Leadership Interviews – “3 Questions” – Redesigned Health Care

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

The Newly Transformed Health Care System: How Nursing Can Prepare for Change

While we know that healthcare today is fragmented and inefficient, we also know that efforts are underway to shake up old systems and embrace innovation with promise. The elderly population continues to expand and so too does the demand for long-term care services, particularly for functionally impaired and chronically ill older adults. Services that support older adults require payment systems that change the status quo in a way that improves quality but does not break the bank. Health care payers are moving more toward a system of payment that relies on new philosophies of paying for value rather than rewarding volume in the old fee-for-service models. With the emergence of Patient-Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs), Medicare payments will shift and health care providers such as hospitals, clinics, physician practices, will need to redesign care delivery and redeploy the workforce in new roles and settings.

In these redesigned new markets, we will see new job titles and roles that will emerge. Care coordination and interprofessional collaboration will be key. In a recent research brief, Dr. Mary Naylor and colleagues dicuss how the nature of nurses’ jobs are set to change in this new redesigned system of care.

Nursing in a Transformed Health Care System: New Roles, New Rules (E. Fraher, J. Spetz & M. Naylor) Penn LDI Interdisciplinary Nursing Quality Research Initiative (INQRI) Report: Research Brief, June 015.

Mary Naylor is the Marian S. Ware Professor in Gerontology and Director of the New Courtland Center for Transitions and Health at the University of Pennsylvania School of Nursing. Her extensive work bringing Transitional Care models to the attention of health systems and payers focuses on older adults with complex care needs, emphasizing care coordination, and changing how we look at Long Term Services and Supports (LTSS). We asked her to elaborate on her recent article by answering 3 Questions!

Veronica D. Feeg, PhD, RN, FAAN

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

Mary Naylor Photo


Mary Naylor, PhD, FAAN, RN, Marian S. Ware Professor in Gerontology and Director of the New Courtland Center for Transitions and Health, University of Pennsylvania School of Nursing, INQRI Program Director

Question 1. In a recent brief, you and your colleagues described new roles for nurses in a redesigned health care system.  Can you describe these roles and their importance to advancing the health of our society.


To listen, click here.

This is an extraordinary time for nursing and for health care and I was delighted to have the opportunity to work with my colleagues Erin Fraher and Joanne Spetz working as part of the Robert Wood Johnson Foundation INQRI (Interdisciplinary Nursing Quality Research Initiative) along with the Leonard Davis Institute on a brief that attempts to bring to the fore some of the – on the one hand tremendous opportunities we have and some of the challenges that we have currently and responding to them.

So nursing, I think has an enormous chance right now to capitalize on changing needs – vastly changing needs of  populations. We focused in the brief on just one example, older adults who are waking up every day with multiple chronic conditions: some of whom are going to be in that state and experiencing the challenges of these health changes for a long time; some of whom are near end of life and need to have a different set of services to meet their needs. So one of the big factors contributing to changes in expanded roles for nursing are the vastly changing needs of our populations.

We are seeing also this enormous change in  delivery system models and much of this is driven by how important it is for our society to recognize that we have to adapt; we have to deliver a different set of health services; we have to engage a different set of health partners. So newer delivery models, I don’t know if they are new today, but patient centered medical homes, accountable care organizations and cross cutting these models are strategies or approaches to care delivery, such as population health insuring and improving care coordination. So these are different I mean, this is not the same old delivery system that we’ve been working in for years, but rather a vastly changing delivery system which has not yet reached where necessarily its going; but the path taking the changing needs of the population and the expansion of competencies of nurses who are exquisitely prepared to address these needs and could get even more prepared in the future to be able to take advantage of and lead a change – I think all of these seemed to align during this period time. So we wanted to highlight that in this brief.

Question 2. How has your team’s work on the Transitional Care Model influenced your thinking about future nursing roles?

To listen, click here.

Well I think the transitional care model is a terrific exemplar that is evidenced based. It’s proven about the contribution that nurses can make in this evolving health care system. So we’ve had the great fortune for many years to both better understand what it’s like to be a consumer of health services; what it’s like to be someone coping with/confronting major challenges in health largely chronic illness; what it’s like to have to try to navigate our health care system as patients and families are increasingly being asked to take on roles and responsibilities related both to their health and coordinating their care; and how it is that nurse led solutions such as the transitional care model can make that better – can both help people more immediately address their needs and at the same time can really help them as they try to interact with multiple clinicians in multiple settings.

So it is essentially saying to patients and families caregivers “you’re not out there alone! That part of what we do in our health care system is not only help you meet your needs, but also to make that journey as easy as possible” – especially given the stress that these patients and families are under.

