrettable that Arnold Relman had to suffer so much to learn the value of good nursing care. All of us, including nurses, physicians and policy makers, are fortunate that he has written about his new appreciation of the differences good nursing care makes. - Martha N. Hill, PhD, RN, FAAN Immediate Past Dean Professor of Nursing, Medicine and Public Health The Johns Hopkins University School of Nursing

“And in Flew Enza”

David Vlahov

An old joke runs like this:

A child was alone in her cavernous bedroom at the top of a wide, curling staircase in a Victorian Gothic-style house balanced atop a craggy hill. On this pitch-black night with gusty winds and cold, pelting rain, the house was lit only with the strobe of lightning. Windows rattled with each boom of thunder. Suddenly, tall, hinged windows in the bedroom heaved and burst open. With the funnel of cold spray, through the flapping sheers, in flew Enza.

Influenza. It’s that time of year again, and it’s important to remember that influenza is no joke. It comes with morbidity and mortality that are serious threats to public health. As of early January, the CDC reports over 2,600 influenza-related hospitalizations have occurred already this flu season, with 20 states reporting high levels of influenza-like illness. Nationwide, 10 children have died from influenza since October - and in California, the number of deaths is already very close to the number for the entire flu season last year - and we are just entering peak season, which typically occurs from January through March.

The real tragedy here, however, is that providers and individuals too often ignore or underuse effective strategies to mitigate the threat.

As health care providers, we have to make clear to patients that strategies to reduce the risk of an influenza epidemic include education about hand washing, covering one’s mouth and nose when coughing or sneezing – but not with one’s hands – and taking sick days to minimize transmission. Parents should keep sick children home from school.

Immunizations, of course, are especially important, but in past years, rates of influenza immunization have been disappointing. Factors that have influenced low uptake of immunization include the sense that influenza is a trivial inconvenience, that the vaccine is not very effective and that it comes with side effects that might be worse than getting influenza itself. On a population level, data simply do not support these beliefs.

Some also voice concerns about allergy to eggs – some flu vaccines contain tiny amounts of egg proteins, although reactions are uncommon. Some have resented the increasing use of mandatory programs on principle, often expressing mistrust of government, “Big Pharma” or both. Strategies and messages to address these concerns are evolving.

Clinical settings can, of course, help allay these concerns, but especially for hospitals, clinics and neighborhood pharmacies in underserved areas, limited access to care, limited availability of the vaccine and health care providers’ failure to recommend the vaccine have been shown to be the most important factors in unnecessarily low rates of immunization.

There is, however, a model for improving immunization rates. An outreach program I led – with nurses going to communities with high levels of wariness and low access to care – has shown positive results in increasing uptake of immunizations. Project VIVA arose from the Harlem Community and Academic Partnership (HCAP), which was created as a partnership of 30 community-based organizations, four academic institutions and the local health department. In an effort to address health disparities in Harlem, the basic strategy of HCAP was to have health professionals work with communities to develop nontraditional tactics to enhance the work of public health departments.

After establishing an intervention work group to address the low rates of influenza immunization, the Project VIVA team began by assessing the reasons for the lower rates. Then, by tapping into the leadership ability of community members, we developed a number of strategies, including having community members design brochures for distribution and having outreach workers provide education and referral to convenient, nontraditional settings such as street corners where nurses provided immunizations. The result was that even among those who expressed reservations about the vaccine and were frustrated by the inconvenience of scheduling visits in traditional clinical settings, our efforts improved the rates of immunization.

We believe the presence of nurses was a crucial success factor. Over the past decade, nurses consistently top national opinion surveys about the most trusted professions. No matter the setting, our taking the time to talk with patients about influenza – including behavioral steps to reduce transmission and the role of immunizations – is an important strategy for reducing the risk and impact of influenza epidemics.

