Leadership Interviews – “3 Questions” – Aging in Place – TigerPlace

Welcome to the Nursing Outlook Blog – “3 Questions” – Timely Interviews with Thought Leaders in Nursing and Health Care Policy

As the population of the United States continues to age, we face numerous challenges in health care delivery systems that go beyond health services and impact supportive and appropriate housing issues as well. Most Americans want to age in place, that is, stay in their own homes as their abilities wane and health needs increase. But ideal housing is not easy to find and retaining independence is difficult. Our systems need to think differently about the organization of health and independent housing services than what is available for most elders today.

With the federal government tackling the cost and quality of health available to citizens, nursing as a profession needs to pay attention to the discussion. Independent housing, aging in place (AIP) and the optimum packaging of supportive services need creative solutions with sound evaluations to perpetuate what works and model outstanding programs. Following legislation to test the AIP model In Missouri, the Sinclair School of Nursing at the University of Missouri, partnership with Americare Systems, Inc., built “TigerPlace,” a senior housing facility with care coordination as the centerpiece.

The March April 2014 issue of NURSING OUTLOOK describes the statewide evaluation of the continued success of TigerPlace and the registered nurse (RN) care coordination model for long term care. Dr. Marilyn Rantz discusses here how this model has evolved over time and its successes can be replicated in other states.

Marilyn Rantz, is Curators’ Professor and  Helen E. Nahm Chair at the University Hospitals; and Clinics Professor of Nursing and Executive Director for Aging In Place and TigerPlace. She is also Associate Director for the Interdisciplinary Center on Aging, Sinclair School of Nursing, University of Missouri.

For links to the Aging in Place in Missouri, click here: www.agingmo.com.

We invite commentary that is thoughtful and provocative! Join the online dialogue!

 

Click here for the TigerPlace website”:

We invite commentary that is thoughtful and provocative! Join the online dialogue!

Veronica D. Feeg, PhD, RN, FAAN
Editor/Moderator

Marilyn J. Rantz, PhD, RN, FAAN

Sinclair School of Nursing at the University of Missouri

Question 1. What will it really take to make senior housing options, like TigerPlace, to “spring up” across the country so the benefits of cost and quality outcomes demonstrated in this state evaluation are realized nationwide?

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The key, from my point of view, is to have a funding mechanism for RN care coordination. What we found in our state evaluation at TigerPlace, is that the corner stone is care coordination. It needs to be done by a well-qualified nurse, and we built TigerPlace around those ongoing costs of health promotion: we bundled the cost of health promotion; we combined a 24 hour nurse on call, wellness center hours that are open several times per week, and four private visits from a nurse per year in your home; and organized exercises class. Those are really health promotion. We do a class called healthy steps and another class on Tai Chi and Yoga – lots of strength building, those kinds of focuses for health promotion classes that are movement oriented – because we know that if people keep moving it really helps them promote their health. We combined those costs, bundled those costs so that there’s a small charge that is combined into the monthly rent of everyone’s apartment. In TigerPlace, the monthly rent also includes meals, housekeeping, and transportation – those amenities of living in a typical assisted living setting, and also in a lot of independent housing settings. But we put the health promotion package in there too and that small investment really helps promote the health of all the people who live there, and it results in a lot of major improvements surrounding the physical function, the mental function. And the declines that typically we see through the end of life are shortened, to a shorter period of time at the end of life and people can be really functionally active through the end of life. It is really wonderful to see the outcomes of lower costs overall – we save about $20 thousand per year on the cost of typical long term care, nursing home care when our residents would qualify for nursing home care. That cost savings is really helpful for them and their families. But, more importantly, they have a better quality of life and better function through the end of life.

Another thing that it’s going to take is: we really need to learn how to used Advanced Practice Nurses and other qualified care providers under the new CMS guidelines and payment mechanisms for complex chronic care coordination and also for transitional care management services. We now have CPT codes. Those codes we will put in the document that goes along with this narrative. Those codes are relatively new on the scene for us to use, and we have not at TigerPlace, tried to use them yet for billing purposes for an Advanced Practice Nurse. So we would really welcome other people who have been successful at billing through those codes. I suspect that we can use that mechanism and help promote TigerPlace concepts across the country using that payment mechanism.

The other thing that would be very helpful to happen across the country is the policy work that needs to take place, state by state, to enable the construction of elder hosing that allows people to stay there through the end of life with this health promotion focus. (Because) you really can’t continue to do business as usual, forcing people to move from setting to setting to setting because of the licensure and regulation across those settings. Typically, one is forced to move from senior housing, to assisted living to nursing home, because of the state and regulation. But, what we did in Missouri is work through those with our Division of Aging and also passed legislation that enabled us to license the care and NOT the setting. Although, in the end, we ended up licensing the building as intermediate care, so that people could use their long term care insurance – that was a piece of the puzzle that people had found really helpful. But we still have the care provided under the licensure of home care and that seems to be a really sound approach than focusing on making people move from place to place to place.

Question 2. What can organized nursing do to enable the “springing up” of TigerPlace concepts around the country?

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A major initiative that needs help across this country that would facilitate this is APRN unrestricted practice. We really need unrestricted practice in every state in this country. That needs to happen. I know that organized nursing nationally has been focusing on this, and helping states one by one change their regulations and their nurse practice acts to enable unrestrictive practice for advance practice nurses.

We have restrictive practice in this state, where collaborative practice arrangements are required and some onerous review processes as well as onerous limitations on the distance once can be from your collaborating physician. We have also done an analysis of the health outcomes in our state and health outcomes in all states comparing restrictive practice guidelines regulations with the health outcomes and then hospitalizations of Medicare and Medicaid patients and all of those are highly correlated in each state with restrictions on advance practice nurses. It is time that we get unrestrictive practice nation-wide. That needs to happen! And that will facilitate the development of these types of operations because we can have a funding mechanism with the Medicare availability under the CPT codes that I talked about earlier, which are the transitional care management and the complex chronic care coordination services. It would be possible then to have a funding mechanism available for APRN independent practices in these housing developments and facilitate this nation-wide.

That will be critical in something that organized nursing state by state needs to embrace. I know we have in this state. I know we have legislation pending, but once again, we are at that time of year and we have now been thwarted again by organized medicine and we are going to have another initiative next year. Hopefully we will be successful next year and try some slightly different strategies and hopefully that will have a positive outcome in this state. And I hope other states are doing that too.

The other thing that organized nursing can do is to continue policy forums where nurse entrepreneurial efforts are promoted and you demonstrate the cost and quality outcomes. We do that in the American Academy of Nursing through the recognition of Edge Runner programs. TigerPlace and the Aging In Place research that has been done at the University of Missouri is an Edge Runner program. That helps to promote new modes of care that hold the answers for many of the complex care problems and cost and quality programs that we have in health care across the nation. Nursing can take the lead, nursing has many of the answers and we can bring other disciplines to the table.

Question 3. Do you have any advice for others wanting to replicate or build on what you have learned in the Aging In Place evaluation at TigerPlace?

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You know, that is my goal! We have done consistent evaluations, and what we had wanted to do in our state demonstration project is lay a good foundation of data as well as a good foundation of materials for people to use to be able to build on what we have done. We have been very careful to document all of the evaluations and publish those. We have been very careful also to document process descriptions of how we went about doing different things and the major components of The Aging in Place project and particularly building TigerPlace. We have a compendium and lots of information about Aging in Place on our website. You can use those materials and we will work with you, too, as you use those materials, but we have lots of that on our website.

The other thing that we did that I think works really well: in fact at lunch today, I am going to Jeff city our state capital and meeting with state regulators. You have to have a relationship with your state regulators. Develop a positive relationship, maintain that positive relationship and work with them because they want to see that projects like this succeed. They will collaborate with us. They will work with us. They have the same goals in mind of helping older people, of any population that you want to work with, but these are particularly people who are focused on older adults. They want to see that people get the right care and services, so they’re open to new ideas. Develop those relationships and figure out how you can gain their cooperation to do projects like this within your state. I think some states will need very little change, if any, to be able to just go ahead and duplicate TigerPlace within your state, and, other states will require some adjustments in state statute or regulation. We had to adjust statute and regulation in this state to enable its construction, and it’s flourishing. So, I really want to work with people and we are working with some people, but it’s important to have the regulators and have a positive relationship with them as you are developing this.
The third thing is that we have prepared the operational materials too, to help others implement this idea, particularly the concepts of care coordination in senior housing settings. Right now we are in discussion with the College of Nursing at the University of Arkansas for Medical Sciences in Little Rock and they really want to replicate the Aging in Place model. So we have got really good potential working with that college of nursing to be able to replicate what we have been able to accomplish here at TigerPlace. Particularly care coordination and doing another key in our model of care is doing variable billing on the costs of care, so that as people need more services, we put services around them, and withdraw those services as they become independent again. That controls the costs. They are very interested in helping to replicate this model and particularly to be able to work on the changes in funding and the variable billing for funding.

It has been a delight to be able to be a part of the Aging in Place Project here at the University of Missouri. I have spent almost 20 years working on this project now. We started in 1996, and I can tell you it has been some of the most exciting work that I have been able to do. Sometimes, I very much feel that this is the work that I was intended to do and that is why I was put here.

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Leadership Interviews – “3 Questions” – Immigration Policy and Internationally Educated Nurses

Welcome to the Nursing Outlook Blog – “3 Questions” – Timely Interviews with Thought Leaders in Nursing and Health Care Policy

Immigration policy plays a critical role in the economy and workforce issues related to nursing. With the undersupply of nurses in the U.S. and worldwide education of nurses, the flow of nursing professionals has provided a steady stream of professionals in our hospitals and health care communities. We as a country have relied on internationally educated nurses (IENs) and our professional policies have worked hard to keep pace with establishing global standards for education and competencies that – at least – do not interrupt the flow.

With the federal government tackling the issues of immigration in general, nursing as a profession needs to pay attention to the discussion that generally sounds like topics related to undocumented workers when, in fact, a highly educated group of nurses may be part of that discussion. With the intellectual capital at stake, and with the U.S. no longer the country of choice for some immigrating nurses, we need to be vigilant in balancing the flow of IENs and hospital needs with local economic forces.

The January February 2014 issue of NURSING OUTLOOK tackles the multiple aspects of immigration and the internationalization of markets for goods and services, including the nursing workforce. In this interview, the lead author of the article that describes historic and current trends in countries that have often supplied the U.S. health care system, Dr. Leah Masselink adds commentary to the articles published in Nursing Outlook and provides historic backdrop to the international power of nurses and the intersection of IENs and immigration issues.

Leah E. Masselink, Ph.D., is Assistant Professor of Health Services Management and Leadership at the George Washington University School of Public Health and Health Services. Dr. Masselink joined the HSML in July 2012. Before coming to G.W., she earned a PhD in Health Policy and Management from the UNC Gillings School of Global Public Health and completed a postdoctoral fellowship at UNC School of Nursing. Her work focuses on internationally educated nurses and nurse migration in the Philippines. She has served as a consultant and assisted on the Health Workforce Development team for the USAID Health Care Improvement Project.

For links to the recent Senate and House legislation:

See the full article published in NURSING OUTLOOK at:

Masselink, L. & Jones, C.B. (2014). Immigration policy and internationally educated nurses in the United States: A brief history. Nursing Outlook, 62(1), 39-45.

We invite commentary that is thoughtful and provocative! Join the online dialogue!

Veronica D. Feeg, PhD, RN, FAAN
Editor/Moderator

Leah MasselinkLeah E. Masselink, PhD
Assistant Professor
Department of Health Services Management & Leadership
The George Washington University
School of Public Health & Health Services

 

 

 

Question 1. The article briefly mentions that internationally educated nurses (IEN) hiring patterns in the U.S. reverberate in source countries like India and the Philippines. What has been the political and social impact of the reduced demand for IENs in these countries after the Great Recession?