So the Transitional Care model helped us to understand much more intimately the needs of a population whose health is changing all of the time and also helped us to understand how nurse led solutions, which are team based, which capitalize on the gift of physicians and social workers and every other member of the care team, but how all of that which has a nurse as a quarterback better positions the people that are counting on us to have their needs meet in a much more timely manner. And to do that in a way that makes much efficient use of resources.

Question 3. From your perspective, what needs to happen to ensure widespread use of nurses in these new roles.

To listen, click here.

Well I think nurses really, really need to understand that right now we’re going through major system redesign. It has enormous implications for the discipline and for specific roles that nursing will play. And so we need to be major partners in that system redesign because the workforce implications are emerging simultaneously. I think it is essential that we: commit ourselves as a profession and to develop some of the expanded competencies that are really at the forefront of system redesign – so this work around patient engagement and family care giver engagement the competencies needed to manage complexity help people manage both the health and social risks that they are experiencing in their communities; understand what it means to be able to take on this construct of population health which is  to say we know how to not just care well for individuals or groups of individuals but we know how to care for the population of individuals  in communities; understanding how to use and bring to the fore skills in managing  the care of populations over time.

I also think  it is essential  that competencies around teams which are (you know we hear about everyday how important teams are) but when we actually have a grounding a socialization a history of working in partnership with other health clinicians in partnerships with community based organizations whom I think are emerging as core members of future teams – those that are based in service organizations helping people to get their meals and their transportation, helping them get their copays for their medications. And finally I think competencies around performance improvement. There is nothing that is going to be static about our health care system and nurses really need to understand  how to risk stratify populations so they can best match needs with services available. They need to: understand processes that continually enable them to get better; how to use data big and small to improve the quality of what they do; and how to be great stewards of resources.

So I would say that the needs right now are for every part of our system – our leadership our educational systems and our practice environments to be aligned in working to make sure that nurses emerge, not just with a central role because that’s what we are hoping for our profession, but  emerge as the providers  – key  providers – of services because they are the best positioned to be able to accelerate improvements, redesign, and better care and outcomes for our society.

Additional Follow-up. Do you have anything else you might to add to advice for nurses?

This is a really good time not just to be at the table. It’s essential time, obviously, to be at the table, but to be able to represent all of the possibilities that are grounded in evidence about ways in which nurses contribute as members of teams as team leaders as coordinators. So when you have that chance to be at the table, make sure that you’re there as the most exquisitely informed and articulate spokesperson for the range of possibilities that will enable nursing’s voice to be heard, nursing’s contribution to part of future health system redesign.


Leadership Interviews – “3 Questions” – Future of Nursing: Campaign for Action

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

The Campaign for Action: Transforming the Nursing Profession

The Affordable Care Act and the changing landscape in health care are among the hot topics of the day. The pace of change requires nursing to be vigilant for the profession and engaged with policy makers, providers and boards who are instrumental in decision making that impacts health care. Education, workforce, and scope of practice are all part of the national conversation. These 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 now offers an online environment – “3 Questions” – to engage nurses with nursing leaders in discussions around focused topics that are important for the profession.

The Institute of Medicine (IOM) Report published in 2010 – THE FUTURE OF NURSING: LEADING CHANGE, ADVANCING HEALTH – set the stage for changing health care forever. This report kick-started national activities and awoke the nursing profession to organize toward maximizing the reach and opportunity for nurses in order to improve health of all citizens. Many of the recommendations launched organizations to begin to take action toward achieving goals by the year 2020. The Robert Wood Johnson Foundation (RWJF), mobilized by the Report with its key partner, the Center to Champion Nursing in America at AARP, were instrumental in creating the Campaign for Action.

Susan B. Hassmiller, Senior Adviser for Nursing with the Robert Wood Johnson Foundation, has been leading the charge from the IOM Report and speaks to the numerous activities underway with national organization partners and all 50 states and the District of Columbia in the “Campaign for Action.” According to the RWJF website, Dr. Hassmiller is shaping and leading the Foundation’s nursing strategies in an effort to create a higher quality of care in the United States for people, families and communities. Drawn to the Foundation’s “organizational advocacy for the less fortunate and underserved,” Dr. Hassmiller is helping to assure that RWJF’s commitments in nursing have a broad and lasting national impact. We asked her to elaborate on her recent article in NURSING OUTLOOK by answering 3 Questions! We invite commentary that is thoughtful and provocative! Join the online dialogue!

