Guest Blog: Collaboration at the SFVA
These days, all the talk in education is about the “flipped classroom” and about the work of the Khan Academy. The flipped classroom is a disruptive innovation in education that takes students out of the lecture hall and, instead, provides asynchronous (i.e., whenever it’s convenient for the student) online content, and synchronous (i.e., scheduled teacher and student group) online or in-person meetings during which teachers and students work through exercises to master content.
The Khan Academy takes disruptive innovation a step further by using an adaptive learning strategy for competency-based education. Students log on at their convenience. Regular quizzes test whether students are ready to progress to the next level; if they are not, they receive alternative presentations that move them toward mastery of that level’s content.
For teachers who have enjoyed filling lecture halls with students marveling at their presentations – or holding forth in seminar salons – the flipped classroom may be an uncomfortable change.
After one university made the simple move of taping lectures to post online for students, one teacher I met complained about the diminishing percentage of students who actually attended her lectures. Of those attending, most were idling on Facebook. The teacher’s threatened response was to email the class that attendance was mandatory and viewing Facebook during lectures was prohibited. According to this teacher, discussion sections to review problem sets were hardly better, as some irritated students summarily discarded problem sets and demanded answers. The teacher snarled that Generation Xers were raised with an overabundance of positive reinforcement for simply showing up. All but holding her nose, she exhaled that students today learn differently.
On that last point, she is right – and that’s important for us to understand. The current generation of students grew up with the Internet, video games and social networking; this is their context. To successfully teach such students, we should embrace instructional design that makes the best use of new educational technology.
And let’s remember that adaptive or mastery learning is not new. In elementary school, my silent reading time was occupied with short books and questions; if we answered the questions correctly, we progressed to the next level, and if we did not, we had another short book to complete at the same level before we could move on.
What is new is the mode of delivery. Take a look at lectures on the Internet. I wish that I could have watched, paused and repeated lectures at my convenience. Consider that our students often juggle family and work. Shouldn’t we reward their desire to improve themselves with structured discussion groups that they can join online from home? Isn’t it a positive and reassuring development that they can be guided to develop and progress through competencies at their own pace? Widespread use of the Internet has facilitated the development of tools that make education more accessible – and that’s a good thing.
That said, how the flipped classroom and adaptive learning work in nursing education needs some further thought. There are topics, such as pathophysiology and pharmacology, that would seem to fit neatly with the new educational technology and adaptive learning techniques. Other topics are either less obvious fits or clearly not appropriate. Practicing manual skills and clinical interactions, for example, demands a more direct human touch.
Recently, the American Association of Colleges of Nursing, the Jonas Center for Nursing Excellence and the Khan Academy have come together to work with nursing faculty to take on these challenges. We look forward to the development of these new and exciting approaches to nursing education.
This past week at the World Maker Faire in New York City, MIT’s Little Devices Lab and the Robert Wood Johnson Foundation launched a nationwide initiative called MakerNurse. The goal is to find do-it-yourself nurses and support their efforts to fabricate new devices and devise work-arounds to fix health care delivery problems and improve patient care.
The initiative makes almost too much sense. Nurses are on the front lines of health care delivery and closer to the patient on a continual basis than any other professional in the system – and certainly closer than conventional engineering labs. As such, we are uniquely positioned to identify suboptimal technology and design breakthrough solutions to improve care. MakerNurse aims to leverage this positioning to accelerate the ingenuity of nurses working across the United States. In its first six months, it will uncover and collect stories from inventive nurses to determine what support they need to innovate effectively.
At UC San Francisco School of Nursing, this is a process we understand well, as we’ve steadily built our own nurse-technology interface initiative. Over the past two years, a number of our faculty have engaged with other clinicians, patients and private industry to improve and/or develop new hospital monitors, mobile apps, avatars and gaming platforms. An October 2012 article in this publication highlighted some of our ongoing work in this area. These efforts have largely focused on working with product developers to provide expert advice and guidance on the clinical products, as well as the means to properly validate these products. We have consulted with intellectual property staff to learn how we should conduct ourselves going into these conversations, to ensure that we get proper credit as the work moves forward.
