Guest Blog: Collaboration at the SFVA
Guest authors this month are JoAnne Saxe, Anna Strewler and Krista Gager.
Around the country, team-based, interprofessional care is recognized as the ideal approach to many aspects of care delivery. But training a generation of clinicians who are truly prepared to deliver such care continues to present numerous challenges – to say nothing of implementing such care in real-world practice settings.
With this in mind, since 2011, UC San Francisco School of Nursing faculty members have contributed to the development and leadership of the San Francisco Veterans Affairs Center of Excellence in Primary Care Education (CoEPCE), an innovative program that has successfully forged and documented successful new approaches to interprofessional education and training. The program aims to advance the delivery of primary care that is patient-centered and team-based at the VA and beyond. Perhaps equally important, by assisting with the development, implementation and evaluation of this program, the involved faculty themselves have undergone a remarkable professional journey.
How It Works
Led by physician Rebecca Shunk and adult-gerontology primary care nurse practitioner (AGPCNP) Anna Strewler, the San Francisco VA Health Care System CoEPCE is one of seven such centers in the country. Most of the faculty members are affiliated with UCSF; working together, they have essentially flipped the traditional primary care education model on its head.
In traditional primary care education, faculty members educate trainees in their own professional silos through coursework and clinical experiences. In contrast, the CoEPCE brings together trainees from across professions – including second-year AGPCNP students, postgraduate UCSF NP residents and second- and third-year UCSF internal medicine residents, as well as psychology, pharmacy, social work and dietetics trainees. The model provides these trainees with precepted, team-based primary care experiences that allow them to refine how they work together, while building their individual professional competencies. Specifically:
- The CoEPCE preceptors receive formal mentoring in effective clinician education in an interprofessional setting.
- The NP students and NP residents are paired with internal medicine residents for a one- to two-year rotation, in which they care for a shared panel of patients along with their other interprofessional trainee colleagues and clinic staff members. Each trainee provider has an individual panel of patients, which combine to form a shared team panel.
- NP trainees see their own patients and also serve as backup providers for their practice partners while they cycle through inpatient rotations.
- Case-based clinical learning, patient-centered communication, quality improvement (QI) and panel management training, and team huddles and retreats all help guide the workplace learning experience.
We consistently document the importance and success of this approach. Among the outcomes:
- Quarterly surveys have revealed that trainees from all involved health care professions have found supportive and satisfying clinical experiences.
- Patient surveys show high levels of satisfaction with CoEPCE trainee providers.
- Involved NP faculty from the School and the CoEPCE use their experiences to drive ongoing improvements in the CoEPCE and the School’s AGPCNP curricula.
- JoAnne Saxe and Caitlin Garvey have used the CoEPCE core curriculum to redesign a patient-centered medical home course for AGPCNP students.
- Krista Gager and Saxe co-facilitate a primary care clinical seminar for the CoEPCE AGPCNP students.
- Gager and Saxe co-lead the CoEPCE performance improvement and patient safety learning experiences with physician Maya Dulay.
- Anna Strewler and Saxe have enhanced geriatric learning experiences for CoEPCE trainees and all AGPCNP students via case-based discussions and/or standardized patient experiences.
- Strewler, Gager, Dulay and physician Abbi Eastburn developed and implemented a new curriculum for panel management CoEPCE trainees.
- Drawing on what they learn about performance/QI, trainees are helping to drive important system changes at the SFVA. To date, there have been 33 completed QI projects, with approximately 50 percent of these leading to sustained improvements in care delivery, including increasing the rate of annual urine drug screens among patients receiving chronic opioids and reducing the inappropriate use of proton pump inhibitors.
- CoEPCE faculty have published six articles, two books and a white paper about the related curriculum and lessons learned. Additionally, faculty and/or trainees have presented findings about various aspects of the program at several conferences across the United States. (For additional details, go to http://www.va.gov/oaa/apact/docs/CoEPCE_Bibliography_and_Scholarly_Works.pdf.)
Bolstering the VA Workforce
The program has also helped build a new type of workforce for the SFVA, which is deeply committed to sustaining an academically affiliated, interprofessional, practice-based model where patients receive high-quality care – and to hiring UCSF graduates dedicated to supporting this model. Since the program’s inception, 34 NP students have completed the program; 13 have completed the NP residency. Seven of these NP residents now practice at the SFVA, with six working in primary care and directly involved with the CoEPCE as clinician educators. Two of the practicing NPs are precepting NP students outside of the CoEPCE. As for the physician residents, 94 have completed the program, with several taking on faculty positions or fellowships at the UCSF School of Medicine and/or clinical positions at the SFVA where clinical education is a standard component of their role. One of the pharmacy residents, Andrew Lau, is now pharmacy co-director of the program, and several psychology fellows and social work interns have been retained at the VA in primary care.
Influencing Career Development and Day-to-Day Practice
We have all found that participation in this program has been a career builder, with both Anna and Krista using it as a platform to move into leadership positions at the SFVA and faculty positions at the School.