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

SueHassmillerSusan B. Hassmiller

Director, Future of Nursing: Campaign for Action

Senior Adviser for Nursing

Robert Wood Johnson Foundation




Question 1: The Robert Wood Johnson Foundation has generated nearly $18 million to date and others have supplemented activities of the Campaign for Action following the Future of Nursing release to move the recommendations and sustain the momentum of this historic IOM report. Can you describe the value of investment supporting a national agenda like this to catalyze change in health policy?

The Robert Wood Johnson Foundation has invested in nursing, really since the beginning of the foundation over 40 years ago. And even before that General Robert Wood Johnson was known for reaching into his very deep pockets. He of course was one of the founders of Johnson and Johnson so he used to reach into his very deep pockets to help both nurses and physicians with scholarships. That’s really where it started.

So why does the Robert Wood Johnson Foundation invest in nursing? Not really just for the sake of investing in nursing but because of nursing’s very close link to how we as nurses impact the overall health and healthcare for all Americans – and that’s really the Robert Wood Johnson Foundation mission, which is to improve the health and health care of all Americans. So investing in nursing is very important – it’s a very important means to an end for us. And ensuring that nurses are the most effective and efficient they can be helps with our own mission, and it helps with the triple aim which is what we are very concerned about too: cost, quality and access.

Our return on investment for everything we are putting into our nursing work … and remember it is not just the support for this IOM report and the campaign as I alluded to … we have been doing this for decades! We still have many investments going on: the Executive Nurse Fellows Program, Nurse Faculty Scholars and our investment in programs like QSEN (Quality and Safety Education in Nursing) and TCAB (Transforming Care at the Bedside). So our return on investment will come in the form of patients or consumers and their families having the most highly skilled and educated nurses available. Having nurses whenever they need them whether in schools or in primary care clinics or in places where they work. And that nurses will help in the equation of keeping our healthcare costs more reasonable! And because of this we will all be healthier and have better healthcare because of our nursing workforce.

Question 2: The Campaign for Action was intended to transform and diversify the nursing profession. With its powerful partners over the past 4 years, what do you consider the most profound changes that have been exemplars of an improved health care system?

Well, when you talk about partners, I think we are all on this journey together. There are so many health care partners, both individuals and organizations – partners with how we are helping to improve our health care system. Nursing can certainly help with that, and Robert Wood Johnson Foundation is betting on this equation. A few examples might include our work around insuring that all nurses practice to the top of their education and training. We care about this for all nurses. Yes. There are a lot of investments being made in ensuring that laws are modernized so that nurse practitioners can practice to the top of their education and training. You know, a recent piece that Nursing Outlook published and RWJF helped to fund called “Practice Characteristics of Primary Care Nurse Practitioners and Physicians” – it was a piece that Peter Buerhaus was involved in – and this research, published in Nursing Outlook found that more nurse practitioners as compared to physicians practice in rural, inner city, and more community health settings, and are much more willing to accept Medicaid patients. This is great news! This is really good news!

So working on advocacy efforts to modernize laws to assure that nurses practice to the top of their education and training, and then to have evidence that shows that nurse practitioners are making a difference for very important populations will really help to push this envelope further. And we really need a breakthrough in this area, don’t we?

And I would be remiss if I did not say, speaking of partners, what a key role AARP is playing in this scenario. They can, without RWJF funding, because we are not allowed to actually be on the ground promoting specific legislation. So AARP can be there supporting all of our 51 Action Coalitions – and we have Action Coalitions in 50 states and the District of Columbia. So they’re supporting our Action Coalitions and our Action Coalitions are crafting their own legislative language for these modernization efforts, and offer technical assistance with the legislative process.

In a last example I would use in talking about partners and how it takes everybody to do this is really our current effort around 10 KN – 10 KN – otherwise known as getting 10 thousand nurses on boards by 2020. So even with 51 Action Coalitions and our campaign headquarters which happens to be at AARP working on this, we can’t do this alone. So we formed a coalition starting with 19 other national nursing association to work on efforts to get 10,000 nurses on boards. And they’re doing this and they’re leveraging each other’s work – leadership training work, websites and the like.

So a final note, we can’t do any of what we’re doing alone. This is a campaign, this is a coalition. By its very definition, we use hundreds of partners. We have policy maker involvement, business involvement, national association involvement, consumer groups … it will take many to see this through.

Question 3: From your perspective, what needs to happen for the collective activities of the Campaign for action to reach a summit of widespread success?