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In India, nurses historically have earned very low wages and worked under poor conditions not unlike other sending countries. It historically hasn’t been protested or hasn’t been a much of a problem because usually nurses at least had nurse migration as an opportunity to get out of poverty. With the reduced demand for nurses worldwide (India sends nurses to US, but also to the Middle East, and the U.K.), so the reduced demand after the Great Recession led to protests and strikes in India. The Nurses organized themselves to demand better wages, better working conditions. They protested against bonded service at some hospitals meaning that they were obligated for certain periods of time, including some very dramatic scenes where nurses would go up on the roof of a hospital and threaten to jump. The strikes happened in many states in India but much of the activity was centered in the state of Kerala, which has a long history of nurse migration. The nurses in Kerala have actually formed some of the first independent nurse’s unions. And the state is actually doing now some investigation trying to put some provisions in place to limit work hours and abolish the bonded service.

So the Philippines is in somewhat of a similar situation except probably even more focused on the U.S. market. The U.S. market is somewhat of the gold standard where most nurses are aiming to go. There is a huge production aimed at U.S. market. This overproduction led to thousands and thousands of unemployed nurses in the Philippines when the demand went down in the U.S. So, a few things happened: the nurses were working in private institutions as volunteer nurses who some of them actually had to pay fees to work in hospitals for clinical experience hoping that it would pay off later rather than being paid. This has been outlawed but it is a little unclear whether it is still going on. The government also tried to take some action: started a temporary program for unemployed nurses to send them to remote areas where they could both fill some needs and also get real employment experience for the future; and, has also sponsored some specialty certification programs for nurses to improve their employability in the future. And another really fascinating development has been the formation of a nurse’s political party, which included the election of a congresswoman who is a nurse, who is the former president of the Philippines Nurses Association. That party’s platform includes a lot of activity around protecting nurses fighting exploitation, both domestically and international recruitment, raising salaries and so forth. In both of those countries nurses concerns are a political issue in ways that we probably are not aware and that they certainly are not in the U.S.

Question 2. The article suggests that nurse leaders and hiring organizations bear much of the responsibility for ensuring that hiring of IENs is ethical. Are there any more centralized efforts (regulatory bodies, etc.) in the U.S. to protect IENs and source countries?

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In the U.S, there are several voluntary efforts to protect IENs mostly headed up by either professional associations such as the American Staffing Association and the American Association of International Healthcare Recruitment, which have adopted codes of ethics which are conditions of membership in those associations. A broad variety of other associations have policy statements also on ethical recruitment including the American Organization of Nurse Executives (AONE). There are a few innovative efforts that try to go a little bit farther including the Alliance for Ethical International Recruitment Practices, which is actually run here at G.W. It has a voluntary code of ethics that recruiters can endorse and seek certification as ethical recruiters. Then certified recruiters are monitored for compliance with the code. One additional step that that organization takes is also seeking to promote corporate social responsibilities or efforts to give back to low income source countries.

Other governments and international bodies have also adopted voluntary codes, most all of these are voluntary, including the World Health Organization. The Code of Practice on International Recruitment encourages member states: (1) to avoid recruiting health workers who have obligations in their home countries, (2) to provide opportunities for training and skills transfer, and (3) to treat migrant workers fairly including compensation and legal protections etc. The U.K. also has a broader code of practice for its National Health Service (NHS) recruitment which is based on the WHO Code. NHS employers are “commended” to use only recruiters that comply with that code and internationally educated health professionals must have access to the same legal protections training compensation etc. Another provision that is interesting is that developing countries are specific – there’s a list – and they must not be targeted for recruitment unless they have entered in to an explicit government to government agreement with the U.K. So obviously this type of thing is a little bit more difficult to imagine in the U.S. because our health system is a bit more complex than a national health system. So there are efforts, but most all of them are voluntary.

Question 3. How might current or future immigration policy changes (e.g. comprehensive immigration reform) affect internationally educated nurses?

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This is obviously still a work in progress, as of today. But the Senate actually did pass a bill back in 2013, so at least we can examine some of the provisions. Two categories were really affected, one was H1B Visas, which are increased quite a bit under that policy. The increase could create more opportunities for nurses but the impact is a bit unclear because H1B has not been used very much by nurses in the past. It’s intended for skilled immigrants who have bachelor’s degrees, and since nursing jobs are not necessarily posted with bachelor’s degree listed as required, those jobs are not always H1B eligible. The other category is the employment based visas, the immigrant visas. That policy proposed a shift to a merit based system rather than a family based system with points being awarded based on skills, education experience and English language proficiency. So nurses would likely compete strongly under this system, especially those with bachelor’s degrees or higher, as many IEMs do have, especially from the Philippines, which actually most all of their programs are run as BSN programs.

Another provision related to EB employment based visas is that is also seeks to clear the backlogs of visas and eliminates country specific caps, which has historically affected nurses from large sending countries such as India and the Philippines. The House had bills that died in Committee, the House Judiciary Committee and Homeland Security Committee, so they didn’t make it beyond that. But actually the provisions for skilled immigrants like nurses were fairly similar, adding H1B visas and employment based visas. No new visa categories were proposed in either of these pieces of legislation and the House bill also paid less attention to the existing employment based visa backlog. The House just now has unveiled a draft framework again, mostly focused again on undocumented immigrants, but it appears as if the idea of expanding H1B and employment based visas would most likely find support in the House as well. It remains to be seen how that will all turn out.

Follow-up Question. Where do you see this going?

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It’s starting to turn around now and there has been now more interest again in trying to come to the U.S. So I think that they are beginning to see hope. I think there is a lot of interesting and probably developments that we cannot even imagine with the Affordable Care Act and future economic changes. It is a little uncertain, but nurses in some of these sending countries are beginning to look at the U.S. again as a destination.

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Leadership Interviews – “3 Questions” – Transition: Adolescents and Emerging Adults with Special Health Care Needs

Welcome to the Nursing Outlook Blog – “3 Questions” – Timely Interviews with Thought Leaders in Nursing and Health Care Policy

Although our health system has made great strides in clinical technologies, it has been largely ineffective in service delivery for the large and growing population of individuals with disabilities and children with special needs. While the field of pediatrics has addressed issues of children and families when facing a life of limitations or health problems, as the children age through adolescents and transition into adulthood, the service delivery system and fragmentation of adult services serving this population continue to create barriers to care. It is time for organized nursing to step up and champion the research and practice needed to lead the changes necessary for minimizing disparities and facilitating transition.

In this interview, the lead author, Dr. Cecily Betz adds commentary to the articles published in Nursing Outlook and advocates vociferously for nursing to get engaged in the research and practice of this emerging science. She discusses how nursing has a unique opportunity to make positive differences in all adolescents and emerging adults with special health care needs. Nursing needs to be visibly present and the time is ideal!

Cecily L. Betz, PhD, RN, FAAN is an Associate Professor, University of Southern California (USC) Keck School of Medicine, and the Department of Pediatrics and Nursing Director/Research Director at the USC UCEDD at CHLA. She is also the Director of the Spina Bifida Transition Program. For over 20 years, Dr. Betz has been the Editor-in-Chief of the Journal of Pediatric Nursing, and a prolific writer and speaker on issues pertaining to children with special health care needs. She was the co-chairperson of the American Academy of Nursing (AAN) Expert Panel on Children, Adolescents and Families (CAF) and co-author of the AAN-CAF Guidelines for Health Care of Children.

See the full article published in NURSING OUTLOOK at:

Betz, C. L. (2013). Health care transition for adolescents with special health care needs: Where’s nursing? Nursing Outlook, 61(5), 258-265.

We invite commentary that is thoughtful and provocative! Join the online dialogue!

Veronica D. Feeg, PhD, RN, FAAN
Editor/Moderator

CecilyBetz

Cecily L. Betz, PhD, RN, FAAN

Associate Professor, University of Southern California

Keck School of Medicine, Department of Pediatrics

Nursing Director/Research Director, USC UCEDD at CHLA

Director, Spina Bifida Transition Program

Editor-in-Chief, Journal of Pediatric Nursing

Question 1. Why did your team select this question for investigation?

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Our team was interested in looking at the needs as we understand it from an empirical perspective. What were the concerns of adolescents and emerging adults with special health care needs as they transfer in, and transfer to adult care, but also as they transition to adulthood? This is a particularly relevant issue as somewhere between (the estimates are not exact) somewhere between 500,000 and 750,000 emerging adults with special health care needs actually transition into adulthood. Those are enormous numbers. And in fact, for a couple of groups, adults with cerebral palsy and those with congenital heart defects (actually the adult numbers are greater than those for children and adolescents). So that is a very significant shift in the way that health services have been conceptualized.

So we wanted to know more about how this phenomenon is affecting adolescents directly. That was one of our questions that we had as we looked at the literature. What we did (and the details of the process of our systematic review are identified in our article), however, we ended up ultimately with 35 articles that were appropriate for our review. There were a couple of things that we found that were unexpected and that was in terms of the research designs and methodologies.

First of all, we found that it was hard to really locate or identify just what were the age groups that were studied. There seemed to be very diverse sampling techniques used. So we have some studies (approximately 9 of them) that looked at those adolescents between the ages (early adolescence and emerging adulthood) 9 to 21 who were sampled who were actually going through the process. Then there were about six studies where there were combinations of adolescents and emerging adults who were currently undergoing transition or in the process itself, and those who had been through the process. And then lastly there was a group sampled who provided retrospective impressions and perceptions of their experience. What was particularly interesting to us was that of the studies, (there were 35), 10 of those were conducted in the United States. The majority – about 60% of the studies – were conducted internationally, and their system of care is very different than the U.S. system of care. So that was an underlying factor to consider as we were analyzing these responses of adolescents. And interestingly too, when we looked at what did we learn from the adolescents in the U.S., which would be most pertinent to nurses in the states, they sampled actually rare populations for the most part: adolescents and emerging adults with solid transplants, those with sickle cell disease, those with JRA, and not some of the other populations of adolescents and emerging adults with special health care needs that you would typically think would be part of this systematic review – that you would find in these studies. And interestingly, several groups of teams that were part of our analysis from those recruited in the states were those enrolled in the mental health system, some recruited from school settings, and foster care. So actually it was just half of the studies of those that were reviewed that originated in the United States were conducted in clinical settings. So in a sense we know very little.

Question 2. Were there unexpected findings generated from your systematic review?

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There were several of them:

1. First of all, we found that the findings of this systematic review were very similar to those reviews conducted earlier, approximately 10 years ago. It reflects, still, an area of practice and an area of research that are in the seminal stages of development.

2. The majority of studies that we reviewed, approximately 60% were conducted internationally. And of those studies conducted in the United States which were 10 (about a third), half of those studies were conducted in clinical settings. So in essence we really don’t have much data to inform us as to what really the needs, the experiences of adolescents and emerging adults are as it pertains to this very important process of transfer to adult health care and transition to adulthood.

Other things we found too that are important to consider when we are talking about our findings was the fact that with the exception of one study, which was a program evaluation, they were all descriptive designs. There were problems with psychometrics. For example, if an interview schedule was used, the process for developing that interview was not really described. Tools with weak psychometrics were used. But all of this reflects the emerging science and practice of healthcare transition.

As we looked at this, there were several areas that emerged, themes that were evident. And those were the recommendations for healthcare transition planning (what was important to them):

1.  They needed more information and more information not only about their condition but also in terms of clinical management; self-management was considered to be very important; more information about the adult system of care. And importantly too, when you’re thinking about working with adolescents in terms of clinical implications, we sometimes make assumptions that are not necessarily warranted developmentally when we’re talking about adolescents and emerging adults because it’s more difficult for them developmentally to conceptualize.