Yet perhaps most interesting is the impact on how we practice each and every day. In brief, by gaining an in-depth understanding of how our fellow professionals deliver care – their priorities, mindset, type of expertise and communication strategies – and by working through the many large and subtle challenges involved in transforming a culture of practice, we find that our work is both more effective and more rewarding. As experience allows this understanding to deepen – as we become better at understanding how, when and where to deploy a particular type of expertise and as we learn from each other – we believe that the impact on patient outcomes will continue to be significant.
We expect to focus in more detail on this idea in future posts, but already we believe the CoEPCE here in San Francisco and at VAs around the country will ultimately transform primary care education and practice, while creating further opportunities for academic pursuits.
JoAnne Saxe is a founding faculty member in the CoEPCE, director emerita of the Adult-Gerontology Primary Care Nurse Practitioner program at UCSF School of Nursing and a health sciences clinical professor at the School. Anna Strewler and Krista Gager are 2014 graduates of the AGPCNP program and the CoEPCE. Both are now volunteer clinical faculty at the School; Strewler currently co-directs the CoEPCE, and Gager is one of the associate directors for this program.
Each year, UC San Francisco School of Nursing is ranked among the top graduate schools in the nation. Please visit the Adult-Gerontology Primary Care Nurse Practitioner section of our website to learn more about our work in this area.
In place of her blog post this month, we speak with Dean Sandra Weiss, PhD, DNSc, FAAN, who in September 2016 was named interim dean at UC San Francisco School of Nursing. 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 professor in the Department of Community Health Systems.
What are your most important priorities for your time as interim dean?
One of my key priorities has to do with the people that make up the School of Nursing. I want our faculty, staff and students to feel as if they’re seen for and recognized fully for their many contributions. Sometimes we think of the School as an organizational structure rather than as the people who comprise it. But it is our faculty, staff and students who are the essence of the School. They are responsible for everything the School is and can be. It’s vital that we recognize their contributions and that they feel valued for all that they are doing.
My feelings about this are very congruent with the UCSF PRIDE initiative [a renewed push to raise the visibility of the UCSF core values of Professionalism, Respect, Integrity, Diversity and Excellence]. These values have always been a strong part of how our School has operated, but as this campus initiative gains momentum, we will be incorporating these values into many different efforts that further elevate their profile.
Respect for our people needs to be front and center. I want to bring the element of respect to every aspect of how we work with people here. Certainly, part of it is formal recognition, but it’s more of what we do on a daily basis, in our ongoing interactions with people. Do we fully attend to what each person is doing and how she or he makes a difference in the success of our School? And do we comment on these contributions so that people know they are appreciated? Fortunately, I believe all of the people who come into nursing and related health sciences fields inherently have some of this sensibility in them. Each of us can build on this to improve our interactions with others.
A second priority for me is to support an environment where our faculty and staff can think more deeply about their work and ways to best advance the School’s many missions. If we don’t create more contemplative time amidst the pressured expectations of our work, it’s much more difficult for innovative, cutting-edge ideas to emerge. I’ve recently put a work group into place that is identifying priorities for the School. While its primary focus is to enhance our fiscal health, it will also serve as an opportunity to develop new workplace models that can support a less stressed and hectic work environment. I’m hopeful – with the help of other things, like “lean” training – that these efforts will enable us to use our time more efficiently, strategically and thoughtfully, rather than trying to do it all with a sense of frenetic overload. It’s my belief that a focus on our people, instead of setting some external goals that I want to achieve, is the best way to ensure that we continue to excel in research and the science that drives our discipline, that we offer the very best educational programs in the world and that we serve our local, national and global communities with the fervor and commitment they deserve.
Continuing our efforts to diversify our student body and our faculty is also a high priority for me. This necessitates the presence of a climate that is welcoming and supportive and that provides resources to ensure success. We have some remarkable people who are leading these efforts – Associate Deans Judy Martin-Holland and Shari Dworkin as well as our amazing DIVA (Diversity in Action) and Recruitment and Retention committees. Although we are making inroads, all of us know that we are not yet where we need to be.
What existing strengths can we build on?
We have many areas of strength, some of which have been around for a while and some that have emerged in the last few years, whether its aging and palliative care, health care technology, symptom science or health policy. My goal in all of these areas is to encourage people to look across departments and our research institute to identify and pursue possibilities for collaboration. Financial support plays an important role in enhancing collaborations, as an incentive for people to look closely at where their individual efforts intersect with others’ and how their related work may contribute to the School’s overarching goals in new and exciting ways.
And the biggest barriers?
Our biggest barrier is the lack of adequate financial resources, which is certainly not a challenge that is unique to us. That’s why the work group on fiscal health I mentioned earlier is so important. We need to find ways to enhance our resource base and to get the most from existing resources without overburdening our students with large tuition hikes.
To that end, another work group we’ve created is exploring with UCSF Health (UCSF’s world-class clinical enterprise) how our faculty can contribute more fully to the clinical mission of the campus and enhance the School’s clinical income in the process.
What strengths do you, personally, bring to these efforts?