One of the most important recommendations that many are working on (we’re working on at national headquarters at AARP, Robert Wood Johnson Foundation has a separate national program office working on this as well, spearheaded by our own tri-council) is really  the 80/20 recommendation. That means of course getting 80% of all nurses in the country to a BSN or higher. You know many people ask me if I think we will attain that goal but 2020 and I say “you know definitely in pockets we will get there!” But this is really, really hard because  as many new baccalaureate graduates as we have, community colleges are pumping  out just as many graduates on their own. So it’s almost like the dog chasing its tail. We’re getting … there we’re doing it! It’s unbelievable, but there’s just so much work. So by the 2020, we’ll certainly get there in pockets. But what we’re really doing in this campaign with this recommendation and other things is building the infrastructure. We are on a path to build an infrastructure. Community colleges – what do I mean by that? Community colleges are working with universities; memoranda of understandings are being formulated; acceptable transfer credits both in numbers and types are being agreed to; faculty at all sides are working with each other; employers are developing policies about hiring preferences; and continuing education (and who gets recognized and who can go on).

So this is all about building the infrastructure and this takes time. It’s just not simply a matter of counting numbers. The infrastructure must be built. This is about changing cultural and social norms. So in 2020, my goal would be that every nursing student coming out of a community college program, like I did, would fully know, understand, and have the wherewithal to continue his or her education. They would come out and they would say “OK … so this was my first step. This is where I’m gonna’ go now” …  Nursing students don’t have to think about whether they should go on – they just know they will, because the infrastructure is there. They would know that community colleges are only a first stop. That to be a nurse in the United States will take moving on to a BSN. And it’s the same with our 10 KN coalition (ten thousand nurses on boards).

It’s about changing social and cultural norms so that no decision makers, CEO, or persons asking for testimony on Capitol Hill will ever have to think about or wonder whether they should have a nurse on their board or providing testimony. They will just automatically have it because they know that nurses are on the front lines. They are the reality check to any decision that is being  made in this country.  We think it is wonderful that lawyers and doctors and other policy makers are there making decisions, but if we are not there, then those people are making decisions for us and for those we care for … and that’s unacceptable!

Follow-up Question: In closing, do you have anything else to add?

I’m really excited that Robert Wood Johnson Foundation has given me the opportunity and has given our country the opportunity to build this capacity in our nursing workforce. It’s so very important – but what that means is we all have to be involved. I talked about needing partners and that means everyone listening to this today – what does it mean to be involved? Go to the website and look up your state. There’s a place where you can click on your state – Alabama, Alaska, Minnesota – see what’s going on there. You can see who your leaders are and you can see how you can personally help make this nursing profession the best ever! This is history in the making and we need everyone.

Leadership Interviews – “3 Questions” – Virginia Saba Wins Award at the 2014 FNLM – NI Awards Ceremony

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

Electronic Health Records…Meaningful Use…Required Patient Care Documentation…Nursing Terminology!


These are among the hot topics of the day in hospitals facing astronomical changes in the technology growth that has affected all aspects of budget, planning, regulation and patient care! These critical issues that are important to nursing warrant rapid dialogue among informed readers, and traditional modes of publishing, like software procurement and implementation, 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 now offers an online environment – “3 Questions” – to engage nurses with nursing leaders in discussions around focused topics that are important for the profession.

In the field of Nursing Informatics, there is no one more well known than Dr. Virginia K. Saba, EdD, RN, FAAN, FACMI, President and CEO SabaCare, who received the FIRST Friends of the National Library of Medicine (FNLM) Nursing Informatics Award for her pioneering work that has rocketed the field of Nursing Informatics nationally and internationally. She gave her remarks at the event on September 14, 2014, in Washington DC. Her publications and manuals are used by many vendors and nurse informaticians to code nursing care. Her comments and opinions are always provocative and she has been instrumental to move the dialogue forward for a nursing terminology that captures the “essence” of nursing electronically, lest our professional actions continue to remain invisible in the electronic health record. Click here to read her comments: Saba FNLM-NI Award Speech Sep 14.

For links to the SABACARE website, click here: SABACARE.

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

Veronica D. Feeg, PhD, RN, FAAN



Virginia K. Saba, EdD, RN, FAAN FACMI

President and CEO, Sabacare



Click on the bars below to listen to each question in the interview.


Question 1. Why is nursing care not visible in the Electronic Health Record (EHR) or Healthcare Information Technology (HIT) systems which are required for the implementation of the HITECH Act of 2009 and primarily for its ‘meaningful use’ legislative requirements?