2. Other areas that we found were the adolescents own reflections of their transition experience in terms of: Was it a positive experience? Was it an experience that was fraught with challenges? And we sort of found across the spectrum perceptions that for some, it was a very positive experience, and some would describe it as transformative. Others found it more difficult. They felt unprepared. And I think you can go back and look at how those experiences might inform us as service providers how to better prepare adolescents and emerging adults for their transfer of care to adult care and also their transition to adulthood.

3. Another theme that we extrapolated from these studies was the obstacles and problems. Some of these really related to the changes in the adult system of care in contrast to what they were obviously exposed to and experienced in the pediatric healthcare system. For example, many of the services that they had as pediatric patients – OT, PT, nutrition services – were no longer available in the adult system. The adult system was organized differently, it looked different, it wasn’t as inviting or warm. Those  were issues that had they been better prepared it may not have been so difficult for them to navigate. Again this goes back to this theme of improved and better preparation for what are going to be very significant changes.

4. Another theme was the expectations related to the eventual transfer to adult care. For some it was so ambiguous they were fearful about: What is this going to do to my own health status? Will I anticipate some serious health changes with my condition? Is my condition going to deteriorate and how will that affect then my lifestyle? Some were very worried and insecure. If we look at this, we can see that having very directed, thorough and consistent preparation to support adolescents and young people as to what to expect, and to talk to them very candidly about what the future holds for them, would be helpful to them.

5. The final theme was becoming self-reliant with their special health care need. It was issues related to their concerns, or perhaps their confidence as it pertained to how they would manage their health needs and frankly their lifestyles. However, evident throughout, and this was actually why we chose the title “voices not heard,” was that adolescents and emerging adults throughout all of these studies that we reviewed, it was really evident that they weren’t being heard. That they weren’t the full partners!

Question 3. What are the research implications of this work?

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There are some implications based on what are findings were. Some of this is predicated on the fact that this is an emerging area of practice and research. There aren’t at this point in time and evidence based guidelines to assist providers in terms of development of services and perhaps the discipline that has advanced more thinking and recommendations in this area has been pediatrics.

There really hasn’t been much in terms of recommendations or practice guidelines from the other disciplines, nursing being prominent in that regard. And until we have the evidence needed to help direct us in terms of what is helpful, what will support adolescents and emerging adults, we’re going to continue to rely on expert opinion in terms of the evidence that exists. And this certainly too goes back to the need for more systematic and rigorous research designs; that we have designs that are quasi- experimental, randomized controlled trials, that really test the effectiveness of various intervention models.

This is an ideal role for nursing not only in terms of development of practice models but certainly in terms of conducting research studies that contribute to the body of literature and contribute to the science that is developing in this very early stage of practice. This is an ideal area of practice for research endeavors for nurses to undertake. There have been few studies conducted by nurses in this area and nurses can serve in very important practice roles and also in program development affecting models of care that will assist adolescents and emerging adults to transfer and transition to adulthood.

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Leadership Interviews – “3 Questions” – Gun Violence and Health Policy

Welcome to the Nursing Outlook Blog – “3 Questions” – Timely Interviews with Thought Leaders in Nursing and Health Care Policy

The newspaper headlines daily bombard us with tragedies of unspeakable scope. Firearms and guns are most often at the center of the incidents. The ongoing debate in Congress about gun ownership as a right and gun control policy as a public health intervention seems to ebb and flow with the latest random acts of violence. Whether or not gun violence is a public health matter, it is most certainly of concern to Nursing.

The American Academy of Nursing has recently applauded the legislation introduced by Senator Feinstein (see link to AAN statement) that has made an attempt to curb the epidemic of gun related tragedies. With the guidance of the Expert Panels on Violence and Psychiatric/Mental Health/Substance Abuse, the American Academy of Nursing sent a letter to Senator Dianne Feinstein endorsing her legislation to re-establish an assault weapons ban. In the May-June 2013 issue of Nursing Outlook, members of the Academy (Amar, Beeber, Laughon, & Rice, p. 184) ask policymakers to act on behalf of us all. These thought leaders provide us with recommendations and commentary about how we can make substantive policy changes that prevent the estimated 30,000 firearm-related deaths each year. The following are current bills introduced in Congress that address gun violence:

Assault Weapons Ban of 2013 Senate – http://www.govtrack.us/congress/bills/113/s150/text

Assault Weapons Ban of 2013 House – http://www.govtrack.us/congress/bills/113/hr437

Safe Communities Safe Schools Act Senate -http://www.govtrack.us/congress/bills/113/s649/text

In this interview, one author, Dr. Michael Rice adds commentary to the discussion about the escalating violence today. Dr. Rice describes the failure of our current policies and the ridiculous arguments that assault weapons are in the purview of responsible gun ownership. Read more about the legislation that has stalled in the House and Senate that we should all strive to move forward.

Michael J. Rice, PhD, APRN-NP, FAAN is a Professor at the University and Associate Director of the Behavioral Health Education College, College of Nursing, University of Nebraska Medical Center, Omaha, NE.

We invite commentary that is thoughtful and provocative! Join the online dialogue!

Veronica D. Feeg, PhD, RN, FAAN
Editor/Moderator

 

PhotoMichaelRiceMichael J. Rice, PhD, APRN-NP, FAAN

Associate Director, Behavioral Health Education College

College of Nursing, University of Nebraska Medical Center

 

 

 

Question 1. What are the forces that promote or hamper changes in Federal Gun Legislation and how is healthcare affected by those forces?  Are the issues restricted to legally owned weapons? 

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The forces that are affecting the current federal gun legislation really have more to do with a frame of reference. Responsible legal gun ownership is different than the right to buy high capacity weapons that really amount to weapons of mass destruction. Self defense does not involve weapons of mass destruction, and military weapons with high-capacity magazines are just that. They are weapons of mass destruction or guns of mass destruction, particularly when owned in civilian populations and environments. We are no more okay carrying pressure cooker bombs because they’re high-capacity, but ironically we seem to allow high capacity magazines.

The second part of the issue is: Really, where do legal and illegal guns come in? One of the statistics that gun control advocates often throw out is that 30,000 people a year are killed by guns. That is true. However, if we break that down we find out that less than 6,000 people a year are killed by legally owned weapons. But 30,000 people a year – the remaining group, are killed by illegally owned guns – in drive by shootings, in urban areas of our cities etc. These are illegal activities that we cannot stop through gun legislation of legal owners. However, at the same time, legal and responsible ownership would naturally dictate that we not have high capacity kind of instruments that would allow people to harm large numbers of people at a time. What we need to realize is that we will not stop the activity, but we can minimize the consequences by eliminating the potential for stolen guns of mass destruction.

This recently raises the question about what is being defined here. With 4 million members of the NRA and 300 million citizens of the country, then we really need to reexamine how we look at weapons and what they’re for, and what’s an appropriate venue for those weapons. The real issue is people want a simple solution to assure themselves of safety that they don’t have to invest in or think about. The reality is there are complex solutions for complex problems, and they involve effort.

Now one of the things that always comes up in this is about mental health. If we look at the statistics, less than 3% of those people that are in prisons for murders are seriously mentally ill – less than 13% have a diagnosable mental illness of any kind. And yet, here we are looking at the 12 deadliest shootings in U.S. history, 6 of which have taken place since 2007, and/or at least 62 mass shootings in the past three decades (according to recent Mother Jones survey). Of the 62 that occurred within the last three decades, 24 have been within the last 7 years alone. If we look at the issues that this really presents to us, there is some association in the last 7 or 8 deadly shootings of people having a serious mental illness. But it’s not the presence or absence of a mental illness that’s the problem; it’s the presence or absence of them being in treatment. One would really have to logically argue that if we hadn’t cut 1.4 billion dollars out of the mental health budget since 2008 in all 50 states, that these things could have been prevented and that we certainly could have gotten services to people and saved innumerable number of services in the future.

Question 2. There are some who wish to distance healthcare from gun legislation.   Could you speak to why healthcare should or should not be involved?  

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Generally I agree that they are two separate distinct issues. First as I noted earlier, responsible gun ownership is different from a responsible health policy. Eight of the last nine public tragedies involving shootings have been associated with people with mental illnesses who have not been followed up, not seen, not have access, not received services. So, from a public health issue, we are paying really for the reduction in services across really all 50 states. Not even since the downturn, but really for decades – decades that have eroded the services, eroded the number of providers. We’re probably at the highest time period of need yet the lowest supply of trained psychiatric mental health providers ever in the history of this country.

The promise in those cases when we focus on health is always to close the institutions – which is a good idea – and to turn the money over and use it for community-based services. What we’ve done however is that we’ve consistently slashed the budgets and found those dollars spent someplace else. Since 2008, the National Alliance for the Mentally Ill reports that the budgets have been slashed $1.8 billion out of the total state mental health budgets. But the real issue is that it was never replaced after the institutional closings in the 1960s. So, when we have a group of people who are increasingly vulnerable, with mental health needs and services, we see that the health issues begin to escalate. Are gun shootings much more lethal in forms of suicide and suicide attempts? Absolutely. There is no question about it. Are domestic partner assaults more lethal if there’s a gun involved? Absolutely. There is no question about it. Are hate crimes more lethal when guns are involved? Absolutely.

It is not really a public debate as so simply become tools – and so the argument really is do we separate the tools and somehow then continue to allow ourselves to avoid dealing with the base issue which is our national attitude in health policy. I find it amazing when we look at the backlash of people – Senators who talked about voting “no” for gun legislation – that they immediately throw up mental health care. To be honest it is somewhat disingenuous – to throw up healthcare having never done anything about it and not intending to do anything about it.

While we have the national health care policy, we certainly don’t have the infrastructure in place anymore particularly in terms of personnel or staff to deal with the existing health care needs let alone the additional mental health needs of the additional 30 million people who will be put on the Affordable Care Act rolls. So the bottom line is, there’s a price, and what that price is. That’s something we’re going to pay for, for a very very very long time. Why? Because people wanted to save a few dollars.

Question 3. How would you characterize the beliefs about how this legislation affects mental healthcare\substance abuse,  veterans healthcare, intimate partner violence and the societal impact on gun violence?

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It really becomes disingenuous to argue about supporting gun ownership while at the same time saying that you’re going to support mental health care and then quite literally doing nothing about either one. As I said when we started, these [issues] are about weapons and guns of mass destruction – magazines that have the capacity to eliminate 1- 200 people to create tragedies such as we saw in Connecticut.

The legislation really has very little to do with controlling that, although at best for those individuals who have histories of violence or histories of intimate partner violence, histories of assaulting people with weapons, it might help to do the screenings and it would be at the very least a minimum kind of first step. But the belief system to categorize them and everyone with mental illness as having a problem is preposterous. One of the statistics we need to be very clear about, and I get very strong on, is that if we look at the number of veterans from Iraq and Afghanistan because of the improved body armor, 53% have PTSD. That’s a mental illness. That means with the implication of passing [proposed legislation] that we restrict guns from all who have mental illnesses that we restrict 53% of the veterans who have fought for that very right. That could be problematic.

It would seem that much more common sense approach would really be to deal with the support and infrastructure of the health care system that deals with mental health care substance use, veterans mental health, intimate partner violence, and the societal impact on – for lack of better term – civility. We’re an incredibly fractured country in our tolerance for variations – it’s almost beyond my comprehension anymore. And that’s where we get back to the Justice Department’s 30,000 individuals killed with guns each year. Again, about 6,000 of those are with legally owned guns and we don’t know what percent of the background checks, if they had histories of violence or checks, would have stopped that.

What we do know is the remaining 24,000 to 30,000 people who are killed with illegal guns in this country is not something that we can do something about and it is not a mental health care issue. It is something outside of either one that quite honestly spending time and effort enforcing our existing laws would probably be far better. The bottom line of all of this is that we can fix the gun legislation all we want and continue to do silly things like support guns of mass destruction. But until we deal with some of the basic thread issues in our society such as mental health care substance abuse, veterans mental health care, intimate partner violence, and the use of guns being okay, we’re not going to find a resolution.

