Category Archives: Voices from the Field
If we want to create a Culture of Health in America, a 2015 priority must be to focus on ways to break down the barriers that separate us and keep us from being as effective and efficient as possible. Currently, health care systems, education, housing, and public health work in siloes; they are funded in siloes, and workers are trained in siloes. Yet, people’s concerns and lives are not siloed and a community health culture/system cannot be either. One of the places to begin coordinated cultural change is in schools.
Schools are a smart choice to target because nearly 98 percent of school-age children, in their formative years, attend school and schools provide access to families and neighborhood communities. The Department of Education’s Full-Service Community Schools Program and Whole School, Whole Child, Whole Community Initiative reminds us that, in order for children to be educated, they need to be healthy and there must be a connection between school and community.
There are many school health initiatives in place, such as healthy food choices, physical fitness, healthy policies, school health services, community support, and after-school programs. The potential is there—but so are the siloes. But when schools are appropriately staffed with school nurses, the nurses help break down the siloes; that is because school nurses are extensions of health care, education, and public health and thus can provide or coordinate efforts to ensure a holistic, resource efficient, healthy school community.
Rachelle Bernacki, MD, MS, is director of quality initiatives in the department of psychosocial oncology and palliative care at the Dana-Farber Cancer Institute, associate director of the Serious Illness Care Program at Ariadne Labs, and an alumna of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program (2004-2006).
The Institute of Medicine recently released a report entitled Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. The news headlines read: “Panel Urges Overhauling of Health Care of End of Life.”
Here’s why: Most Americans wish to die at home and want to avoid heroic measures to keep them alive. Yet most die in institutional settings like hospitals and nursing homes, and 20 percent die in intensive care units.
The transition of death from the home to institutional settings over the past 40 years has been promoted by the advent of new medical technologies. While these remarkable technologies can be life-saving for certain patients, for many others aggressive therapies may simply prolong the dying process and extend suffering. In addition, many patients who die in institutional settings die with undertreated pain and difficult or labored breathing. And many report inadequate communication with their physicians about their end-of-life preferences.
Numerous studies show that patients want to have conversations about their end-of-life care and expect their physicians to initiate these discussions. When these conversations occur, there is greater alignment between patients’ wishes and the care they receive; higher patient quality of life; less frequent use of non-beneficial life-sustaining treatments; more use of hospice care; reduced family distress; and reduced resource use and costs. However, many physicians do not feel comfortable having these conversations and, in fact, identify more barriers to having these discussions than do patients.
Tatiana Sadak, PhD, PMHNP, is an assistant professor at the University of Washington School of Nursing and a Robert Wood Johnson Foundation (RWJF) Nurse Faculty Scholar (2013-2016). She is working to promote “dementia caregiver activation,” a process of preparing caregivers to become ready to manage the multiple needs of loved ones with dementia while caring for themselves.
The well-documented personal and societal burdens of dementia are the central focus of the National Alzheimer’s Plan, which calls for extensive reforms in the delivery of health care for patients with dementia and their family caregivers. RWJF answered this national call to action by funding several innovative dementia health services research projects and nurturing the careers of junior dementia researchers.
I was fortunate to receive RWJF Nurse Faculty Scholars funding. It will make it possible for me to focus a majority of my time on improving health services for people living with dementia and for their family care partners—or ‘caregivers.’
Dementia patients suffer brain failure that leads to progressive loss of autonomy and the inability to understand and meet personal health care needs. Clinicians conduct health assessments, create care plans, and treat symptoms, but it is dementia family caregivers who deliver the day-to-day care and health management these patients need. There is, however, considerable variation in their capacity to assist care recipients in making health care decisions, for providing daily care, and for navigating health care systems.
Barbara Bricoli, MPA, is executive director of Nurses Improving Care for Healthsystem Elders (NICHE), an international program based at New York University’s College of Nursing that is designed to help improve the care of older adults. The program was developed by Terry Fulmer, PhD, RN, FAAN, chair of the National Advisory Committee for the Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellows program.
The rapid expansion of the aging population is a national concern. Nearly 20 percent of the U.S. population will be over age 65 by 2030, according to the U.S. Administration on Aging. And our aging population will place a heavy burden on our health care system; older adults, in fact, are hospitalized at three times the rate of the general population.
Yet health care providers lack adequate training in geriatrics and gerontology to care for older patients. Nurses Improving Care for Healthsystem Elders (NICHE) is working to change that.
Based at New York University’s College of Nursing, NICHE aims to better enable hospitals and health care facilities to meet the unique needs of older adults and embed evidence-based geriatric knowledge into health care practice. Hospitals and organizations that adopt NICHE report improved outcomes, decreased lengths of stay, better patient and staff satisfaction levels, and higher success in building systemic capacity to effectively integrate and sustain evidence-based geriatric knowledge into practice.
Lisa Cooper, MD, MPH, FACP, is the James F. Fries Professor of Medicine at Johns Hopkins University School of Medicine, Director of the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, and an alumna of the Robert Wood Johnson Foundation (RWJF) Harold Amos Medical Faculty Development Program.
Have you ever had the experience of being sick and in need of help from a health professional? How about having a parent, child, other family member, or friend who had some health issue for which he or she was seeking answers? What was that like for you? How did you feel, and what were you looking for from that doctor, nurse, or therapist?
Did you ever feel afraid, and alone? Confused? That no one understood what you were going through? Or cared? Or even worse, that the health professionals may have made some assumptions about you or your family member that were wrong – even perhaps blamed you for having your condition or judged you for how you were dealing with it?
If so, you are not alone. Many people who find themselves in the role of a patient have felt these same feelings and had these same thoughts. And if you are poor, don’t have private health insurance, or if you are a person of color or belong to another minority group in our country, you are more likely than others to encounter these problems.