Today, professional nursing practice is not visible in the electronic health record (EHR) systems primarily because nursing services are not required to be reimbursable.  The HITECH act of 2009, which implemented “meaningful use,” has not included nursing practice in most of its legislative requirements for Stage 1, which was implemented in 2011/2012 and Stage 2, which started in 2013 and is still going on in 2014. They do not specify nursing involvement related to CPOE (which stands for Computerized Provider Order Entry), Quality Indicators, Outcome Measures, or Discharge Summaries.

At this time, the federal agencies responsible for implementing the “meaningful use initiatives” – namely the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator of Health Information Technology (ONC) – do not seem to recognize professional nursing as an essential, independent discipline.  They only seem to recognize those healthcare specialties that are revenue generating because they have established cost values for their coded terminologies that are reimbursable such as the services provided by the laboratory, radiology, pharmacy etc.   However, our professional nursing organizations do not seem to be recommending that nursing departments in hospitals and other healthcare facilities become revenue generating in order to establish costing values for coded nursing services based on a standardized nursing terminology.

The introduction of computers in the patient care setting during the 1970s provided an unprecedented ability both to capture and automatically aggregate nursing care data. Since then, nursing informatics (NI) programs have expanded in our colleges and universities, and the cadre of nursing informatics (NI) certified Experts have emerged.  In 1992, the American Nurses Association (ANA) officially recognized Nursing Informatics as a new nursing specialty. Despite this evidence of successful assimilation of computers by our nursing profession, nursing currently is still invisibile as a member of the healthcare team in the electronic health record (EHR).

The physician-centric focus of the federal requirements for “meaningful use” keeps nursing invisible and puts the needs of nursing in a secondary position.  Currently, nursing departments, as I said, are not revenue generating and do not require [charge] for individual nursing services but remain in the hospital room rate.  Hospitals receive their funding for their nursing staff based on a formula (pre-determined by CMS) that calculates the percentage of the rate per patient for nursing services regardless of the intensity of nursing care required.

Thus the federal government’s incentive program for “meaningful use” provides financial incentives for only physicians and hospitals to implement and utilize electronic health records systems; however, it is virtually ignoring Nursing – and our profession bears much of the responsibility.

Question 2: What is the status of nursing languages in today?  And, are they being used for documenting professional nursing practice?

The American Nurses Association (ANA) has traditionally supported the documentation of nursing practice.  As early as 1970, the ANA recommended that professional nursing documentation should follow the 6 steps of the nursing process.  Since then, the ANA has supported many initiatives and endorsed the integration of computer technology for documenting nursing practice including the development of the criteria for a nursing classification and/or terminology.  In 1992, the ANA recognized the first four of the 12 recognized nursing classifications or terminologies “recognized” today. The twelve languages consist of two data sets, two nomenclatures, and eight classification systems, all of which were developed at different times, by different groups at universities or at private organizations, were structured and classified differently, and are marketed differently.  Also because of the copyright restrictions and how they are structured, the remaining eight classifications cannot be harmonized and even have difficulty being computerized.

Regardless, the ANA does not want to endorse one single free standardized nursing language for the documentation of nursing practice.  As a result, the federal government and the electronic health record system developers or vendors have been presented with the dilemma as to which nursing terminology to endorse, select, and/or recommend.   Because of the different terminology standards review processes the ANA was not able to harmonize or recommend one terminology for the EHR systems.

Furthermore, since several of the nursing terminologies were integrated into the SNOMED-CT, (which stands for Systematized Nomenclature of Medicine -Clinical Terms), the federal government indicated that the nursing terms and concepts in SNOMED CT would be acceptable as a nursing language.  The federal government therefore has designated SNOMED-CT as the ‘interoperable’ standard for electronic healthcare information exchange including nursing which has to map to it to meet federal regulations.

SNOMED- CT was originally developed by the College of American Pathologists (CAP) and distributed in the United States by the National Library of Medicine (NLM) Unified Medical Language System (UMLS) called Metathesaurus.  SNOMED CT is considered to be a reference terminology in that it is similar to a dictionary of thousands of healthcare terms not categorized by specialty but by domains or characteristics. As a result, the nursing terms in SNOMED CT overlap, are not defined, and not easily retrieved for the documenting nursing practice or developing nursing plans of care, making it difficult for nursing to implement in any electronic health record.

Even though nurses represent the largest group of healthcare professionals in hospitals and other healthcare facilities, the nursing profession has not implemented or utilized computers for the documentation of their practice in most hospitals and other healthcare facilities. Furthermore, even though the ANA has outlined professional nursing practice as the documentation of the 6 steps of the nursing process they do not use it to document in actual practice either manually or in any electronic health record (EHR) system. As a result, we have a problem in today’s electronic health record with a mixture of electronic nursing notes that still remain.