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Leadership Interviews – “3 Questions” – Dialogue on Race and Racism

Welcome to the Nursing Outlook Blog – “3 Questions” – Timely Interviews with Thought Leaders in Nursing and Health Care Policy Issues of the Day

The conversation on racism in health care is largely quiet – and rarely reaches an opennes of other important issues of the day. Are nurses and health professionals engaged in the dialogue about the unspoken questions of racism while talking aloud and frequently about health care disparities? Does our research focus on questions of concerned for all races and do we educate our future nurses to understand the sources of race-based inequities?

A new article in Nursing Outlook (May/June 2013) by Joanne Hall and Becky Fields takes a close look at how structural and interpersonal racism, in general, and in nursing encounters, specifically, may marginalize patients of color. And well-intentioned White nurses may not even realize it!

These are among the hot topics of the day. All the critical issues that are important to nursing warrant rapid dialogue among informed readers and traditional modes of publishing cannot keep up with the pace of information available. “Agility” is needed to deliver contemporary arguments electronically for persuasive commentary for building consensus that is timely, substantive and prepared for discourse. Blogging and blogs are increasingly providing a paperless platform for professionals to present and debate ideas in the socially connected evolving web. Nursing Outlook is now hosting an online environment – “3 Questions” – to engage nurses with nursing leaders in discussions around focused topics that are important for the profession. Interviews will be routinely edited and posted for readers to learn from thought leaders of the American Academy of Nursing and a variety of other nursing and health care megastars.

The authors’ intent is to show the need for White-to-White conversation. We invite commentary that is thoughtful and provocative! Join the online dialogue!

Veronica D. Feeg, PhD, RN, FAAN
Editor/Moderator

Joanne Hall PhotoINTERVIEWS WITH AUTHORS:

Joanne M. Hall, PhD, RN, FAAN

Professor

University of Tennessee College of Nursing

Knoxville, Tennessee

 

and

Becky Fields PhotoBecky Fields, PhD, RN

Associate Dean

South College, Knoxville, Tennessee

 

 

Question 1. Dr. Fields: Looking at the recent history of the U.S., do you really think the problem of racism is still that serious? What precipitated the writing of this article at this time?

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That’s a very interesting question. I do believe that as we look at the history of this country, it is far time for us to really think about the conversations that we have in general and for me in particular as a nurse, for our discipline. As I think about that question – “do you really think the problem of racism is still that serious?” – I have to say it is probably more serious. For far too long, there have been many conversations, but they have not been mainstream conversations surrounding race, in general in this country, and in particular in our discipline in nursing. As I am a nurse, I’m certainly concerned about that. In order for us to be real self-actualized as a nation, as a group of people, we really have to think about the health of everyone. As nurses, being apolitical surrounding the idea of universal health care, without talking about the issue of race and racism, then we devalue or we treat as unimportant the whole issue of health in this country. For persons of color, racism is still very serious, and perhaps even more so. Because the fact that we have a person of color as our President, really highlights the fact that – yes – socially, we have really made some strides, perhaps politically we have, but we continue to have health disparities in this country. Primarily African Americans – even in the midst of the increase in the Hispanic population – African Americans still maintain worst health in this country. And that’s of concern to me and to many nurses. Part of it, we think, has to be surrounding racism in this country and the ill health effects of racism. We have spent thousands, millions of dollars, both in advertising and creating interventions – things we have tried to address disparities in this country. Even around something as simple as infant mortality – we still are far below other countries in the world in terms of infant mortality for persons of color in this country. That’s concerning – that shouldn’t be! So, do I think the problem is serious? Absolutely, I do.

Now in terms of what precipitated this particular article, Dr. Hall and I have been colleagues for several years. I was educated at the university where Dr. Hall is a professor. Later on, I came to teach there, so we have had a very interesting relationship both as colleagues, mentors and now as friends and collaborators in terms of our research. She has been a leader in the field in terms of talking about marginalization of people. My research has stemmed around vulnerability in individuals, particularly looking at older adults and minorities and women. So race and gender have been very important to me. We had a natural collaboration in terms of talking about the issues that affect people who are marginalized, people who are on the edge – trying to figure out what we can do as nurses in terms of creating knowledge and generating knowledge that would help and be instrumental in providing better care, and decreasing the gaps that we have surrounding health disparities. And so, it was a natural next step in terms of the discussions, the conversations that Dr. Hall and I have had to look at who else needs to be in this conversation? Who else needs to be talking? So we talked about how the burden of looking at health disparities really has been carried quite a bit on nurses of color – we’ve talked about it – both professionally, in the classroom, in the clinical area, in our homes, in our churches, in our neighborhoods. But we don’t see, at least, where the conversation has happened between White nurses, in particular around how does White privilege – how does the dominant culture in terms of White privilege – how does it impact individuals of color and then how does that affect health?

 

Question 2. Dr. Hall: What is it that White nurses need to talk about with each other? Aren’t nurses doing more than many others about unfairness and health disparities? Nurses have a history of including culture in our scholarship, and a commitment to vulnerable populations. What would this conversation accomplish?

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Well first of all, I think if nursing kind of looks in the mirror and we can see the level of our diversity has just not changed in step with the history of other health professions or just professions in general. So I think it’s cause for concern that if it continues to be the same and I’m not sure we’re investigating heavily enough scholarship wise, and finding out first of all, why that’s the case and then to really understand the implications of that lack of diversity. We may have some illusions about just how culturally open we are as a collective. And when I say “we,” I am talking to White nurses myself right now as a White nurse, that we present, I think, sometimes to ourselves and to each other and to the public a kind of essentialist view of the nurse. We hear educators talking together about the qualities of a “good nurse” as though that’s kind of monolithic. I think some of those frozen ideas that we have about who’s a good nurse, perhaps we are working in unconscious ways to exclude people who don’t fit that mold for cultural reasons. And then, I think also, we’ve perhaps looked at culture, and not really race, very seriously, because we’re maybe content to acknowledge that there is a lot of diversity – that many cultures have different beliefs, values, etc.  – and we can appreciate that. But we don’t go that other step to say that the differences between the groups that we are pointing out don’t take into account often the power dynamics, and the fact that these groups are marginalized. If the cross cultural, or trans-cultural, or culturally competent – we’ve used so many phrases for this – but I don’t know if we’ve made appreciable dents in the perceptions that our patients of color might have about nurses. Have we looked at it? So, I guess I would just raise that question. If not, why not?

Nurses maybe console ourselves with that we repeatedly are considered the most trusted profession, and, I’m not exactly sure what that means. What do people trust us with? Are we content with that just as a comparison to what is the standard that the public is expecting? Maybe we’re the most trustworthy, but that doesn’t really include all the things that we sort of have a social contract with the public about. Certainly to make services accessible, to decrease health disparities, I think there are a lot of unturned stones that we could look to. We could do research in the area, for example, taught in our school of nursing what’s the curriculum around race, racism, race relationships, and the real harm I think that is caused in these daily micro-traumatic interactions that people of color are telling us happen with White people. I think that White people need to talk with each other because people of color have been giving us this message all along. And, I’m not excluding people from that conversation, but sometimes I think that similar groups need to kind of withdraw, look at themselves, and hold each other accountable. In the narrative interviews that Dr. Fields and myself are doing currently about these daily, we call them racial micro-aggressions: First of all that they will laugh in the interview because these are so commonplace to them and indeed do happen on a daily basis. I think White people in general are not mainly conscious about the ways we behave towards African Americans. For example, that they’re perceiving as derogatory, little insults, slights, being ignored, being followed in a store. What’s the accumulated stress? Can nursing be the profession that becomes, not only good at taking care of patients of color, but we should be an expert on these possible connections with daily micro-stress, if you will, possibly these huge health disparities that we make goals about every season, and they’re still there. We have not resolved all the aspects that we could be investigating about health disparities.

I think the key concern of nurses is the health care encounter itself. How much damage there would be if these small aggressions are inadvertently transmitted in the health care encounter? We’d have even more distrust by minorities of the health care system. We would be just throwing everything a step backwards, and I think, contributing to health disparities. This looks to me like a fertile area for nursing scholarship.

Question 3. Dr. Fields: Nurses consistently are considered the most trusted profession. We care for everyone, and value cultural competency and advocacy. Aren’t you talking to the wrong people?

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No, I’m talking to the right people – the people who can hear it. Because nurses are in the front line of talking to people, people listen to them. Nurses do care about people. And, really when you think about it, [we should be] having conversations between White nurses. As a Black nurse myself – my mother is a retired diploma nurse – so nursing is rich in my family. I’ve listened to nurses talk, growing up. I’ve listened to wide varieties of nurses growing up. Being a nurse myself for over 20 something years, I know nurses. What I do know about nurses is that nurses do not intentionally do things that bring harm to other people. It is not their intent. People are drawn to nursing because they care about people. As a nursing professor, as I’m reading letters or things that our students write about why they want to be a nurse, caring always comes up. And, if you think about nursing, nursing is equated with care. And if you ask people what do nurses do? – Nurses care.

So, nurses are the ones who really need to have serious conversations, to really take the shades off – take the blinders off – to have true conversations about the things that nurses can do. In particular, [what] White nurses do unintentionally that really add to the aggressions and micro-aggressions, the perceived discriminatory treatment that persons of colors have. Nurses are not doing these things intentionally. But the fact that they are not talking about them from the perspective of persons of color is detrimental to all of us in nursing – not just White nurses – to all of us who call ourselves or wear the hat of nursing. If we don’t talk about the issues, having true conversations about race, racism, racialization, aggression, discrimination – if we don’t talk about those things, then we truly, truly, truly aren’t taking care of all of the patients or all of the people that nurses touch every day. We absolutely have to have this conversation – because we haven’t had it – in the way in which we need to have it.

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Leadership Interviews – “3 Questions” – Marian Grant

Welcome to the Nursing Outlook Blog – “3 Questions” – Timely Interviews with Thought Leaders in Nursing and Health Care Policy

Although our health system has made great strides in the field of palliative care, research is still lacking to guide health providers and policy leaders toward improving patients’ experiences at end-of-life. In 2012, the National Institute of Nursing Research (NINR) hosted a summit on the state of the science of palliative and end-of-life research. A collection of 8 papers were published in the November 2012 issue ofNursing Outlook that resulted from the summit and offer a variety of perspectives from contributers and their colleagues for “next steps” in the research development of palliative and end-of-life care. These thought leaders provide us with recommendations and commentary about how we care for patients whose symptom management warrants coordination and evidence based practice. Equally important is the role of the caregivers in supporting their loved ones at end-of-life. In a review of literature by McGuire, Grant and Jumin focusing on the caregiver, it is made clear that informal caregivers are a key component of end-of-life/palliative care and are increasingly recognized as recipients of care.

In this interview, one author, Dr. Marian Grant adds commentary to the review of literature and makes clear that caregiver support is essential in caring for the patient. Dr. Grant is an active “blogger” on the Journal of Palliative Medicine social media portal and has studied the impact of online support for patients with cancer and their families.

Marian Grant RN, CRNP, DNP, University of Maryland School of Nursing in Baltimore is an Assistant Professor at the University of Maryland’s School of Nursing and works as an NP on the University of Maryland Medical Center’s Palliative Care Consult Service. She does research on nursing communication. Prior to nursing, Dr. Grant was a marketing executive with the Procter & Gamble Company. She is a member of the Journal of Palliative Medicine Social Media Portal (“Blog”) – a Journal of Palliative Medicine SoMe Initiative, founded and directed by VJ Periyakoil, MD, Director, Stanford Palliative Care Education and Training, and Senior Editor, Journal of Palliative Medicine.