MakerNurse is taking a slightly different slant. Its focus is on empowering nurses themselves to design and prototype the devices and workarounds. This is an exciting development. We are enthusiastic about the possibilities and are reaching out to MakerNurse to request a conference where we can share ideas and strategies for collaborating on the development of tools, devices and programs. Coordination and collaboration will optimize our efforts to improve care and will better enable the world to see the critical contribution that nurses can and do make.
On August 28, 1963, the March on Washington for Jobs and Freedom began at the Washington Monument. The destination was the Lincoln Memorial, where the most enduring memory is of Martin Luther King, Jr., delivering his “I Have a Dream” speech. Over a quarter million people arrived from around the country in more than 2,000 buses, 21 chartered trains, 10 chartered airliners and other regularly scheduled transportation. Being there was one of the most potent and transforming events in my life.
Half a century later, I’m proud to add from a professional standpoint that nurses have long played significant roles in the civil rights movement.
Dean David Vlahov at the commemorative March on Washington, August 24, 2013. Top photo is of Vlahov with fellow marchers from 1963, Robert Rouse and Eve Rodgers. Bottom photo is Vlahov with his grandchildren Leah and Ethan Vlahov. In the middle is the banner an 11-year-old David Vlahov carried at the original March on Washington, August 28, 1963.
Ethel Mason was a nurse and a civil rights advocate. She was a longtime member of Ebenezer Baptist Church, where Dr. King preached, and she helped integrate Grady Memorial Hospital in Atlanta.
In 1965, the National Student Nurses’ Association recognized a severe nursing shortage, especially in inner cities, and started the Breakthrough to Nursing (BTN) project. Before then, minorities were steered into licensed practical nurse and nursing assistant roles. In the beginning, BTN consisted mostly of volunteers who worked countless hours to recruit minority high school students into nursing.
Despite these pioneering efforts to integrate the nursing workforce half a century ago, obstacles remain, including promotional materials from nursing schools that fail to show diversity, limited financial resources and few role models for minority students and a lack of cultural humility among some faculty and fellow students. At UC San Francisco School of Nursing, we recognize these obstacles and continue our own efforts at, finally, fully integrating the nursing workforce. Most notably, we recently updated our Diversity in Action (DIVA) program and are developing it for use by other institutions. We know we have more work to do.
This August 24th – 50 years after the original March on Washington and 150 years after the Emancipation Proclamation – there will be a commemorative March on Washington. It will be more than a reunion; it will be a show of commitment to equality, opportunity and justice. I hope to see you there.
“Gov. urges nurses to help fight climate change.”
When I read that headline in the San Francisco Chronicle earlier this week, I thought: “What?”
But the more I pondered the headline, the stronger my belief that the population health impacts of climate change demand that nurses take a role in fighting this global threat.
After all, the regional weather variations associated with climate change – which include heat waves, extreme weather and alterations in precipitation that lead to regional droughts – have dramatic health impacts. One has only to look at the withering heat waves in Chicago, Philadelphia and Paris that took lives, especially those of the elderly and otherwise vulnerable. Hurricanes Irene and Sandy were two “storms of the century” that hit the New York City metropolitan area about 14 months apart.
On a global scale, we can see and anticipate not only increases in physical injuries and deaths related to extreme weather, but also changing ecologies that can increase water- and food-borne diseases, vector-borne diseases and the deleterious effects of food and water shortages such as malnutrition. Ultimately, the disruptions associated with population displacement and increasing poverty can lead to mental health problems such as post-traumatic stress disorder, anxiety and major depression. And the disruption of health service delivery in major adverse weather events makes frontline responses more difficult to mount.
What actions can nurses take?
First, think global and act local. Fundamentally, nurses can learn and then practice and lead others on their personal and institutional practices, implementing the principles of reduce, reuse, recycle, recover and re-educate at home and in the workplace.
Second, when health is at stake, take an active role in bringing this to the public’s attention and advocating change. As an example, Ruth Malone, professor and chair of the Department of Social and Behavioral Sciences and leader of the health policy track at UC San Francisco School of Nursing, published a commentary in this e-magazine titled “How Nurses Can Help Grow the Anti-Tobacco Industry” and has been a strong public anti-smoking advocate in many settings. Generally, health professionals – especially nurses, the most trusted profession in the United States, according to annual Gallup surveys – are highly credible. We should use that credibility to influence policymakers to review the environmental impact of proposed projects and to educate the public about the effects of climate change on health.