Well, I’ve served in multiple administrative and leadership roles in my career. Hopefully, I’ve learned something from those experiences that I can bring to this position. Also, my primary field is psych/mental health. I have a PhD in psychology as well as a PhD in nursing science, with a specialty in psych/mental health. This background reflects my inherent interest in what makes people tick. I think this background gives me some insight into my own behavior and helps me consider a variety of factors that may improve my work with others.
Also, by temperament, I’m a collaborative person. I learned that from my mother, who was an unbelievable role model. She exemplified a sincere kindness and ability to listen to people that was deeply inspiring to me. She was never telling everyone about herself or how grand she was. I respected those qualities tremendously. I once heard somebody say she was “a mouse” because they perceived her as not being aggressive enough. I disagreed. She was a very strong person who didn’t feel the need to always use her innate power to control the situation. She was highly successful in accomplishing her goals, but in a collaborative, sensitive and very astute way.
Finally, how does being an “interim” dean help or hinder your ability to achieve your vision?
Maybe it’s because I’ve been so much a part of everything that is happening in the School as part of my faculty role, but I don’t even think about being “interim.” That’s the beauty of shared governance (a core approach to governance in the entire University of California system that actively involves faculty in decision-making and leadership roles). There is a sense of “we” and that we’re all in this together, regardless of whether someone’s official role is as “faculty” or “administration.” So I think of my interim dean’s role as just one more leadership role in the School through which I can contribute to our various missions and our success in accomplishing them.
I’m stepping in as a guest blogger for Dean Sandra Weiss, to do two things this month: recognize a redesign of Science of Caring, and welcome the new school year. As a retired faculty member and administrator, I am quite familiar with and fond of both experiences.
I have been involved in the design of Science of Caring from its origin in print through the current online version, and want to say a few words about what this evolution means to me personally.
We long ago recognized the need to bring the best of UC San Francisco School of Nursing – its faculty, research, students, graduates and staffers – to the public eye. We designed the publication to help do that. It was first mailed quarterly to thousands across the country and the world, and is now available online to many more, with greater frequency. It gives me pleasure to know that this new look continues a tradition of conveying the urgency, relevance, timeliness and productivity of our School. Science of Caring has helped recruit new students and faculty, as people far and wide learn of our interests, research and other activities. Our graduates keep in touch, and we’ve profiled many of them for your reading pleasure. Let us know, please, if you have suggestions or thoughts on specific articles or in general – there is always a place for your voice in each issue.
While the publication is wonderful, it can capture only a fraction of the extraordinary work that goes on at the School, which is why I am so thrilled to welcome our group of over 450 new and continuing nursing students back to campus for the fall quarter. The UCSF community is a remarkable, fascinating and energizing place, and this campus infographic, which provides a breakdown of all students entering in 2016, opens a small window into the richness of this community.
As for our School, the best way to convey its vitality is to describe what I saw recently, when the faculty asked me to provide some feedback on teaching techniques and other aspects of a Master’s Entry Program in Nursing (MEPN) course on sociocultural issues in health and illness. Mind you, it’s been a while since I retired, and longer still since I taught actively in prelicensure education, but I’ve known of the quality of our students via my work on MEPN admission screening committees. What an absolute treat it was to see those students and faculty in action.
The MEPN students bring wide differences in age, gender, and sociocultural and educational backgrounds, but all bring a deep commitment to excellence in their newly chosen profession. They also bring a good grounding in study skills and communication strategies, as well as clear enthusiasm for new learning, which makes their group discussions invigorating. They clearly embrace the worth of cultural humility and social justice, and talk readily about strategies to bring safe and quality outcomes of care to a diverse population of patients. They question each other, and themselves, bringing reflection and thoughtfulness to their discussions.
They are starting their nursing career at a time when nursing has never been more vital, with a clear indication of our professional worth in today’s economic and political landscape. The paths they can walk – and run, more likely – vary greatly from the days when I was a student. They are navigating through many nursing career options, actively considering where they’ve been, where they will go next and the choices for their long-term future. Judging from their approaches to the classroom, they will explore these options passionately and intelligently, and their impact will be felt throughout the School and, later, their communities, I am certain.
Our School has always been a place where students can make the most of the many opportunities in nursing, and I anticipate that these students will bring their own drive to continue this strength. I look forward to learning more about and from them!
— Retired Associate Dean Zina Mirsky
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.
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. https://data.oecd.org/healthres/health-spending.htm. 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. http://www.usnews.com/news/best-countries/quality-of-life-full-list. Accessed August 24, 2016.
[vi] OECD data: social spending. OECD website. https://data.oecd.org/socialexp/social-spending.htm. 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. http://qualitysafety.bmj.com/content/early/2011/03/28/bmjqs.2010.048363.abstract. 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. http://www.rwjf.org/en/culture-of-health/2016/08/how_social_spending.html?rid=s88gyymtNUXPDVwZ-JNU9USGEF1u5oKjEoTEIbK2gC0&et_cid=644614. Published August 17, 2016. Accessed August 24, 2016.
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.
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.
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.
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.
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.