Click here for the Journal of Palliative Medicine “blog”:

We invite commentary that is thoughtful and provocative! Join the online dialogue!

Veronica D. Feeg, PhD, RN, FAAN
Editor/Moderator

 

Marion Grant, RN, CRNP, DNP

University of Maryland School of Nursing in Baltimore

Question 1. Why is evidence about caregiving and caregivers so important for palliative care?

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It’s very important for a number of reasons. The first one that comes to mind is that when we think of about the unit of care for palliative care it’s always more than just the patient. It always includes what we say are either family or caregivers. And we know that for serious illness, family and caregivers, are very involved in the whole aspect of serious illness. They are there before the illness occurs, they are there as the illness progresses, often they are part of the process of working with the medical system. And so, they have needs and they have issues above and beyond those of the patient.

We also know that patient outcomes, if you’re measuring things like quality of life or symptom management, are better when those loved ones who are providing care to them are able to do a better job of it are more comfortable, more knowledgeable, more confident in their skills. So we know the patient outcomes are better. But there’s also an evolving literature that is really kind of scary that tells us what happens to family caregivers who don’t get help through the process. We know for instance that in the intensive care area after a protracted critical illness, even if the patient survives, the family often has psychological, emotional issues, signs of PTSD, dysfunctional bereavement, and that those things can last for months beyond the hospitalizations.

As we’re thinking about trying to improve the care for those with serious illness, it wouldn’t make sense to just focus on the patient. Families are an integral part of that and for this article we defined caregivers as being those informal nonprofessional caregivers in the patient’s life. We know that that’s a term sometimes used for clinicians as well, but we really were looking at the loved ones, the family members who are providing caregiving. So that was the definition we used for this literature search.

Question 2. Can you give some more perspective on the quality of evidence to date on this topic (palliative care and caregivers)?

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So when we did this literature review, it was a little bit overwhelming, because there is a huge body of evidence about the effect of health and illness on family members or family caregivers. However for our purposes and for the NINR conference, we were really focusing in on that part of the evidence that focused on palliative care, hospice care, end of life and those aspects of it. You could say that we probably missed things that are in other aspects of the literature because the keywords wouldn’t have been categorized in the way we were searching for the evidence.

We took at look at a lot of things and we ended up with 141 articles – 109 were studies. The state of the science is very early on. It’s mostly things that we already kind of suspected for those of us who work as clinicians in this area, but there were lots of small samples, a lot of descriptive studies, a lot of [studies that] were qualitative. They did confirm what we had already observed as clinicians, which is helpful, because at least we can say that at least this phenomenon that I have witnessed is indeed a phenomenon and affects family caregivers with other illnesses or in other parts of the world. But we obviously don’t have a lot of information about: “…and then what?” What should we do next with this information? Because what we have is kind a better sense of what is going on out there, but it doesn’t really help us to know: “…so what are the kinds of interventions we should be providing to these caregivers?” It confirms our concern that yes, serious illness and end-of-life and things related to palliative care are very important and affect a lot of aspects of these caregivers’ lives and therefore affect the patient’s lives, but it doesn’t tell us exactly what we should do about that. So our sense was that this literature is in the early stages and that’s wonderful that people are kind of doing the basic building blocks but now obviously there’s the opportunity to build on that.

Question 3. What are the key next steps for future research in this area?

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So building on the fact that we’re looking at the early stages of this body of evidence, it would be wonderful to have more prospective, more longitudinal studies. A lot of the things we looked at were retrospective. They often lacked conceptual or methodological rigor. You know, I read one article that was about how in an inpatient hospice setting, they had instituted afternoon tea for families. They actually had done a little bit of study on that. And it was kind of lovely, but it leaves you with the feeling that there are a lot of little efforts going on out there – like “Hey! Let’s put on a research study!” And not necessarily being rigorous about: Do we have a conceptual framework? What is the theoretical framework?

There is not a lot of agreement yet on what the measurement aspects of these studies should be. Are we using common measures? Are we using validated tools? Are the tools measuring the right things? There certainly are validated instruments out there but we didn’t find that they were consistently used. And are we measuring the same outcomes? There’s been a lot of focus in the literature so far on the outcomes to the family caregiver but not so much necessarily on how that might affect patient outcomes, which obviously when you start thinking about funding some of these efforts is important – because the healthcare payers are not paying us to make the family caregiver’s lives better, they are hopefully paying us to make the health and the lives of the patient better.

We need more sophisticated statistical methods and I think that goes along with having better measurement tools and better measurement information. And, I would say, it would be helpful to understand more about the roles of caregivers. You know people kind of fall into this. They are part of a family unit where somebody develops a serious illness, and then it kind of is like: …Well I guess it’s you mom, who’s going to be the family caregiver here.” So what is that process? We know that in serious illness there are trajectories. Some illnesses are rather quick and the decline is pretty steady and takes place over a few months; whereas others might go on for years. If you care for a loved one who has Alzheimer’s, your role initially in that illness might be very different from how it might be in the last stages.

There’s been wonderful evidence done about bereavement affecting obviously family caregivers but going beyond that, what happens to people a year later or two years later, or five years later?

What happens to the family dynamics down the road? Are people able to overcome some of the more difficult aspects of a serious illness? I think that there are certainly many permutations of caregiving. There are disease specific aspects. So how is somebody who cares for a loved one with Alzheimer’s disease having a different caregiving experience from somebody who is caring for a loved one with cancer? What about things like long distance caregiving? Now with the Internet and with technology you have loved ones who are not physically present but who might be very much a part of the support system for a patient.

So, there is just a lot more to learn in this area and I would strongly urge anyone who has an interest in this to certainly give this consideration – because I think this would be so helpful, not just for the family members but I think it would be helpful for patients. And I think it would be helpful for people providing care for people with serious illness and their loved ones to know with more confidence that “….you know, this thing that we’re doing is really the best thing we could do for people in this situation.”

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Leadership Interviews – “3 Questions” – Afaf Meleis on Gender Inequity and Nursing

Welcome to the Nursing Outlook Blog – “3 Questions” – Timely Interviews with Thought Leaders in Nursing and Health Care Policy

After a near century following the classic reports of Flexner (1910), Rose-Welch (1915) and Goldmark (1923) that laid the foundations for higher education in health, we find ourselves today challenged to keep pace with the revolution in health professional education and desperately seeking reform to meet the demands of educating future physicians, nurses and public health professionals in a global world. In 2010, the independent Commission on Education of Health Professionals for the 21st Century was launched with the aim of focusing globally on the field, identifying gaps and opportunities, and offering recommendations for reform published in Lancet. The Institute of Medicine (IOM) Global Forum on Innovation in Health Professional Education has launched activities that are inspired by the Lancet report and the Future of Nursing report to explore promising, scientifically based innovation in health professional education and to cultivate new ideas through multi-disciplinary collaboratives that are undertaking the recommendations.

Does gender matter in these issues? Dr. Afaf I. Meleis takes a hard look at gender inequity as a global phenomenon that manifests itself in different forms (see Meleis & Glickman, Nursing Outlook, 2012, v. 60, issue 5 supplement: “Empowering expatriate nurses: Challenges and opportunities – A commentary”, p. S24 – S26). She speaks passionately about linking some of the issues in nursing with global issues that affect women in general, including health professional inequalities in the workplace and educational change needed.

Afaf I. Meleis, Dean and Professor at the University of Pennsylvania School of Nursing, speaks to the issues of gender inequity and nursing.

Click here for the Lancet report.

“Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World.”

We invite commentary that is thoughtful and provocative! Join the online dialogue!

Veronica D. Feeg, PhD, RN, FAAN
Editor/Moderator

Afaf I. MeleisAfaf I. Meleis, PhD, DrPS (hon), FAAN

Margaret Bond Simon Dean of Nursing

Professor of Nursing and Sociology

University of Pennsylvania School of Nursing

 

 

Question 1. Are there opportunities and forces that promote or hinder the changes in the occupational structure that dominate healthcare systems?

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There are. The pyramid view of the health care system reclines at the base and physicians at the apex. It’s being challenged, but it still continues to be the norm in our country and actually globally, and that’s definitely a hindrance. There are lots of indicators though that this is being challenged and challenged well. One is the Lancet report – the title is “Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World.” It’s a global report challenging the current way by which we are educating nurses, physicians and public health folks. The recommendations of that report speak to the urgent need for a new era in education which transcends the silos. It breaks barriers between the professions – those three important professions – and calls for creating curricula that are more integrated, that could lead to more teams functioning after they graduate. Instead of waiting for them to form teams after they graduate, they teach them ahead of time in teams so that they can graduate and continue to do what they learned in school.

And so, as a follow-up to this Lancet report, IOM (Institute of Medicine) took that really seriously and developed a three year commitment to a global forum for innovative education programs lead by inter-professional principles. Some of these things are going to break not only the silos, but that pyramid view. So that is the first challenge.

The second challenge is to this hierarchical approach – created by the advanced preparation of nurses, allowing them to take on more responsibilities. So that pyramid is being challenged by the Lancet report, but it is also challenged by preparing nurses – graduating nurses – who are well prepared with knowledge, evidence and research, that allows them to have a wider scope of practice and to have the evidence behind it. I believe that nurses are better educated in science and systems. And it gives them the tools and the power to become partners and challenge that pyramid approach.

The third challenge to the status quo is the more informed consumer. Consumers are far more informed now. They expect to be part of the decision-making and they will not want that somebody makes the decision for them nor will they accept that pyramid approach.

So, I think these things provide the framework that promotes a more egalitarian relationship and as such, we know that the egalitarian relationship actually affects the kind of care that’s provided and the outcomes for patients.

 

Question 2. In the past, nurses distanced themselves from gender inequity and feminism.  Could you speak to why you connect gender inequity with inequities that nurses face?

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Excellent question! I think it has been disconnected in the past and I think we really are not going to make a difference and move forward unless we connect some of the issues. Since the nursing workforce is still made up of 90 percent women (and we are trying to change that situation, definitely, by recruiting more men in nursing), but since it is 90 percent women, has been in the past, we should not and cannot separate the situation of women in the world from that of nurses. Putting nurses’ issues within the context of inequalities due to gender provides us with a platform to understand, to explain, to interpret how nurses’ options and how the opportunities manifest themselves – and how the obstacles, why they have obstacles in front of them.

Women, I think we know, have been treated as objects, as helpers, as caregivers, and as such they are expected to be altruistic, they are expected to be giving, they are expected to be sacrificing without expecting compensation. That’s really our history. Many women are sacrificing wives, sacrificing mothers in the world, and what they do – my research when I studied women in different parts of the world – they expect to be rewarded in their old age by their children. That is their reward. So they sacrifice all their lives but they know it’s going to happen later on – that they are going to be rewarded. They expect this delayed reward by family when they become the respected matriarch, whom others then sacrifice for.

The analogy between women and nurses’ situation is partially similar. Nursing grew from a sacrificing war model as well as a church model: nurses as caregivers in wars and as nuns were expected to be compassionate caregivers. They are altruistic and they expect no immediate reward other than the reward of just really caring for others, and that should bring that intrinsic wonderful feeling. Compensation in monetary terms was not the main consideration – they were taught not to really expect immediate rewards and compensation, financially, as an immediate reward. So nursing and mothering as a calling, not as careers really required little compensation other than the intrinsic reward from the act of giving to others. So here are some of the similarities that prevented nurses from being compensated appropriately.

Now, while women as mothers may get their rewards later on in life and nuns after they go to heaven, they expect to get those rewards, nurses may end their lives with little reserved savings to support them – and with actually the lack of valuation because of the little compensation they are given, because, I think societies tend to value people who are well compensated. As we carry the analogy further, we can understand why nurses’ work is valued – just as mothers’ work is very much valued. I think caring all over the world is very valued – there is intrinsic value in it – but the value does not translate into more regulated hours, to more respect, to better compensation equal to the effort – and to more power and to more autonomy. So it doesn’t translate to these things – it just translates to “yes, we love caring people and we value caring.”