Question 3:  Is there a standardized nursing language that can be used for documenting nursing practices? If so what should its characteristics be and why should it be used?

Nursing does have a single nursing language that is free, coded, and has a standardized framework with nursing diagnoses, nursing interventions and nursing outcomes for describing the “essence of nursing care.” It is a unified nursing language with a framework that addresses the 6 steps of the nursing process – namely the Clinical Care Classification (CCC) System.

The CCC System as it is called was empirically developed from research using live patient care data from over 8,000 patients’ documentation for an entire episode of illness.  It consists of two interrelated nursing terminologies: 176 CCCs of Nursing Diagnoses and 528 Outcomes; and 804 CCCs of Nursing Interventions and Actions, both of which are classified by 21 Care Components to for one unified system.  The CCC System is a standardized coded nursing language that has been ‘recognized’ not only by the ANA but also accepted and recognized by the federal government in 2007/8 as a free nursing language that codes “Nursing Care” and has the capability to be exchanged since it is interoperable across settings and systems.                 

The CCC System was specifically designed and developed for the electronic health record (EHR) and requires no licensing fee. It meets all the criteria not only for the ANA but also those recommended by the national standards organizations such as:  the concepts are atomic-level, with a unique identifier that is a code number, explicit definition, has concept permanence (that means they are only used once), and compositionality of the concepts which can combine to form unique concepts etc.  It used a five digit code similar to the coding structure of ICD-10.

The CCC system is used to document nursing practice based on the Nursing Process: assessment, diagnoses, expected outcomes, planned interventions, implementation of the interventions, and evaluation of the patient’s response to the nursing care provided; and also provides unique codes designed to capture all nursing care documentation or nursing plans of care data elements.

Because a single codified nursing language is not being used, our profession has not been able to collect comparable data on nursing practice to demonstrate our value; and, as a result, nursing is being overlooked in the current federal EHR meaningful use initiatives. Instead, vendors are primarily focusing on developing capabilities for physician-centric electronic health record systems that ignore the needs of nurses and that may prevent professional [bedside] nurses from practicing as the independent professionals we’ve struggled so long to become.

If the CCC System was recommended as the primary standardized, coded nursing terminology for documenting nursing practice in the electronic health record, nursing would become “visible.”  The CCC nursing data will be used to measure quality, patient outcomes, workload, as well as the costing out of nursing care.  Such data can also be aggregated to generate evidence from across the continuum of care, showing the positive impact nurses have on patient care. Once a single nursing language is implemented in all EHRs, nursing will be able to communicate effectively and efficiently within and across settings, collect comparable data on nursing practice, become visible, and ultimately provide the federal agencies and healthcare reimbursement entities the patient care data that they need to measure nursing’s unique contribution to patient outcomes.

Nurses must realize the importance of the patient care data they document in providing evidence of the impact nursing care activities have on patient outcomes.

Nursing to embrace the electronic documentation of patient care data is needed in order to prove that what nurses do makes a difference in patient outcomes and to become an independent, visible profession for the practicing nurses.

FOLLOW-UP QUESTION: What is your solution?

My solution is the following: For over 30 years, I have promoted the integration of computer into nursing practice for the benefit of our patients and our profession. Today, we are at the crossroad and can no longer wait for a miracle to happen.  My call to action is for the professional nurses and the professional nursing organizations to demand that the electronic health record systems support coded nursing care data using one unified language that  can be used to document nursing practice based on the ANA’s Nursing Process – namely the CCC System.

That is why I recommend that the CCC system become the nursing profession basic standardized coded language of choice using its framework for collecting the critical data needed to make nursing a visible member of the electronic health care team in the electronic health care systems. This is a critical time for nurses to act! We must become visible to remain viable as a profession.

Leadership Interviews – “3 Questions” – Advancing Symptom Science

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

With the complexity of our health care system in the United States growing, it has become even more important for nursing to parse out the domains most important to patients and families and contribute to the knowledge related to illness and comorbidity through nursing research. Symptom domains such as insomnia, pain, anger, anxiety, depression, nausea and fatigue are among the numerous troublesome problems that patients experience with illness. A symptom or cluster of symptoms may be the result of disease or other etiology, and we need to draw our research attention beyond the disease to formulate evidence based interventions that work.

The nursing science upon which to build our understanding of symptom management is aided by the development of the National Institutes of Health (NIH) development of the Patient-Reported Outcomes Measurement Information System (PROMIS), with the National Institute of Nursing Research (NINR) playing a lead role. This national attention to realize a goal of standardizing research approaches to measurement offers us new ways to advance the state of symptom science. Empirical findings related to symptom assessment and management are essential to inform health policy in efforts to restructure health care systems that meet patients’ needs.

