The Dean's Blog: Sandra J. Weiss, PhD, DNSc, FAAN
“Citizen Health” is a movement that envisions patients becoming more engaged in their own health through growing access to health information on the Internet. Fostering engaged and informed patients is a good thing, but with the quality of information uneven and many citizens ill-equipped to sort through it to make an informed decision, there is cause for concern.
Today many patients arrive in clinical settings with information that has shaped their thinking about diagnosis and treatment. A few even have full online access to their medical records – and those numbers will increase dramatically – as well as online access to many different ideas about best practices for managing their condition. This alters clinical interactions in ways for which few clinicians have been prepared – and which can lead to an unsatisfactory rapport between patient and clinician that erodes the clinician’s credibility.
The risks of credibility erosion can deepen as access to information increases. In February 2011, IBM’s Watson computer appeared on “Jeopardy!” and defeated two of the show’s most successful human contestants. Now IBM and Nuance Communications are developing Watson as a clinical decision-making tool. Once it becomes available to physicians, how long before it becomes accessible to patients as well, especially given the speed of development and democratization of health informatics?
What is the future of nursing in this brave new world of Citizen Health? First, we must stay abreast of technological changes, no matter how rapidly they occur. Second, we must lead in providing insight into the unintended consequences of technology: When and how is information counterproductive? Third, we must explore the myriad ways that true health literacy can enable citizens to more effectively participate in health promotion and disease prevention.
All of this should lead us to a hybrid approach in which the patient’s access to intelligently vetted health information can supplement the human touch, training and experience of the nurse and physician. Nurses will still need to coordinate care, identify gaps, direct patients and families to resources, and advocate for the preventive and therapeutic care that drives people to information in the first place. To shape and participate in this hybrid approach, we need to be prepared for both the present and the future.
As numerous articles in Science of Caring have illustrated, that is precisely what we are doing at UCSF School of Nursing. We were the first school of nursing in the country to upload content on Coursera, which provides free access to high-quality courses on health information; our two courses combined already have over 20,000 registrants from around the globe. Faculty here develop new theories and validate protocol-based products for self-assessment and management. At scientific meetings and product exhibitions, they present their work on the use of apps, computer avatars and gaming platforms to improve diagnosis, treatment and care.
And as highlighted in this issue’s feature story, UCSF nursing faculty had the first of what we hope to be many meetings with GE Healthcare to describe clinical problems that may be addressed with technological solutions. Partnerships of this type provide the opportunity to create a shared vocabulary and processes for collaboration. They enable nurses to become more adept at understanding where technology fits in the framework of identifying clinical problems – and to better understand technology’s potential to bring together the citizen patient, his or her family and the clinician in meaningful ways to improve health.
David Vlahov, PhD, RN, FAAN
Professor and Dean, UCSF School of Nursing
Recently, UCSF School of Nursing co-hosted an event with the Jonas Center for Nursing Excellence on caring for veterans returning from wars in Iraq and Afghanistan. Discussions focused on improving nursing care to this population and recruiting and retaining veterans as students and faculty. The latest of many efforts to acknowledge and improve diversity in nursing, the event was an acute reminder that for reasons both practical and principled, diversity and inclusiveness must be core values in schools of nursing.
In most cases, I’m proud to say, they are. But there’s a difference between professing values and successfully living up to them, and for all of us in this profession, living up to these values demands a hard look in the mirror.
That look begins with definitions, because too often the terms diversity and inclusiveness are used loosely and vaguely.
Diversity refers to human qualities that are different from our own and those of groups to which we belong, but that are manifested in other individuals and groups. Dimensions of diversity include but are not limited to age, ethnicity, gender, physical abilities/qualities, race, sexual orientation, educational background, geographic location, income, marital status, military experience, parental status, religious beliefs, work experience and job classification. Inclusion is a sense of belonging: feeling respected and valued for who you are – even more than that, feeling a level of supportive energy and commitment from others so that you can do your best work.
Diversity is important because we need a nursing workforce that mirrors the population. Consider that disparities in health exist across almost all diseases and conditions. For example, African American adults, Hispanics, American Indians and Native Alaskans and Hawaiians receive a diagnosis of diabetes – one of our country’s most significant public health problems – about twice as often as non-Hispanic whites. Numerous studies have shown that a more diverse health care workforce holds enormous potential to reduce disparities, in part by enhancing the cultural understanding and creativity of the work environment. And it is inclusiveness that enables us to tap that potential, first by fostering diversity in recruitment and retention and then by creating an environment where honest exchanges can occur.
Over the past 30 years, the nursing workforce has become more diverse, but even today over 83 percent of the 3 million registered nurses in our country are non-Hispanic white, a group that makes up only 66 percent of the general population. The proportions of registered nurses who are African American, Asian and Hispanic are 5, 5 and 3 percent, respectively; by contrast, the proportions of the US population that are African American, Asian and Hispanic are 13, 5 and 15 percent, respectively. And men account for only 6.6 percent of the US nursing population today.