Such efforts are not new to nurses. The American Nurses Association (ANA) adopted a resolution on global climate change in 2008. Acknowledging the reality of climate change, the ANA called for a decrease in the contribution by the health care industry to global climate change, support of local policies that endorse sustainable energy sources, and reduction of greenhouse gas emissions. Their resolution calls upon nurses to speak out in a united voice and advocate for change on both individual and policy levels.
Both Barbara Burgel and Karen Duderstadt from our faculty have led the way by including climate change content in their courses over the last few years. Gov. Brown’s call to action points to the need to have nurses informed and prepared at nursing schools in environmental health, health policy and advocacy. This education on climate change is fundamental to nursing leading the way toward a healthier population.
Having spent the last few days talking with nurse leaders from around the globe, I’ve come away inspired from the International Council of Nurses (ICN) 25th Quadrennial Congress in Melbourne, Australia.
This congress is a global platform for the dissemination of nursing knowledge and leadership across specialties, cultures and countries. This year’s theme was equity and access to health care. Consequently, all the presentations – which addressed major public health problems such as HIV, tuberculosis, disasters and maternal-child care – came through the lens of the social determinants of health, including women’s rights, education and poverty.
On maternal-child care, many participants referenced the United Nations’ Millennium Development Goals. Among other things, those goals make improving maternal, infant and child outcomes an important global priority. To that end, we exchanged new information and accumulated experience, while renewing our dedication to advance practice and policy. This month’s Science of Caring conveys some of the knowledge we’ve accumulated at UCSF to improve maternal and child health care here and abroad.
Dean David Vlahov at the WHO Collaborative meeting in Melbourne, Australia
A highlight of the ICN congress was the Florence Nightingale International Foundation’s award luncheon. This year the foundation recognized the Girl Child Education Fund, which identifies and supports the primary and secondary schooling of girls under the age of 18 in developing countries whose nurse parent or parents have died. The fund pays for fees, uniforms, shoes and books – and works in partnership with member national nurses associations to ensure that the money goes directly to education costs. Every girl in the program is paired with a nurse volunteer to monitor her progress at school and at home.
This fund really is a testament of appreciation to the nurses who served their communities. Addressing the determinants of health, education and social support goes a long way toward creating healthy individuals and communities. Those with an education early in life have lower maternal deaths, lower infant mortality, lower rates of HIV, greater participation in the workforce – with higher wages – and a greater chance their own children will be educated. The Girl Child Education Fund is a model program in need of our support – and support is easy to provide. Simply click this link.
Other highlights from this year’s congress were reports from the Japanese Nursing Association about the lessons learned from the nursing response to the 2011 Tōhoku earthquake and tsunami, which led to the Fukushima Daiichi nuclear disaster and radiation exposure. Hiroko Minami – president of the University of Kochi, past president of the ICN and a UCSF School of Nursing alumna – announced the launch of a new PhD program in disaster nursing, which she directs. With their experience and accumulated expertise, Dr. Minami and her colleagues will undoubtedly become the global resource center for preparing advanced practice nurses and researchers in disaster preparedness and response.
Finally, the global network of WHO collaborating centres in nursing met and provided reports on their activities from countries that included Australia, Botswana, Brazil, Canada, Germany, Japan, Korea, Portugal, South Africa and the US. Part of our report from the UCSF School of Nursing WHO collaborating centre included a description of our close interprofessional linkage with UCSF Global Health Sciences. We believe this important collaboration dramatically enriches our global efforts. We also described how we developed and delivered free massive open online courses (MOOCs) on Coursera, where in our first two offerings, we engaged 80,000 students from 190 countries. We continue to be encouraged that such an approach is one important way to disseminate and democratize education.
Of course, much more went on at the ICN congress, but more than anything I was struck – not for the first time – by the substantive and sustained contribution our profession makes to creating a healthier and better world. I couldn’t be more proud.
According to recent projections from the US Census Bureau, the US population age 65 and older will more than double between 2012 and 2060, from 43.1 million to 92.0 million. That will be one in five US residents. The increase in the number of the “oldest old” will be even more dramatic. Those 85 and older will more than triple, from 5.9 million to 18.2 million.