Now, give nurses, as we give women more power, give them better compensation, give them more autonomy, and some of that translates to their ability to do even better work in supporting the patients and in making a difference in society, making a difference in the health care system. It gives them the potential of having a voice, and it gives them the potential with that power to be able to effect the changes that they believe should happen in the health care system and society.

I really think very strongly that gender inequity in work or life has the same properties and the same consequences, whether it is for women or for nurses. So why not use the example of nursing to change gender inequity? And why not use gender inequity in general as a platform for inequities that nurses experience? I think by linking them we have more voice and we are empowering a larger group of people. And we’re going to make a difference in policies and make a difference in patient care.

Question 3. How would you characterize the current situation in nursing?

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We need to change the metaphors that describe nursing and differentiate nursing from medicine. The metaphor is that nursing is soft, compassionate, caring, historical, and “touchy”; and the metaphor for medicine is hard evidence of science. I do like the nursing metaphor. It should continue to be compassionate caring and giving, but it should also be attached to the metaphor that it is hard evidence, scientific, and it is a career. And I think that sums up where nursing is now. There is such an amazing momentum now that nurses must take advantage of with health care reform and with all the reports that are coming out. It’s the best time for nursing and we have to take advantage of that time to move forward.

By empowering nurses and by allowing their voices to come forth on the policy table – we  are a very large body of people and we are very large in the world – we really could become such an amazing force in improving the quality of care in the world and increasing access to health care. At the same time we use that power to empower women, and if you empower women then you empower families, you empower communities, and you empower society. Maybe that will bring us some peace in the world.

 

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Leadership Interviews – “3 Questions” – Geropsychiatric Nursing

Welcome to the Nursing Outlook Blog – “3 Questions” – Timely Interviews with Thought Leaders in Nursing and Health Care Policy

Last year, NURSING OUTLOOK featured a special issue on Gerontological Nursing: Development of the Science, Education and Practice. Early this year, Nursing Outlook published: “Carpe diem: Nursing making inroads to improve mental health for elders” (Evans, Beck & Buckwalter), a summary of the accomplishments of the Academy’s Geropsychiatric Nursing Collaborative (GPNC), a Hartford-funded project. Here, all three authors expand on their points of view and the lessons learned from the project and the evolving specialty of geropsychiatric nursing.

We invite commentary that is thoughtful and provocative! Join the online dialogue!

Veronica D. Feeg, PhD, RN, FAAN
Editor/Moderator

Evans, L., Beck, C. & Buckwalter, K. (2012). Carpe diem: Nursing making inroads to improve mental health for elders. NURSING OUTLOOK, 60, 2, 107-108. 

Cornelia Beck, PhD, RN,FAAN

Louise Hearne Chair in Dementia & Long-Term Care

University of Arkansas for Medical Sciences


Question 1.  “Why is it important that geropsychiatric nursing (GPN) be integrated into other specialty programs?”

[TO LISTEN TO THE FULL INTERVIEW CLICK HERE]

I think it’s very important because we find that people often don’t just have a mental illness. They often have that along with another chronic illness. For example depression and diabetes commonly co-occur. The cost of caring for diabetic with depression is much higher than the cost of caring for an older adult with diabetes without depression. So, even people who don’t consider themselves mental health psychiatric nurses have a need to understand the relationship between the mental health illnesses like depression and anxiety and other chronic conditions.

Now, I think the same is also true if we look at Alzheimer’s disease. For example, people who have Alzheimer’s disease are often cared for by people from other specialties – even let’s say, a women’s health nurse practitioner might be caring for an older woman who has Alzheimer’s disease and some other chronic condition. We know from all lot of work that the cost of caring for someone with Alzheimer’s disease, if we just look at Medicare claims alone, is about three times as high as people with other diseases. I think it’s not because they’re sicker but it’s because often practitioners who are caring for them don’t take into consideration all of the issues that are going on with the other chronic diseases and the co-occurring mental illness. So, the person doesn’t get the kind of treatment and care that’s needed. It’s also probably also true for family nurse practitioners who may be caring for even children and their grandparents and knowing about the mental health issues of the older adult who might be a grandparent and how that plays with the rest of the family care.

I think that one of the reasons it’s a particularly important for all nurses to have some knowledge about geropsychiatric nursing – about mental illness in older adults – is because in each of their practices they are going to be caring for people who not only have physical illness but also have some kind of psychiatric illness or mental health issues. With the baby boom generation coming up, they are seen to be higher risk for depression and anxiety disorders and substance abuse disorders – more so than people who were born before World War II. So as we see the baby boomers coming more into health care, all nurses and nurse practitioners need to have the knowledge to address those mental health care needs of that population.

Lois K. Evans, PhD, RN, FAAN

van Ameringen Professor in Nursing Excellence, Emerita

University of Pennsylvania School of Nursing

Question 2. “What have you learned from this project about the importance of networking and collaboration?”

[TO LISTEN TO THE FULL INTERVIEW, CLICK HERE]

Well I think that in the middle of the project and certainly in retrospect, we recognized that we would never have been able to accomplish even a miniscule amount of the goals that we did accomplish without using our contacts, our professional networks and taking advantage of opportunities as they arose during the course of this particular project. We had started out with a very ambitious goal to improve the mental health of older Americans by preparing nurses at all levels to provide some geriatric mental health. It was fortuitous that we set the goal that broadly. We set two particular strategies: one was to develop some competencies in geriatric mental health for nurses, and then to develop or make available curriculum materials that faculty could use to actually help nurses learn how to provide mental health services for older people. But by having the goals so broad – improve the mental health of older Americans by nurses, we actually could take advantage of all sorts of opportunities that occurred over the project. So maybe I’ll just share a few that come to mind, because I think there are lessons to be learned in it.

Once we recognized that we couldn’t do it all – we are three: Cornelia Beck, Kitty Buckwalter and myself – who had planned this project with the John A. Hartford Foundation and housed it at the American Academy of Nursing because we wanted it to be seen as a national nursing project, not something that was closely aligned with one school or one particular setting but one that could be more national in scope, similar to how the Hartford Building Academic Geriatric Nursing Capacity (BAGNC) project has been running at the Academy until recently.

We housed it there and we had collaboration of certainly the three of us, and we came from three different schools representing three of the Hartford Geriatric Centers of Excellence in the country. (There are now nine of them that Hartford supports). We came from Arkansas, Iowa and the University of Pennsylvania. Each of us had some expertise with a history of expertise in research and teaching with some practice in geriatric mental health. But we knew that we couldn’t just among ourselves to do everything – so we really reached out early on by developing a national task force that was pulled together to help develop the competency statements for this project. Now, we couldn’t even do that by ourselves. One of the things we did early on was to review the status of competencies and program competencies for nurses in all the different fields that actually work with older adults. We were overwhelmed by how many there are, who writes them, the fact that none of them are sequentially done in the same timeframe – some got done in 92 and some and 96 and 02 and some in 08.  There was no clarity about when they would be revised or what the schedule was for that sort of thing. We also recognized that it was not timely to think about preparing competencies for a whole new field – geropsychiatric nursing – and I’ll spend a minute just saying about that.  The problem is that it is an area of practice that probably has two strikes against it at least. One of them is that it’s focused on mental health which still has a lot of stigma in our country in the general population, but also certainly among nurses. The second area of stigma is that it’s about old people. So put both of those together and it’s been very difficult to recruit nurses to train in that area to practice in that area etc.

We realized that the timing was short to be able to prepare the cadre of health providers in all the mental health fields that are going to be needed to care for the rapidly increasing elderly population where the estimate is that about one in 5, 20% of people in late life do have mental disorders or mental health problems that require service. At the moment we are woefully under-prepared in terms of just the sheer numbers of providers who have any training in geriatric mental health. Nursing is probably the lowest group for that because we have never had a specialty area proclaimed – there’s no certification exam for it etc. So we said that the best thing to do is to really figure out how to infuse this knowledge and skill set into the preparation of all nurses who are ever going to touch older people. That model was one that had been used by the Hartford Institute of Geriatric Nursing, housed at NYU, in trying to really make geriatrics be a more prominent component of undergraduate and graduate education. They recognized that probably 80% of hospital patients are over the age of 65, and most homecare patients and in many other settings are in fact elderly, but hardly any nursing schools had geriatric course. There were few geriatric nurse practitioner or geriatric CNS programs in the country. The notion was: we really need to get that kind of content and skill set in the hands of all nurses not just a handful. So we use that same kind of model and said let’s see if we can write competency enhancements for all of the programs that prepare graduates to work with adults, therefore with older adults. In our case we chose entry-level including associate degree and baccalaureate level graduates.  And then we looked, at the time there was still an adult health program (this was in 08), adult health, geriatrics, psych mental health, family health, women’s health and acute care were the areas that we targeted because they all care for older adults.

We pulled together a selective group through our networking – who did we know, who had practice expertise, educational expertise from across the country. We represented all the regions of the country, we represented diversity in terms of practice backgrounds, people who were essentially educators, undergraduate and graduate levels. We made sure we had gender diversity and ethnic racial diversity on the team. We tried to cover all of our bases, but again, putting together that committee or task force together, we reached out to our network to identify who were key people. That group worked diligently over a two-day period with materials we had already pulled together for them, to lay out what the essence of these competencies would be.

Again we had reached out of the process to someone who from the AACN, Joan Stanley, who had lead the process of competency development for a lot of the graduate programs when they were looking at how to infuse geriatrics into those graduate program competencies. She had a well-developed process that had been funded by HRSA. We consulted with her about how to go about doing this in a way that would be consistent and would therefore have credibility in what we were doing. She agreed to serve with the director of AACN on our national advisory panel. Beyond that, we used our national advisory panel which was also was a group of people deliberately representing credentialing, education, accreditation and practice, and other kinds of arenas where a lot of work is going to develop geriatrics in the country. That group has really served us very well to identify opportunities, trends and things that were happening before we knew it that might be ways that we could collaborate to further our cause in this project without having to reinvent wheels. I think that was another goal that we had – that we really didn’t have the resources (the time, the money, the personnel) to be able to reinvent wheels. It was too costly to do. We really needed to take advantage of opportunities as they came along and to piggyback onto projects that were already being developed and implemented that related to geriatrics infusion, helping people to recognize that infusion of geropsych was a part of infusion of geriatrics.

People just hadn’t thought about it, but when we brought it up to them they were very willing to have us work side-by-side to add value to the products that they were already producing. A couple of examples of those are: the Hartford Institute of Geriatric Nursing together with the American Association of Colleges of Nursing were preparing a series of geriatric cases – case studies that could be used for teaching core competencies around good geriatric care. It had not occurred to them to have any that related to mental health. But when we talk with the leaders of that project, they saw right away the value doing that and were very willing to add two new cases that related to geriatric mental health.

With our network, mostly capitalizing on people we knew including some alums from the Building Academic Geriatric Nursing Capacity (BAGNC) program, the pre- or post- doctoral training program that Hartford had supported over the years, we were able to help some people produced to wonderful case studies. One of them relates to mental health function in primary care, primarily for nurse practitioners, and the second one was geared toward the clinical nurse specialist and it had to do with confusion in the acute care setting. Those were really well done. They are posted on the NYU web site and I believe you can get to them from AACN, and you can also get to them from our postings on POGOe, which is Portal of Geriatric Online Education. That’s an example of collaboration. The timing was right, we learned that they were into this project. We said – “what about a having a couple of mental health ones?…great!…can you get them done in this time frame?…” and now they’re out there for people to use.