A Nurse’s Glimpse into the Human Condition on Christmas Eve

David Vlahov

When I think of the last two weeks of December, I look back to my days as a harried clinical nurse in a large, busy hospital. During that time of year, as many patients as possible were discharged to be home with family and significant others. The few who had to remain were moved together so that as many staff as possible could be given time off for the holidays. There was a type of lottery to see who would have time off, but I often volunteered to work Christmas Eve.

I remember coming into work those nights – some years there was a crispness in the air that comes with fresh snow on the ground – and giving a quick wave to the unhurried front desk as I rode up to my floor in an uncharacteristically empty elevator. When the elevator doors swooshed open, I looked towards a glow of light at the end of a long, darkened and muted hallway; the light was coming through the glass windows in the doors leading to the makeshift ward of those who could not be home. As I moved to the light, the volume of monitor alarm beeps and the rhythmic mechanical breaths of a ventilator rose from a muffle to a tune that accompanied now audible conversations.

There were few visitors remaining. Some were already in their overcoats, leaning over a family member to say hurried good-byes, anxious to be on their way. Other visitors delayed until the last possible moment. I remember one in particular, an older gentleman with white hair and rimless glasses, who was undisturbed by everything going on around him. He sat quietly, facing and conversing with his wife, as if they were at home, sitting side by side on a love seat. One nurse spoke gently and soothingly with her patient and his family, who were reluctant to leave; at another bedside, another nurse comforted a patient who had no visitors at all.

I made my way to the nursing station, where my hospital friends came over to say hello, offer me a slice of fruitcake, wish me a happy holiday and give report. When the shift turned over and the day nurses left, the last of the remaining family members said their good-byes.

Now only the evening shift remained. For the rest of the night, in the quiet and darkened hospital, we stayed close to our patients as they expressed their anxieties and fears, related their life stories and shared their hopes and dreams. My memories of those special hours are among the most cherished and meaningful of my entire career.

In this season, I urge you to take time to reflect on your experiences. Remember how much of a difference you make in caring for others – and how much better they make you both as a nurse and as a human being.

Best wishes for a happy holiday.

Comments

Thank you, Dave, for as we rush from place to place completing our various tasks, I appreciate you for bringing to the fore the spirit of the holiday season and the essence, purpose, and gift that is nursing. - Judy
I remember those nights working during holidays, the crispness in the air. Staying close to people no matter where we find ourselves this is art! Happy holidays to all the wonderful UCSF people in the word:)
Thanks Dean Vlahov for bringing back our daily bread memories and experiences as nurses in various ways of which we treasure. When I am at the bed side or taking care of our seniors in homes, or in delivery room with a mother and her family expecting their newborn, or listening to a call from an individual who needs my attention, what more reward can I ask of a happy Christmas holiday! Our lives, minds and hands touches many individuals through healing process by our presence in their midst of that moment by our empathy, kindness, and support of their emotions they are going through. I have no regret of being of service at this holiday season on night shift taking care of our seriors who have limited movement to do things or celebrate the holiday they used too! My presence was of joy and comfort. Thanks to the gift of nursing profession as we celebrate this holiday season. Alphoncina.

Featured Articles

April 2014
The Future of Geriatric Nursing: A Conversation with Jack Rowe – Renowned geriatrician John W. Rowe discusses how an aging population and a shortage of geriatricians present nursing with what could be a historic opportunity – and challenges the profession to seize its moment.
April 2014
Finding and Training a Workforce That Can Address Older Adults’ Long-Term Care Needs – A new UCSF health workforce research center is charged with mapping the long-term care needs for an aging US population.
April 2014
How Can We Reduce Adverse Events in Long-Term Care Settings? – Laura Wagner examines the role of health information technology in reducing a virtual epidemic of adverse events in nursing homes and assisted living facilities.
April 2014
Geriatric Nursing Experts Share Knowledge, Ideas for the Future – At a recent conference, nurse researchers from UCSF School of Nursing and other health policy experts presented their work, as well as insights into the future of geriatric nursing.
March 2014
A Reassuring Voice for Parents – Pediatric nurse practitioner Meg Zweiback helps parents deal with the everyday challenges of raising young children.