Nursing Outlook TALK
3 Questions – Kathryn Laughon on the Policy Brief “Recommendations in Response to Mass Shootings”
Welcome to the Nursing Outlook Blog – “3 Questions” – Timely Interviews with Thought Leaders in Nursing and Health Care Policy
Policy Brief: R. Gonzalez-Guarda, E.B. Dowdell, M.A. Marino, J.C. Anderson, K. Laughon (2018). American Academy of Nursing on Policy: Recommendations in Response to Mass Shootings Policy Brief. Nursing Outlook, Volume 66, Issue 3, 333 – 336.
When Americans attend large events in public places or when children go to school to learn or families go to church to pray, they should feel safe and not afraid. The mass shootings and rampant gun violence in this nation has reached unthinkable records. It has affectedus deeply and we needto stop offering our thoughts and prayers to survivors and families, but to garner the public support to take steps toward addressing the incomprehensible actions that are perpetrated by individuals without remorse. The national debate has been loud and public. Our nursing organizations are poised for positive change. Our profession cares about the health of people collectively and with resolve, and we have taken to the stage with policy recommendations to reduce gun violence published in Nursing Outlook (American Academy of Nursing on policy: Recommendations in response to mass shootings – 2018) with our leadership speaking out on the federal policy stage.
On September 26, American Academy of Nursing President Karen Cox spoke at the House of Representatives “Gun Violence Prevention Task Force” press conference, hosted by Representatives Lauren Underwood (D-IL), Mike Thompson (D-CA, Chair), Lucy McBath (D-GA), and Jahana Hayes (D-CT).She listed the 7 evidence-based recommendations that included:
- Creating a universal system for background checks designed to highlight an applicant’s history of dangerousness and require that all purchasers of firearms complete a background check.
- Strengthening laws to assure that high-risk individuals, including those with emergency, temporary, or permanent protective or restraining orders or those with convictions for family violence, domestic violence and/or stalking, are prohibited from purchasing firearms.
- Banning the future sale, importation, manufacture, or transfer of assault weapons, and calling for a more carefully crafted definition of the term “semiautomatic assault weapon” to reduce the risk that the law can be evaded.
- Ensuring that health care professionals are unencumbered and fully permitted to fulfill their role in preventing firearm injuries through health screening, patient counseling, and referral to mental health services of individuals with high-risk danger behaviors.
- Focusing federal restrictions of gun purchase for persons on the dangerousness of the individual and fully funding federal incentives for states to provide information about dangerous histories to the National Instant Check System for gun buyers.
- Supporting enriched training of health care professionals to assume a greater role in preventing firearm injuries through health screening.
- Researching the causes of and solutions to firearm violence. (https://doi.org/10.1016/j.outlook.2018.04.010)
Dr. Cox thanked the Violence Prevention Expert Panel for its prompt preparation of the policy brief that further describes the issue of gun violence and presents the evidence behind the seven recommendations published in this issue. This timely response by our collective voices is critical as we work to craft policies with the potential to have a national impact.
We interviewed Dr. Kathryn Laughon, one of the authors of the policy brief, to discuss the issue of mass shootings and speak about key policy aspects to reduce gun violence using our 3-Questions format. Dr. Laughon, a forensic nurse examiner and associate professor at the University of Virginia, School of Nursing, has focused her work on a range of issues related to intimate partner violence and its impact on women and children. She offers us insight into the raging epidemic of gun violence and offers ways that nurses can advocate for change.
We invite commentary that is thoughtful and provocative! Join the online dialogue!
The policy brief authors would also like to acknowledge the contributions of Gordon Lee Gillespie, PhD, DNP, RN, CEN, CNE, CPEN, PHCNS-BC, FAEN, FAAN, Rachell A. Ekroos, PhD, APRN, FNP-BC, AFN-BC, FAAN, Annie Lewis O’Connor, PhD, NP-BC, MPH, FAAN, Eileen M. Sullivan-Marx, PhD, RN, FAAN, and the members of the American Academy of Nursing Violence Expert Panel for reviewing and providing suggestions for this policy brief.