Our second one was one of our representatives on the advisory panel was a leader in the National League for Nursing at New York, and she had been a leader in establishing a new program called ACES [Advancing Care Excellence for Seniors] that had to do with teaching geriatric nursing to their generic students at any level – associate degree, bachelor’s degree. And when we learned about that project, the leader said “is there any way that you can review what we’re doing and make sure that we have all the key concepts from the geropsych project embedded in this project?” So we were able to facilitate that being done. So those cases are enriched with geropsych as a result – again timing, connections and helping build awareness for these opportunities to enrich what was already being produced.

And a third one is all the work that was being done by AACN and the Hartford Institute to help prepare faculty for integrating geriatrics into their education program included a set of webinars on examples of how to go about reviewing one’s curriculum, selecting material, how to find material etc. We proposed to them “what about one on geropsych?” – we were trying to get the word out (we had notified the deans of all the schools, making a lot of presentations, we published articles, we were trying to make as many people aware of this as possible, but it takes a long time for the word to get out for people to use it). They were very happy to use it in their final webinar that was focused on infusing geropsych into the curriculum as a the component of geriatric care. That got done this past fall and is available. A lot of people participated in it while it was live but the recording is available on line for people to access as well. It’s a really important way of getting the word out.  Again, timing, collaboration and networking as a way to get those things to happen.

We have collaborated in addition with the nine Hartford Centers. We engaged them in thinking about how to help their own faculties infuse geriatric mental health into their curricula and we involved the alumni from the pre-doc and post-doc programs. There are quite a large number of them now who do have an interest and background mental health. That group has been very eager to participate is now beginning to assuming some leadership nationally for promulgating the information, doing some of the talks at national meetings, helping keep/update materials that are already posted on the website etc. So were really happy about that.

One other that I can think of – we were planning to produce a video that would highlight the work and thinking of some of the national leaders in geropsychiatric nursing. We really did not have enough resources within this particular project grant to be able to do a videography of some sort. But then we learned about one of our colleagues from Penn State who had actually produced a number of videos, short video clips that were being used to try and interest young nurses in the field of geriatrics. In the process of making the videos, they had a lot of clips that just went onto the cutting floor – and so we said “do you have any pieces from those video clips that might be mended together in a way to make a coherent story about geropsych?”  because all four of the persons that we wanted to showcase on the film had been interviewed for those videos. So we worked with the professional staff at Penn State and they were able to do it. We wove the story – now we have this video for a very modest amount of money and the videotape has been circulated broadly and free online for use. Another example of how as we knew people and things that were happening, and people would tell us “did you know about this or that”? We had filters on our glasses and [filtered] anything about mental health and aging for this project, this opportunity, these new things that were happening.

I guess the last thing I would really want to mention is the opportunity that really showed itself in the publishing of the Consensus Model document, which did happen in late 2008 when we were already finishing up the first year of the project. That Consensus Model – by making the decision that nursing at the graduate level would focus on six populations, four of which dealing are adults and therefore would include older adults that the gero and adult health populations would be merged into one group. But that every of the other four groups (women’s health, psych mental health, family health nursing) all because they were dealing with older adults in their adult population, they all had to have some geriatrics both didactic and clinical learning experiences in their curriculum. Now that requirement was brand new. Many of these programs may have a lecture or two on something related to older people. But to acknowledge that they are actually the major provider of geriatric care, because we don’t have that many geriatric specialists in the country, it now means that they are recognized and are scrambling try this get more content and clinical opportunities for their students. One of the things that consensus document did was to open up the pressure at the credentialing level and accreditation level to say “Now that you have to have geriatrics, geropsych is part of that. Let’s see how we can help you with meeting these new requirements.”

So that is how we’ve sold this stuff. We also sold it by saying “it really is infusing; it really is enhancing what you’re doing; it’s not completely changing what you’re doing but helping you have a broader lens to know some of the specialist information about geriatric care that is so important.” As we’ve worked with a range of people, we’ve been able to have either members of our secondary team or those that we know who are experts, appointed to the competency revision groups or panels that have been put together early on by AACN when they were developing what the adult gero – the new fused program – would look like. We were able to have a geropsych person on both the NP panel and the CNS panel and the same for the gero-adult acute care groups. So the first one was focused on primary care and the second set was focused on acute care. So the views of our geropsych people were infused into those two documents. We were also able to have that level of participation in the revision of the baccalaureate competencies as well. Then when NONPF (National Organization of Nurse Practitioner Faculties) was working on how to make the last three (the women’s health, psych mental health and family nurse practitioner) competencies fit with the new Consensus Model, we were able to have input into those as well.

We’re hoping that the whole area of mental health, as the Affordable Care Act – however it comes forward – everyone is talking about the need for more integrated care. Certainly, mental health needs to be integrated into primary care, community care, acute care etc. and geriatrics needs to be integrated into all of those areas as well.  I think our timing is right for having something available and building awareness of the country both in nursing and outside of nursing about the importance of this field and we obviously could not have done all of that in a short four-year period with just the three of us. The networking, the collaboration and the timing, I think, gave us opportunity to take advantage of all that came forward to move towards our goal of helping to improve the mental health of older Americans – [and]it has been a fabulous, fabulous road to be on for these four years.

 

Kathleen “Kitty” Buckwalter, RN, PhD, FAAN

Professor Emerita, University of Iowa College of Nursing

Question 3.“What do you think the future holds for geropsychiatric nursing GPN?”

[TO LISTEN TO THE FULL INTERVIEW, CLICK HERE]

Well I’m very optimistic about the future of geropsychiatric nursing. I think there are a lot of indicators over the last few years and good promise for continued growth and enhancement of geropsychiatric nursing in the future. Some of those indicators include the number and quality of Building Academic Geriatric Nursing Capacity (BAGNC) alumni, whom I believe are the largest subgroup of the alumni organization and who are actively engaged in the preparation and presentation of papers in the area of geropsychiatric nursing. [They] have been helping us to develop case studies, for example, that we can post on the Portal of Geriatric Online Education – or POGOe – for use by others as they infuse geropsychiatric content into all levels of nursing education. We also see with support from the Hartford Foundation the continued growth in the number of pre-and postdoctoral students and fellows who are prepared to do research in the area of geropsychiatric nursing and who will become faculty to teach others about the needed content.

There is also growing national attention to the issue of mental health and substance abuse in older adults. In particular, there will be an Institute of Medicine (IOM) report forthcoming  [Released:July 10, 2012] – the official title is the Committee on Mental Health Workforce for Geriatric Population. This report is really an outgrowth of the 2008 Retooling for an Aging America report that highlighted the need for more and better trained practitioners. In this case, the report focuses on workforce issues for the mental health and substance abuse needs of older adults. So that will be exciting and the Institute of Medicine reports generally have high impact and garner the attention of funders and Congress. So we are looking forward very much to that report.

Our geropsychiatric nursing collaborative (GPNC) and, as you know, with the support from the University of Arkansas, the University of Pennsylvania (in particular Cornelia Beck and Lois Evans from those institutions) and myself here at the University of Iowa, have really accomplished a lot in the past four years [in terms] of increasing visibility of the field of geropsychiatric nursing. We’ve developed and revised brochures that can be used on the “Hill.” We’ve published a number of articles about geropsychiatric nursing in both the periodic peer-reviewed literature and book chapters. We’ve made presentations around the country – most recently at nursing educator conferences, and with the NLN – but also at interdisciplinary meetings such as the Gerontology Society of America. We have convened a joint mental health and aging workgroup at the American Academy of Nursing. While not officially one of the interest groups of the Academy, it is comprised of members from both the mental health and aging special interest groups. They have been active and will continue to outlive the GPNC work.

We also have provided technical assistance to schools of nursing that were interested in infusing geropsychiatric nursing content into their curriculum. And other indicators to me include – I was the editor of the Journal of Gerontological Nursing up until January 2012 for 13 years – and over that 13 year period, I noted a marked increase in both the number and quality of submissions and publications relevant to geropsychiatric nursing. The same thing could be said for the other journal, Research in Gerontological Nursing, that I established four years ago [that] is primarily a research journal whereas JGN is primarily clinical in orientation. But, the high number and extraordinary quality of research articles with geropsychiatric nursing focus has also been very heartening.

Finally, there are two other areas – the growth of evidence-based practice protocols – those coming out of the Hartford Institute of Geriatric Nursing at NYU, and from our Hartford Center of Geriatric Nursing Excellence at the University of Iowa. This will really help to translate the evidence base in geropsychiatric nursing into a usable palatable form for use by clinicians in a variety of acute care, long-term care and community-based settings. (Not that all of the evidence-based protocols produced by the Hartford Institute or the Iowa Hartford Center are geropsych focused, but a high percentage of them are very relevant to geropsychiatric nursing).

The final note I would like to make is that – coming back [just] yesterday from the Midwest Nursing Research Society (MNRS) – I was so impressed again with the quality and quantity of symposia and papers and student posters with geropsychiatric nursing themes. All of these indicators suggest to me that we’re in good shape in terms of the future of the field. But of course, we still face a number of challenges for the future. The challenges include [that] we’re still dealing with a very fragmented and uncoordinated system, especially for older adults with chronic illnesses, mental health and substance use problems.  We’ve got to adapt our acute-care models of care delivery and change them to a more chronic care model. And, despite the recent advances, there are still an insufficient number of nursing faculty with adequate geriatric mental health preparation – and we still need more geriatric mental health content in curricula at the undergraduate and graduate levels.

It still remains a challenge in terms of adequate leadership in the field of geriatric nursing in general but geropsychiatric nursing particular. There are advances in this realm as well. For example, the Geriatric Nursing Leadership Academy sponsored by Sigma Theta Tau and a number of the recipients/participants in that Academy have been interested in geropsychiatric nursing. So, whether they’re from nursing home or acute-care roles, their leadership will serve us all well.

We know a number of other things that happened outside of the work of the collaborative that will foster our work and continues to do so in the near future. One of those is with the advent of the minimum data set 3.0, which came on the scene in October of 2011, there really is marked improvement in the areas of cognitive assessment, mood, routines and activities that are mandated for nursing homes, where many persons with cognitive, functional, and mental health impairments reside. Also we are excited about the proposed APRN regulatory model, the Consensus Model for APRN regulation, licensure, accreditation, certification, and education, because we see with the advent of this Consensus Model, the specialty of geropsychiatric nursing certification is now a possibility. Although full implementation of the proposed model nationally isn’t expected until 2015, work can begin on specialty certification in the field.

Finally a number of the strategic plans of NIH institutes, including NINR, NIMH, and NIA, are very friendly with regard to geropsychiatric nursing. So we are hopeful that as we prepare more better- qualified researchers especially at the postdoctoral level and beyond, they will be able to take advantage of funding opportunities from foundations as well as NIH institutes. We continue to face (a) challenges in the area of tackling mental health disparities in the older adult; (b) the need to systematically demonstrate a cost benefit of mental health nursing services for this population; (c) and to adapt an evidence-base for applications in new settings of care such as prisons and homeless shelters where many older adults with mental health and substance use issues reside.

It’s exciting to think about new service delivery models and setting of care, the research that people with training and interest in geropsychiatric nursing will be able to conduct, and the future emphasis on translation of that research into practice. Still, we need to prepare more nurses with geropsychiatric expertise and who focus, not just on those people who have impairments already, but on health promotion and disease prevention. We still need to develop that critical mass of nurses with the knowledge and skill to provide mental health care to older adults and potentially certifying them in the field.

 

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Leadership Interviews – “3 Questions” – Risa Lavizzo-Mourey

Welcome to the Nursing Outlook Blog – “3 Questions” – Timely Interviews with Thought Leaders in Nursing and Health Care Policy

The Robert Wood Johnson Foundation and Institute of Medicine report, The Future of Nursing, offered bold recommendations for change in the current health system to meet the growing need in health care delivery.