So working on the numbers is one important goal. When we recruit students, we need to be sensitive that the language and images we use are inclusive. We should highlight ways in which we have achieved greater diversity and provide information about the support systems in place at the school and the surrounding community, about scholarships and awards. Wherever possible, we should also demonstrate that we have a committed minority faculty committee, an environment that is supportive at all levels, and mentors in place who can provide guidance and support in a new and different environment. If those things aren’t in place, they should be.
Increasing faculty diversity is equally important, because just as more diverse providers offer something uniquely important to patients, more diverse faculty are essential for achieving a learning environment where nurses of all backgrounds can be prepared to provide the best care in an increasingly diverse society.
But improving the numbers is only a beginning. At UCSF School of Nursing, a cadre of faculty formed a group called DIVA (Diversity in Action) in 1994. Since that time, DIVA has led the way in helping us confront some of the more difficult issues that arise on a multicultural campus – and create and share tools to nurture diversity. The DIVA group has forced us to consider how we can ensure that our entire student population feels fully part of every classroom, to revamp our curriculum and to do the hard work of honestly confronting and resolving incidents of insensitivity or unconscious bias.
For example, back in 2006 DIVA initiated a process that rigorously examined every course in the school to discern how effectively, if at all, it addressed issues of bias or inclusiveness. DIVA looked at student evaluations to understand student experience and held meetings with various groups. That process led to creation of a faculty development program for diversity and inclusiveness that has six modules. In essence, the modules are a series of six training sessions that help faculty:
1. Facilitate inclusive discussions within the classroom
2. Design syllabi and courses to engage issues of diversity
3. Create a respectful and inclusive classroom management approach
4. Encourage a culturally humble approach in the clinical setting and encourage students to be culturally humble
5. Teach future faculty to engage in issues of diversity
6. Form more diverse research teams, incorporate issues of difference into research projects and comply with NIH mandates
The modules are rooted in the concept of cultural humility, which, rather than focusing on particular answers to these difficult challenges, suggests that the way to deal with bias and create an environment that leads to a more diverse and more effective nursing workforce is to recognize, understand and address power imbalances with respect and humility.
We are justifiably proud of such efforts, but that hard look in the mirror tells us we still have a tremendous amount of work to do. I suspect we are not alone.
As the country gears up for the 2014 implementation of the Affordable Care Act, which will open up access to care for 32 million currently uninsured people, advanced practice nurses (APNs) will play an important role.
Working with other health care providers in a variety of settings, APNs can meet many essential needs of a modern health care system, including health promotion, disease prevention and primary and specialty care. In addition, nurse practitioners are a significant part of the solution for improving access to underserved populations.
Perhaps most importantly given the urgency of the situation, evidence exists that APNs take less time to train, provide less expensive care and in the many areas for which they are trained deliver equal or better quality of care and patient satisfaction than physicians.
The catch is that there is a shortage of expert teachers to prepare the next generation of APNs. At the moment, there are 1,200 vacant APN faculty jobs nationwide, and this year we are seeing a rash of retirements in among nursing faculty across the country. Looking ahead five years, between one-third and one-half of APN faculty at our school alone will be eligible to retire. Replacing them will not be easy.
Returning to school for a doctorate requires a special dedication, especially for nurses who have practiced and taken on financial and family responsibilities. Tuition has increased as federal and state funding for advanced education has eroded, making higher-paid clinical positions like nurse practitioner more appealing. Those who choose to teach make personal sacrifices so that we can have a new and more responsive health care system.
Some of those who remain in clinical positions do serve as volunteer faculty and preceptors. Often alumni, they too do a remarkable job of training the next generation of nurses. Yet here again, their role demands sacrifice, and we do not have the numbers to meet the need.
To fill the gaps, most schools are experimenting with new strategies, including advanced simulation labs, online education, and partnerships with other professionals in nutrition and pharmacology as well as among formerly competitive nursing schools.
All of these strategies are important, but none can fully replace the human interaction – the nurse educators who have made personal sacrifices to nurture and guide the clinician who will provide outstanding frontline care, the administrator who will supervise the positive patient experience, and the educator and scholar who will advance knowledge in the university setting.
These individuals deserve more than our thanks. They need concrete support in the form of better wages – not just to show our appreciation, but also to entice others to fill these crucial roles. Schools need more endowed chairs to recognize faculty excellence. And we must maintain and strengthen our relationships with volunteer alumni and other community clinicians who teach students in real-world clinical settings.
Because the flattened economy has caused some nurses to put off retirement or return to work, job vacancies are low in some areas, causing some debate about whether a nursing shortage actually exists. But when the economy recovers, many nurses will again leave the clinical and academic settings, depleting our ranks at a time when the aging of the population will demand more nursing care than ever before. We need nurse educators now to be prepared for the future that is already upon us.
David Vlahov, PhD, RN, FAAN
Professor and Dean, UCSF School of Nursing