Five Reasons to Support a Commonsense Solution for the Primary Care Shortage

April 2014
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

March 2014
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

February 2014
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.

“And in Flew Enza”

January 2014
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

December 2013
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.

Advanced Practice Nursing and Public Health

November 2013
David Vlahov

As we pause this month to reflect on the assassination of President Kennedy half a century ago, many of us with a stake in public health nursing are quite familiar with his leadership role in the fights over Medicare. We think in particular of one address to Congress where Kennedy paraphrased the historian and philosopher Arnold Toynbee. Toynbee had concluded from his research that you could predict the greatness and the durability of any society by the manner in which it cared for its vulnerable populations: the aged, the children and those suffering with illness and disability. What was at stake, therefore, said Kennedy, was nothing less than our survival as a nation and our place in history.

His comments and the battles over Medicare have echoes today, of course – perhaps especially for nurses. With the Affordable Care Act’s refreshing emphasis on prevention, health promotion and wellness, nurses are poised to play an ever more prominent role in the health care system. This makes perfect sense, since we have been the backbone of public health since the beginnings of modern nursing. One need look no further than the model of Lillian Wald, who understood before most others that improving the health of entire populations went far beyond a simple clinical visit – and that nurses are critical to expanding the reach of health-related services.

Wald founded Henry Street Settlement in 1893, part of which spun off to become the Visiting Nurse Service of New York. In addition to individual health care services, she set up education programs, social clubs, language classes for immigrants and more. In doing so, she established herself as a powerful advocate for social reform, public health and human rights.

Wald is the model nursing must look to as we plunge deeper into the era of health care reform. Already, people are looking to advanced practice nurses – practicing to the level of their education – to provide primary care in a wide range of settings, such as local health department clinics, accountable care organizations and public schools. But like Wald, nurses and nurse educators must step outside the clinic to appreciate and act at the community, city, state and national levels for the creation of both programs and policies.

Among other things, this means bringing an environmental health perspective to physical and social environments such as schools and workplaces, as well as to municipal, national and global policy actions. It means closer and more consistent interaction with sectors of government that oversee urban planning, transportation and criminal justice – in short, any arenas that affect or promote health. Likewise, public health nursing must continue to increase its engagement with corporations to promote access to healthy products.

We must also bring our proud tradition of interdisciplinary work – collaborating with nurses, physicians, dentists, veterinarians, behavioral scientists, laboratory scientists, epidemiologists, health economists, health services researchers and policymakers – to interprofessional education. As health professions increasingly explore ways to learn together, nurses bring an important perspective and need to be seated prominently at the table. We can help frame and teach the vocabulary, tools and leadership skills that will, ultimately, strengthen the public health infrastructure at the local and national level.

Finally, to put muscle into achieving an increasingly effective public health workforce, nursing needs more formal faculty development and, as a stretch goal, to incorporate competencies within the NCLEX. Such competencies are important across specialties, including acute care, because practicing nurses in all settings can credibly testify that patient outcomes are shaped by upstream factors – from neighborhood milieus to government policies – that influence individual behavior.

We can thank Lillian Wald for leading the charge to incorporate that essential perspective in our health care system.

The Flipped Classroom in Nursing Education

October 2013
David Vlahov

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.



September 2013
David Vlahov

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.

The March on Washington: 50 Years Later

July 2013
David Vlahov

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.

Editor's Note: For video coverage of Dean Vlahov at the commemorative march, you can go to the local ABC news affiliate or national NBC news.

Nursing and Climate Change

June 2013
David Vlahov

“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.