These are among the hot topics of the day. All the critical issues that are important to nursing warrant rapid dialogue among informed readers and traditional modes of publishing cannot keep up with the pace of information available. “Agility” is needed to deliver contemporary arguments electronically for persuasive commentary for building consensus that is timely, substantive and prepared for discourse. Blogging and blogs are increasingly providing a paperless platform for professionals to present and debate ideas in the socially connected evolving web. Nursing Outlook is now hosting an online environment – “3 Questions” – to engage nurses with nursing leaders in discussions around focused topics that are important for the profession. Interviews will be routinely edited and posted for readers to learn from thought leaders of the American Academy of Nursing and a variety of other nursing and health care megastars.

Risa Lavizzo-Mourey, MD, MBA, President and CEO of the Robert Wood Johnson Foundation speaks out in NURSING OUTLOOK on the commitment to strengthen America’s nursing workforce.. 

We invite commentary that is thoughtful and provocative! Join the online dialogue!

Veronica D. Feeg, PhD, RN, FAAN
Editor/Moderator

Risa Lavizzo-Mourey, MD, MBA, President and CEO
Robert Wood Johnson Foundation
Co-Sponsor, The Future of Nursing Report

Question 1. Why has nurse education become such a high priority for the Robert Wood Johnson Foundation?

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(Prepared Commentary) The Foundation has a long-standing commitment to strengthening the health care workforce and to nursing in particular. For many reasons, nurses are essential to our efforts to improve health and health care, especially as the delivery of care continues to increase in complexity and moves from hospitals to community-based and primary care settings. And at the same time, the roles of the insured will increase by tens of millions of people.

In The Future of Nursing: Leading Change, Advancing Health, the Institute of Medicine (IOM) asserted that in order for nurses to maintain their effectiveness in providing patients with high-quality care, they will need advanced competencies in care management, working as part of interdisciplinary teams and problem solving. These are skills that nursing students attain as they pursue the Bachelor of Science degree; as a physician I have seen firsthand the tremendous impact of these capabilities. We also need more nurses to obtain advanced degrees in order to address shortfalls in both nurse faculty and primary care.

Thus RWJF supports the IOM recommendation to increase the percentage of nurses with BSN and higher degrees to 80 percent by 2020 and is helping to facilitate its implementation through the Future of Nursing: Campaign for Action. Through the campaign, we are engaging a wide range of groups at the national and state levels to make this concept a reality.

Question 2. What can health care organizations do to encourage nurses to advance their education?

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(Prepared Commentary) There are a number of things that hospitals and other organizations that employ nurses can do to facilitate education progression. Employers can adopt policies that favor the hiring of BSN nurses or that require nurses to obtain a BSN or higher to advance beyond a certain level (these are called career-ladder programs). One of the nation’s leading hospitals, Johns Hopkins in Baltimore, does these things. So do the Veteran’s Health Administration and Tenet Health Care.

Certainly paying BSN nurses at a higher rate is a tremendous incentive, as is offering tuition benefits. And having some scheduling flexibility also supports nurses in continuing their education.

Question 3. How are educational institutions approaching the issue?

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(Prepared Commentary) There’s no one-size-fits-all answer, but there are some very promising approaches being implemented across the country. For example, the Oregon Consortium for Nursing Education has created a shared curriculum across community colleges and the Oregon Health & Science University School of Nursing. This addresses one of the barriers to obtaining a BSN by making it possible for students to get the degree right in their own communities through a community college. In New Mexico, too, nurse education institutions are adopting a uniform curriculum and also will share faculty.

Florida and Colorado are working on models to facilitate the transition to BSN either via community college-to-four-year-institution partnerships. And states including Georgia, Illinois and Ohio are offering online doctoral programs for nurses.

These types of innovative solutions, combined with action by employers, businesses and others, are exactly what we need—diverse sectors coming together to transform the nursing profession, which in turn will help to ensure access to high-quality, patient-centered care for all. What we need is for many people and organizations to get involved with Campaign for Action and their state Action Coalitions.

 

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Leadership Interviews – “3 Questions” – Debra Barksdale on PCORI

Welcome to the Nursing Outlook Blog – “3 Questions” – Timely Interviews with Thought Leaders in Nursing and Health Care Policy

Are we getting better patient outcomes today in our healthcare systems? Does our research get implemented where it’s most needed – at the bedside and in patient care?

These are among the hot topics of the day. All the critical issues that are important to nursing warrant rapid dialogue among informed readers and traditional modes of publishing cannot keep up with the pace of information available. “Agility” is needed to deliver contemporary arguments electronically for persuasive commentary for building consensus that is timely, substantive and prepared for discourse. Blogging and blogs are increasingly providing a paperless platform for professionals to present and debate ideas in the socially connected evolving web. Nursing Outlook is now hosting an online environment – “3 Questions” – to engage nurses with nursing leaders in discussions around focused topics that are important for the profession. Interviews will be routinely edited and posted for readers to learn from thought leaders of the American Academy of Nursing and a variety of other nursing and health care megastars.

We invite commentary that is thoughtful and provocative! Join the online dialogue!

Veronica D. Feeg, PhD, RN, FAAN
Editor/Moderator

Debra Barksdale, Board Member of the Patient Centered Outcomes Research Institute (PCORI), spoke at the Council for the Advancement of Nursing Science (CANS) Conference, October 2011. Debra_Barksdale_CANS_presentation_10-12-11(1)

 

Debra J. Barksdale, PhD, FNP-BC, ANP-BC, CNE, FAANP
Associate Professor, University of North Carolina-Chapel Hill
Board of Governors, PCORI  (Patient Centered Outcomes Research Institute)

Question 1. What is PCORI and how has it evolved to date?

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PCORI was established by Congress through the 2010 Patient Protection and Affordable Care Act (PPACA). So, by law it is an independent, non-profit organization.  The Patient-Centered Outcomes Research Institute (PCORI) was created to conduct research to provide information about the best available evidence to help patients and their health care providers make more informed health decisions.

PCORI’s research is intended to give patients a better understanding of the prevention, treatment and care options available, and the science that supports options. The law clearly outlines five core duties or responsibilities of PCORI. These are:

  1. To establish national research priorities ;
  2. To establish and carry out a research project agenda;
  3. To develop and update methodological standards – the scientific standards for patient centered outcomes research (PCOR) and comparative effectiveness research (CER);
  4. To provide a peer-review process for primary research; and last but not least
  5. To disseminate research findings.

The evolution of PCORI is very interesting because in one year, PCORI has created a national research institute basically out of nothing except very dedicated people and some money. The Board was established bylaws and the board has created standing committees. Right now we have four standing committees. By the date of our anniversary, which was September 23, PCORI held six public Board meetings in five different cities. This demonstrates our intention to reach out to communities nationally. We have held patient or stakeholder events in conjunction with every Board meeting since March.

We have provided two opportunities for public input – on the working definition of PCOR (Patient Centered Outcomes Research) and the initial topics for our pilot projects – which go beyond our statutory requirements and show that we are committed to conducting our work in an open and transparent manner that ensures credibility, and access. We have issued three RFPs (Requests for Proposals) and our first funding application is for the PCORI Pilot Projects. Those grants will be due on December 1st.

The Pilot Projects will assist PCORI with ongoing development and enhancement of our national research priorities for patient-centered outcomes research. They will also support the collection of preliminary data that can be used to advance the field of patient-centered outcomes research (PCOR). These Pilot Projects will also support the identification of methodologies that can be used to advance patient-centered outcomes research as well as identify gaps where methodological research needs further development.

The Methodology Committee, which was also created as part of PCORI, was instituted in January 2011. And they have made great progress in the just seven months they have existed. They inform the Board regarding the methodology and methodological standards. They have outlined a clear process for developing our first Methodology Report by May 2012.

Question 2. What is your role and how do you see that connection with opportunities for nurse researchers, educators, administrators and clinicians in health care?

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The statutes were very clear about the composition of the Board of Governors. Those statutes mandated that there had to be at least one [nurse] member of the PCORI Board of Governors. I feel very fortunate and honored to be that nurse selected to serve on PCORI. I was endorsed by over 30 nursing organizations as well as my university, and my local, national and state representatives.

As the only nurse on the PCORI Board of Governors, I think I bring a unique perspective in addressing the needs regarding health and health care in our country. I draw from my knowledge as a researcher, as a primary care nurse practitioner (I’m a family nurse practitioner), and as an educator, so I draw from that knowledge in representing our nurses and our patients on the PCORI institute. I also consider myself an advocate for the disadvantaged, for the underserved and for the underrepresented regarding issues of health and also research.

As the most frequent point of care, because there are so many of us in the country, nurses will be able to use PCORI’s research which will allow clinicians to deliver the best quality care tailored to individual needs. As a result PCORI’s research will affect how we teach nursing, how we deliver patient care at the bedside and elsewhere, and also how we are able to function and continue to function or more effectively function in our role as advocates for our patients and also for our profession.

There’s a tremendous amount of opportunities for nurses to be involved in the work of PCORI. One of the first opportunities is in terms of giving input. PCORI does host public meetings as we move around the country. I am really honored when I see nurses in the audience – nurses who are brave enough to get up to the podium and to address nursing issues with the Board of Governors.

There are also opportunities for nurses to participate through our webinars. All of our public meetings are broadcast via webinars. Also there are opportunities for people to dial in. Our agendas are posted well in advance usually with the PowerPoint slides. So, issues that are really important to nursing will be posted ahead of time and you could dial in or call in when you wanted to listen to that discussion.

Also, in terms of input, we have and will continue to seek input on the decisions that we make. There will be an opportunity very soon for nurses to provide input on the national priorities that we will be setting, and they can do that through our website -  writing in, or, any mechanism just to make sure that voice of nursing is heard.

Another opportunity for nurses is employment. PCORI plans to have a staff of about 40 people which does include some scientists and other types of representatives. So, I would encourage people to check out the website – www.pcori.org to look at those employment opportunities.

There is also opportunity for nurses to apply for PCORI funding and PCORI grants. I mentioned earlier about the pilot projects, but there will be other funding opportunities. And nurses are in prime positions to apply for these grants because “patient centeredness” is what we are all about. And when I say “patient” I mean it in the broader sense of people – people and their health needs.

Another opportunity for nurses is to participate as reviewers of those grants. PCORI is not just seeking the same traditional types of reviewers  – all academic researchers. PCORI is extending its research reviewers so that people who are not [traditional] reviewers – in fact community people, [even] patients can apply to be reviewers for PCORI grants.

So, those are just some of the potential opportunities for nurses to be involved with PCORI. Let me know, let me hear what your needs and concerns are and I will try my best to make sure that those needs are heard by the PCORI Board and are represented in the work that we do.

Question 3. What should nurses know about the plans and potential outcomes for the future PCORI resources?

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What nurses should know about the plans and potential outcomes for the future PCORI resources is that PCORI is committed to patient and stakeholder engagement throughout our work and has provided several channels to receive input and will continue to provide those channels. One of my roles on the Board is to serve on the Communication, Outreach and Engagement Committee. So a lot of our work is around: How do we engage our patients? How do we engage our stakeholders, be they nurses or other types of clinicians or policy makers? So we’ll continue to provide those opportunities.

I hope that the nursing community continues to take the opportunity to provide PCORI with feedback on its work to date and to provide constructive input on PCORI’s national research priorities and research agenda. Individuals and organizations can provide input at PCORI Board meetings, or online, or you could write letters, to www.pcori.org.

So I think the major point I would like to make here is that nurses should expect that the work of PCORI will impact their work at whatever position or level that they are. And because of this I am hoping that nurses will be more involved in the development of those resources in providing input and commentary   on those resources so that it’s not  all about some other discipline setting the  standards that nursing will have to apply in its research, in how we teach or what we teach, or how we function as practitioners in this health care arena.

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