The trend is similar worldwide. Demographic projections from the United Nations suggest that by midcentury, the number of persons aged 60 and older will more than triple from what it was in 2000, to nearly 2 billion. Meanwhile, the number of people age 15 to 64 – those who must assume the burden of caring for their elders – is not growing nearly as fast, shrinking what is known as the population support ratio.
All of these factors demand a response from nursing, since our skill set is ideally suited to addressing older adults’ complex mix of physical and psychosocial needs. In particular, we must adapt nursing education so we are increasingly prepared to meet clinical needs, can play a role in much-needed policy changes and can adapt our research focus appropriately.
One of the most significant responses in graduate nursing education is the merger of what was a separate gerontology specialty master’s degree program with other adult advanced practice nursing programs (nurse practitioners, clinical nurse specialists) for combined degrees. The aim is to grow the adult advanced practice nursing force trained to care for patients across the adult life span.
At UCSF School of Nursing, we have not only revamped our curriculum, but also house a Hartford Center of Geriatric Nursing Excellence. Directed by Meg Wallhagen, the program has trained a steady stream of leaders in gerontological nursing, who play an essential role in many clinical, policy and research settings.
This matters, because the older adult population is not just growing; it is also changing. Consider that nearly three-quarters of persons aged 45 and older – a group that includes baby boomers – responding to a recent AARP survey said they want to stay in their current residence as long as possible. This demands a multifaceted effort. For healthy elders, work opportunities that accommodate their preferences and capabilities can be an important component. For those who are slowing down, there are programs like the World Health Organization’s Global Network of Age-Friendly Cities and Communities, the type of project with which nursing schools and nursing organizations can and should be involved.
In addition, nurses can advocate with public entities to promote affordable housing and transportation, and for community volunteerism that reduces social isolation by keeping individuals connected to others. Nurses can also offer training and respite to friends and family serving as caregivers.
Finally, while for many older adults the goal is to stay at home and in their community as long as possible, inevitably a percentage will wind up in long-term care facilities, in which nurses have always played a central role. Providing exemplary care and delivering the research and leadership to ensure that these facilities incorporate best practices are other critical roles for nursing.
For example, in 2012, Professor Emerita Charlene Harrington’s research drew attention to deficiencies and violations in the largest for-profit nursing home chains. In this issue of Science of Caring, Caroline Stephens talks about her work on reducing unnecessary emergency room visits and jarring transitions for this vulnerable population, while Laura Wagner discusses her work seeking to improve physical safety in nursing homes. Such efforts generate new knowledge that provides the empirical basis for high-quality care. They also demonstrate why now is an ideal time to demonstrate where nursing can lead in health care.
A few months back, when interviewed in this publication, I said: “Our role in technology adoption has to be that of supportive skeptics. We have to evaluate and mold technology-related tools and interventions so that we optimize the benefits and avoid unintended consequences.”
My feelings on this have only deepened in the wake of recent reports that question the ability of electronic health records (EHRs) to achieve their promised clinical and efficiency gains. As our UCSF colleague Robert Wachter writes in The Health Care Blog, EHRs are an absolutely necessary step in improving what clinicians do every day in both hospital and ambulatory settings; I don’t believe we can significantly enhance health care quality while making it more efficient and less expensive without them.
But again as Wachter points out, anyone who believes that EHRs are a panacea, that widespread implementation can be easy or smooth or – as a recent article in the New York Times pointed out – that hard-core capitalism will not play a role has to be living in a world other than the one I live in. So it’s not surprising that there have been a series of reports, both academic and anecdotal, that have pointed out flaws ranging from clunky and time-consuming implementations and distractions from face-to-face time to fraudulent “upcoding” of procedures. Nor have the projections of billions of dollars in annual savings materialized – or at least not yet.
The question for me is: What do we do about it? If we all agree that EHRs are a necessary tool in achieving what has come to be known as the “Triple Aim” – a term coined by former CMS Administrator Donald Berwick, referring to “improving the experience of care, improving the health of populations, and reducing per capita costs of health care” – then how can we ensure that we get the best out of EHRs and avoid as many pitfalls as possible?
I believe the answer is simple and stark: While we have multiple anecdotal reports about lessons learned – Science of Caring ran an extensive piece on this issue for nurses last year – we need more scientific research on the impact of EHR diffusion and adoption for both health care professionals and patients. Such research needs to study the design, implementation, clinician training, and impact on patient care quality, safety and costs. The good news is there are already multiple models for how to successfully approach such research.