Amani M. Nuru-Jeter, PhD, is an associate professor of community health and human development, and epidemiology at the University of California, Berkeley School of Public Health, and an alumna of the Robert Wood Johnson Foundation (RWJF) Health & Society Scholars program. Her research focuses on racial health disparities.
Eric Garner’s death and the failure to indict NYPD Officer Daniel Pantaleo have had a profound effect on communities throughout the United States. But it’s not just Eric Garner. This, and similar cases including Michael Brown, Tamir Rice, Trayvon Martin, and Oscar Grant, have put race relations front and center in the national debate.
I’m tired of it, this stops today...every time you see me you want to harass me, you want to stop me...please just leave me alone” –Eric Garner
These last words from Eric Garner are not that different from what we hear in our work with African American women in the San Francisco Bay area:
Cynda Rushton, PhD, RN, FAAN, is the Anne and George L. Bunting Professor of Clinical Ethics and a professor of nursing and pediatrics at Johns Hopkins University. She is an alumna of the Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellows program (2006-2009). In 2014, she was named a Hastings Center Fellow for her work in bioethics.
Human Capital Blog: Congratulations on being named a 2014 Hastings Center Fellow. What does this fellowship mean for you and your career?
Cynda Rushton: It’s a wonderful honor to be included in this interprofessional group of scholars of bioethics. It’s a terrific opportunity to cross-pollinate with great thinkers and leaders and to think about some of the most vexing ethical issues in health care. It’s going to be a rich container for dialogue, learning, and leadership.
HCB: How will the fellowship work?
Rushton: Fellows have the opportunity to help guide the direction of the Hastings Center, which is an independent, non-partisan and nonprofit bioethics research institute in New York. The center’s mission is to address fundamental ethical issues in the areas of health, medicine, and the environment, and we’ll be bringing up issues that we think deserve more in-depth scholarship and research. This summer, we’re having a retreat where we will be able to work together around issues of common concern, particularly in the area of bioethics.
HCB: What will you focus on as a fellow?
Rushton: My focus has been on how to create a culture of ethical practice in health care. I’m interested in what is required to create that culture and what kind of individual competencies need to be in place to support people to practice ethically and reduce moral distress.
Justin List, MD, MAR, MSc, is a Robert Wood Johnson Foundation (RWJF)/VA Clinical Scholar at the University of Michigan and primary care general internist at VA Ann Arbor Health System. His research interests include community health worker evaluation, social determinants of health, and improving how health systems address the prevention and management of non-communicable diseases.
The emergency sirens sounded loudly for the rising burden of chronic disease in 2014. Chronic diseases, also called non-communicable diseases (NCDs), broadly include cardiovascular disease, chronic respiratory disease, cancer, and diabetes. In 2014, we learned that, overall, 40 percent of Americans born between 2000 and 2011 are projected to develop diabetes in their lifetimes. This is double the lifetime risk from those born just a decade earlier. Rates of obesity, a condition related to many NCDs, remains stubbornly high in the United States. Mortality and morbidity from NCDs, not to mention the social and economic costs of disease, continue to rise.
The United States is not alone in the struggle with a well-entrenched NCD burden. At the end of 2014, a Council on Foreign Relations task force issued a report with a clarion call for the United States to aid in addressing NCDs in low- and middle-income countries (LMICs) where the epidemic of chronic disease poses risks to communities, economies, and security. The task force, which included RWJF President & CEO Risa Lavizzo-Mourey, MD, MPH, among its members, recommended: (1) U.S. global health funding priorities expand from disease-focused objectives to include more outcome-oriented measures for public health; and (2) the United States convene leading partners and stakeholders to address NCDs in LMICs.
Today, we can get access to just about anything in minutes or hours. Smartphones put a world of information literally at our fingertips. Within minutes, most of us can get food we want, entertainment we desire, even travel to another city. But seeing a doctor, an arguably more immediate need, is not so easy. Creating a Culture of Health requires our collective interdisciplinary expertise to make health and health care as accessible and user-friendly as other products and services we use on a regular basis.
Before I left academia, I heard the word “interdisciplinary” tossed around a lot, but I saw it practiced in very safe ways. Typical research teams of grants I was on or would review comprised researchers from only the social, psychological, and health and medical sciences. As public health faculty, I’d hear statements like “Public health is inherently interdisciplinary.” This may be true since public health draws from multiple disciplines, but I couldn’t help but feel that such statements were more a reflection of inertia than anything else.
Malia Davis, MSN, RN, is a nurse practitioner and the director of nursing and clinical team development at Clinica Family Health Services in Lafayette, Colorado. She has cared for patients in the community, including those who are homeless, for more than a decade. She is a 2014 Robert Wood Johnson Foundation Executive Nurse Fellow.
Social and economic disparities define my work each day, and have provided powerful motivation for me to commit my professional life to attempts to minimize these disparities in the health care setting. Community health centers, which provide health care for the homeless, are where some of the sickest and poorest people in our communities seek medical and behavioral health care from people like me, a nurse practitioner who is honored to serve each of these individuals and families.
I believe one common misperception is that some of my patients fail to contribute to society. Working in community health care for 12 years—10 of them serving homeless people—I have found that most people are very hardworking. Many work at day labor and other low-wage, temporary jobs that are physically demanding and fraught with challenges of all kinds. I often hear of workers experiencing abuse, failing to get paid, and experiencing unsafe working conditions.
They have, of course, none of the benefits we usually associate with jobs. Instead, they face the stress of not knowing day to day if they will find work and be able to support their families—or not. This stress is often compounded by the personal experience of witnessing, surviving, and overcoming trauma or violence, often while in poverty and with very limited resources for healing physically or emotionally.