The September October 2014 issue of Nursing Outlook focuses on symptom science with articles that highlight current developments and contributions of the NINR to advance the state of the science in symptom measurement. Dr. Elizabeth Corwin and colleagues discuss a vision for the future with the PROMIS system as a key accelerator, particularly with the potential of “big data” and “common data elements” (CDEs).

Elizabeth J. Corwin, Associate Dean for Research and Professor at the Nell Hodgson Woodruff School of Nursing, Emory University in Atlanta Georgia. She is also PI and Co-PI on NIH grants related to clinical symptoms, and author of the textbook Handbook to Pathophysiology.

For links to the PROMIS website, click here: PROMIS.

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


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

Veronica D. Feeg, PhD, RN, FAAN

Elizabeth J. Corwin, PhD, RN, FAAN
Nell Hodgson Woodruff School of Nursing
Emory University, Atlanta, GA

Question 1. What is different about nursing symptom science now compared to previous years that led your group to call for new ways to envision the future?

To listen, click here.

The culture has really changed in terms of what is expected and what are the possibilities for nursing symptom science. For example, in the past it has often been individual researchers working alone or with just one or two others to ask questions that involve small groups of patients or families. And now we have the capability to think about the big picture including complex interactions between symptoms and across populations. We can share data. We can utilize big data. It’s really an opportunity to jump forward with our research. And the emphasis to start thinking about the bigger picture, and pulling together diverse groups and patients and families has come from the National Institutes of Health itself, which has encouraged data sharing for the common good to really improve outcomes for families and patients.

So, it really is coming from that emphasis: to share data, use resources widely and for the best good for all. Also, with the National Institute for Nursing Research, the emphasis on centers and across all NIH institutes, the emphasis on interdisciplinary work and teams has allowed for new perspectives on diseases, interventions and self-management to really come into light in a way that hadn’t been before.

Another thing I think that has changed that is really driving the future of nursing symptom science is that so many nurses have moved into very very important advance practice roles. And when you’re in advance practice, it is obvious that diseases and symptoms are very complex. And there’s a great deal of overlap between the biological underpinnings of any given symptom, for example fatigue or depression, or pain. There are biological underpinnings [that] overlap across diseases and across populations. And so being able to look at the complex interactions, both from seeing it in real life as a clinician and then thinking about the mechanisms, has made symptom science jump forward. And we have to connect across diseases and across populations to ask questions that are complex but still patient focused. Maybe the best way to describe this is that ultimately it’s personalized healthcare – that includes patient’s perceptions of his or her symptoms as well as the individual context of that symptom, his or her genetics and epigenetics – all are available to us now – these huge opportunities to pull together these complex pieces that will allow patient care and prevention and reduction of symptoms to really be individualized in a way that we never had opportunity to do before. And never even had a perspective of how to think about this potential!

Question 2. What are CDEs and how will consensus on CDEs be attained and their use actualized?

To listen, click here.

Common data elements (CDEs) is a broad umbrella, and it includes measures of symptoms for example – so screening forms, questionnaires – different types of ways to get at individuals’ symptoms. So it does include measures. But, common data elements are more than that. It is any pieces of data – all pieces of data – that are gathered in a study that can be shared. For example: demographic data is a common data element. You can have demographics on gender, age, socioeconomic status, race, ethnicity and a number of other pieces of common data elements that are demographic in nature.

So those are two types: demographics and measures. But then it goes beyond that and it can be clinical indicators. So you can have across populations: hemoglobin A1C, or brain imaging data, genetic data, epigenetic data, telomere length. All of these pieces of information that are gathered within one study can be shared if they are coded the same and available to other researchers. These pieces of information can be shared across studies, across populations, across disease conditions. For example, you can have individuals looking at telomere length, the marker of chronic stress exposure. And you can have those measures in a population of caregivers of Alzheimer’s patients or family members who are caregivers. You can also have telomere length data available for mothers who care for children with cystic fibrosis, or, for patients with heart failure. And these different populations of study participants or patients could be 90 years old, or they could be 12 years old. Yet some of their symptoms can be the same or they may be different – and you could look at the impact of common data elements, the measures, questionnaires you use, the age, the gender, the socioeconomic data, the clinical markers, the brain imaging information, the epigenetics, the genetics. You can share these common data elements between studies, between patients with different conditions, between many different levels to evaluate what’s similar and what’s different, for example, across gender in patients with different diseases.