- Michael Harrison and colleagues published a conceptual piece in 2007 on the unintended consequences of information technologies in health care using an interactive sociotechnical analysis.
- Erin Sparnon and William Marella from the Pennsylvania Patient Safety Authority found 933 reports from 2004 to 2012 in which electronic medical records (EMRs) caused problems due to categories that include human factors (e.g., wrong input, using default values, failure to update data, failure to alert, failure to carry out duty, wrong record retrieved) and technical factors (e.g., output display error, record unavailable, output device down, data loss, access network down).
- For nurses, there is the work of Tom Clancy and Connie Delaney from the University of Minnesota School of Nursing on predicting the impact of an EHR on practice patterns using computational modeling and simulation.
- Joanne Spetz from our own School of Nursing reported in 2010 on the impact of health information technology on nurses and nursing care.
These and other studies provide a powerful framework for the next generation of research that can help us better understand and improve our design and practice, so EHRs can achieve the goal of safe, efficient and high-quality patient care. The potential is there, but without supportive skeptics rigorously molding the tools and processes, we risk allowing the doubters and cynics to win the day.
As health care reform takes effect and the population ages, the demand for health services increases; many have raised alarms about critical shortages in the health care workforce. Primary care is usually front and center, and while much of the attention has focused on physicians, we have repeatedly commented that any response to shortages should consider the contribution that advanced practice nurses, especially nurse practitioners, can make. In nursing, we also need more doctorally prepared nurses to serve as faculty. Physicians and other health care colleagues have their own very legitimate concerns about their pipelines.
Thus it is especially distressing that inaction and political jockeying in Washington is stymieing efforts to address critical workforce issues. Without a robust supply of providers, health care services become anemic and real people pay a real price.
It’s not just the sequester. An article in the New York Times on Sunday, February 24, began this way:
“One of the biggest threats to the success of President Obama’s health care law comes from shortages of doctors, nurses and other health care professionals. But a 15-member commission created to investigate the problem has never met in two and a half years because it has no money from Congress or the administration.”
The article goes on to outline how Congress refuses to fund the commission in any way and how appointed individuals have been warned against even having conversations on the topic they were appointed to help solve.
As to the sequester, while there are supposed protections in the legislation for the most vulnerable among us, some speculate that cuts to federally funded community clinics will seriously impair their ability to serve hundreds of thousands of individuals and families across the country who cannot otherwise afford health care services. The Association of American Medical Colleges projects that cuts to Title VII and Title VIII programs – which help educate providers committed to meeting the needs of the underserved – will seriously deplete the supply of those providers. Billions of dollars in Medicare cuts means hospitals will have to make hard choices about how to spend their resources on patient care. Guess which segment of the population is most likely to feel those cuts.
Yet while there has been a lot of headshaking and disgust at the way politicians in Washington have failed to achieve even the most basic responsibilities of governance, the reaction seems more resigned than outraged. The politicians continue to bicker, and the media cover it as though it is just another sporting event.
Here’s the problem: Cuts in care and in training for health professionals mean, bluntly, that perhaps thousands of people will suffer unnecessarily; some will die. There is no difference between this and when those of us in the health professions engage in self-serving turf wars rather than keeping top of mind the people we are paid to care for.
It’s time for all of us – those in the health professions and politicians in Washington – to make sure the touchstone for all of our actions is the needs of the people we have sworn to serve.
When the Institute of Medicine (IOM) of the National Academy of Sciences issues a report, the IOM panels and review process ensure that conclusions and recommendations are based on solid science. This is a profound principle, one that those of us in health care have long held dear.
It’s especially important as we prepare to expand care to 32 million more Americans, because it is scientific evidence that will be central to ensuring the safest, highest-quality care. So why is it that as numerous articles raise alarms about a physician shortage, they ignore or minimize scientific evidence from the IOM and others that there are alternative and, perhaps, more efficient and lower-cost ways to fill some of the gaps?
Exhibit A: The authors of a 2010 IOM report entitled The Future of Nursing: Leading Change, Advancing Health amassed and reviewed evidence about the role of advanced practice nurses (APNs). Multiple studies – including randomized controlled studies – over several decades had shown that APNs provide high-quality and safe patient care in multiple clinical settings. This led to the recommendation that APNs should be able to practice to the level of their education. Evidence and advocacy efforts continue to grow in support of this recommendation, but in some places it remains an uphill battle.
Moreover, some studies also show that APNs can be trained in less time and for less expense than physicians, and are lower cost in practice even as patients remain satisfied with the care they receive from APNs. These are all relevant metrics for the accountable care organizations springing up around the country in response to the Affordable Care Act.
Exhibit B: Diana Taylor, professor emerita at UCSF School of Nursing, and Tracy Weitz, associate professor, Department of Obstetrics, Gynecology & Reproductive Sciences at UCSF School of Medicine, recently published a report in the American Journal of Public Health. The researchers – who work out of Advancing New Standards in Reproductive Health (ANSIRH) and the UCSF Bixby Center for Global Reproductive Health – completed an observational prospective study that evaluated the outcomes of aspiration abortions completed by 5,812 physicians and by 5,675 newly trained nurse practitioners (NPs), certified nurse-midwives (CNMs) and physician assistants (PAs). The study found that abortion complications were clinically equivalent between the physicians and the combination of NPs, CNMs and PAs.
Policy advocates intent on changing California law to expand access to abortion care have latched onto the study. On the 40th anniversary of Roe v. Wade (1973), advocates held a press conference on the capitol steps in Sacramento to mark the occasion and introduce legislation based on Weitz and Taylor’s study. Authored by Assembly member Toni Atkins, Assembly Bill 154 seeks to allow NPs, CNMs and PAs to provide aspiration abortions.
While health care providers and the general populace will differ on their positions about reproductive health choice, the study from the UCSF schools of medicine and nursing is important for several reasons.
First, it is a potent example of health professions working together to generate new data to inform practice. Second, the study findings – the evidence – are being used beyond academia to spur policy debate and action – always an encouraging development.
Finally, the study joins the IOM’s The Future of Nursing report in the continually expanding literature on the competence of APNs to provide high-quality and safe patient care. Thus these highly and specifically trained professionals – often working closely with physician partners – can mitigate the effects of projected physician shortages and help meet the growing health care, disease prevention and wellness needs of the US population.
The evidence is clear.
As I write this, the country is reeling from the senseless mass murders at an elementary school in Newtown, Connecticut. This most recent gun-related horror is especially shocking as the primary victims were young children. Even for those of us who did not know these children, when we see their pictures we feel nearly incomprehensible sadness. Our hearts reach out to the grieving families and communities.
In a profession dedicated to helping others, it is a shock to suddenly feel a collective helplessness. Many nurses have seen wounded individuals on the street or coming though the door, and have worked to save lives and comfort families, but the human devastation in the Connecticut shooting – and the one this past summer at a movie theater in Aurora, Colorado – is on a completely different scale. Perhaps it is my training, perhaps why I became a nurse in the first place, but after mourning, I can’t help fighting the helplessness by wondering what I can do to make sure nurses prepare for, respond to and help prevent these tragedies.
At one level, there’s the training we can offer nurses in acute care, including trauma care, where the science has advanced tremendously in the past few decades. Nurse clinical specialists who work in acute and trauma care are often among the teams that minister to the victims when they make it through the door, and we must do everything we can to ensure their training is equal to the task.
Other nurses choose to return to school to train as nurse practitioners in community health, including school health. Increasingly, clinics at middle schools and high schools fill an important gap in health care for otherwise underserved communities. Nurses in this setting can be an important resource, working with teachers to raise awareness – and working with police and school officials to train and drill on responses to school emergencies. Here, too, we must see to it that nurses are prepared to fill that role.
But of course, in reality all nurses are frontline community resources. We are more than one-on-one clinicians in outpatient or acute care settings. Nurses bring perceptive and sensible eyes and ears on the ground; we bring our training in communication skills, primary care, mental health and leadership and so can become credible leaders in our various communities, from work to worship and the broader community. Communities are strengthened when leaders and experts work with members to knit a social fabric that helps move individuals and the group toward physical, mental, emotional and spiritual health.
Finally, nurses can be strong policy advocates – and those so inclined should not shrink from that role. We are witnesses, we are credible, we can step forward and, with others, we can frame and change policy to reduce and maybe someday stop this senseless killing.