Common data elements are those bits of information that we use to keep about just one population, one small study – that now, if they’re coded the same and individuals have access to them, can be shared across populations, diseases and studies.

Now in regard to your question on how can consensus on CDEs be actualized? Well that’s difficult in some ways because many of us use questionnaires, for example, that we have used for a long time and they might be (I’ve heard the term used – legacy surveys or questionnaires) “legacy measures.” And so it is sometimes difficult to give up a legacy measure that you have used for a long time and start using a different measure for that same symptom for example. There are reasons that people don’t want to give those up. You can refer back to your previous research if you’re using the common tool and common measures as opposed to not having any standard that you could go back. But the benefits are that then others will also be able to build on your research, extend it, and ask new questions – more complex questions.

So how does that consensus happen? How is it built or agreed upon? Well I think NIH has done that and many institutes or have done that already. It seems that the process is generally that individuals are brought together to perhaps discuss the idea at the earliest stages and then put it out to the community that will be involved, to get input, get feedback, get ideas going back and forth. Do this respectfully and as an inclusive group not exclusive, hear all points of view and work towards identifying the key common elements that studies can share, or, should be encouraged to share. And then perhaps there still could be other measures or tools that an individual researcher wants to include in his or her own research. But adding even just a few that across studies, for example, perhaps across centers that are all aiming towards the same research goals – like self-management centers or cognitive centers – having some common data elements across all centers that have been agreed to by consensus through mutual discussion and respect, and analysis of the available literature. Using these common measures, then, can be added to supplement other measures that people still want to use (some previously studied measures in their own populations). So it will take consensus. Consensus will take development, it takes time, it takes inclusion, it takes in listening to people and then it takes identifying the key pieces of information that most people will agree can be shared across studies.

Question 3. What challenges arise when nurses try to translate their findings into policy? How will the new future in symptom science described in this article address those challenges?

To listen, click here.

The challenges nurses face when attempting to translate their findings are not just unique to nursing. But one piece might be that we often have small sample sizes, especially if we’re interested in unique questions or populations, the sample sizes might be small. And so in the past when everyone was just doing research individually, it was difficult to change policy with sample sizes of 50 or 60 or 100 or 160. But now the opportunity to share data across groups by the use of common data elements and hopefully someday a common data repository that individuals could have access to. Being able to share that sort of data across populations gives power to our own smaller studies [so] that we can start asking bigger questions because we can add to our sample size. The power is improved. So by this way, we will have a chance to change policy.

In addition, as discussed in our manuscript, we will be able to ask more complex questions. For example, previously in our research, even though as nurses we knew that the expression of symptoms depend on the context for the patient – whether the patient is experiencing them at home versus in the hospital, or has his or her partner with them makes a difference, or, whether they are out with their grandchildren that day, or staying at home alone. Context matters. But until the time of big data, until we had the tools to analyze symptom outcomes and patient reports as part of a big data set, it was very difficult to influence policy because we couldn’t include context and how important context is into the presentation to try to affect policy. But now that we can address something like context by big data usage and common data elements, we have a chance, really, to impact patients in ways that are very very meaningful.

Also, previously we considered perhaps one aspect of an intervention, for example, patient satisfaction. But now, having access to other data sets that we can merge with, for example, that one outcome (patient satisfaction), we can now merge that with big data sets on hospital readmission, or, costs to the consumer or to the state. You can merge those data sets now. We will be doing that, and, especially if we code them and have access – common data registries. We will be able to ask those very very complex questions and answer them in ways that can lead to policy change.

So using big data – and that was one of the underpinnings of this discussion – big data will allow us to consider other contributors to patient outcomes, to symptoms, to satisfaction and self-management. We can consider these for larger impact, and so we will have a greater success in actually changing policy. When you can bring in more stakeholders by merging data sets that will become available, the impact of our research grows.

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:

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

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?

To listen, click here.

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?

To listen, click here.

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?

To listen, click here.

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.

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

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?

To listen, click here.

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?

To listen, click here.

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?

To listen, click here.

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?

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.

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


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?

To listen, click here.

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?

To listen, click here.

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?

To listen, click here.

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.

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 –

Assault Weapons Ban of 2013 House –

Safe Communities Safe Schools Act Senate –

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


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? 

To listen, click here.

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?  

To listen, click here.

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?

To listen, click here.

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.

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


Joanne M. Hall, PhD, RN, FAAN


University of Tennessee College of Nursing

Knoxville, Tennessee



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?

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?

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?

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.

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


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?

To listen, click here.

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.”