Veronica D. Feeg, PhD, RN, FAAN
Kathryn Laughon, PhD, RN, FAAN
ASSOCIATE PROFESSOR OF NURSING
DIRECTOR OF THE PhD PROGRAM
UNIVERSITY OF VIRGINIA
Question 1. How does your 2018 policy recommendations relate to the recent mass shootings? What did we know then that we know now? Do you think anything has changed?
I think our recommendations basically still stand. There have not been major legislative changes in the past 18 months since these recommendations first came out. What we know from the point of view of the evidence is that reducing access to firearms absolutely reduces mortality from firearm homicides and that’s of individuals and mass shootings as well.
There is, I believe, major public support for the idea of reasonable restrictions on access to firearms, so that individuals who have been adjudicated to be dangerous through protective orders in the case of domestic violence (several states now are passing “red flag” laws that allow individuals to be identified as perhaps being a danger) and having then, their access to firearms restricted. These laws absolutely work! So we’ve seen that on country levels and we see that in the United States at the state levels – states that enact stricter laws see a drop in their firearm related homicides, and that states that loosen these laws, see an increase.
Question 2. What are the key policy aspects that need to continue to be addressed in this area (i.e. Risk factors? Access to firearms? Missed opportunities?)
So I would put the policy issues in a couple of bins. One is this idea of limiting access to firearms, and limiting access to the type of firearms that individuals can buy, sell, trade, possess. We know that folks who have been adjudicated as dangerous – at the federal level, domestic abusers (I believe is the federal term) may not possess firearms. Those laws exist at the state level as well. There are a number of loop holes in those laws so they typically don’t come into effect until a permanent protective order has been obtained, for example, (and the protective order process is a three stage process) so it’s not until you get to the third stage. It is very difficult in most states to remove firearms. So if a person has a protective order and they are not allowed to possess a firearm, it is difficult to actively remove the firearm. We just have to rely on the individual to not use the firearm, and that is obviously a problem.
When we talk about mass shootings, let’s be clear there are several definitions out there, but the most usual definition of a mass shooting is four or more individuals are killed, not including the shooter, and most of those happen in private homes and among family members. And while it’s the large mass shootings in public places that get a lot our attention, most of the gun homicides happen in these smaller settings among people who know each other. And so there is a real danger to these guns being possessed in the home by people who have already been adjudicated to be too dangerous to have them.
There are loopholes in these laws so that boyfriends, we often call it the boyfriend loophole, so that boyfriends and girlfriends – people who have not been married – are not covered by the federal law and they are not covered by many state laws. Additionally we know and we see it now when we look at some of the mass shootings is that these shooters have often a history of violence against women, but perhaps not have a history of violence against a domestic partner. So they may have a history of abusing their mothers, for example, and we have seen that in some of the shootings where the shooter has killed his mother before going on (I believe that was in Sandy Hook) to enact that shooting. So “red flag” laws that would allow for individuals like the shooter in the Parkland shooting – who many people had recognized was a danger but had no legal mechanism to prevent him from processing firearms – these “red flag” laws would help provide additional tools. So there are some states that have passed “red flag” laws – there is a move right now at a the federal level that the Extreme Risk Protection Order Act is working its way through the Senate right now.
The other issue that we have not talked as much about, but that is becoming clearer and clearer is the intersection between white supremacy, violence against women and mass shootings. And we have now seen a number of mass shootings that fairly clearly have a white supremacist intent have been enacted by people who also have a history of violence against women, and I think we need to be paying more attention to this. So that’s one of sort of bin of laws of being able to identify individuals who are at risk and insuring that they don’t have access to firearms, or if they have firearms, that they have those firearms removed.
Question 3. What role(s) have you played in your own research and advocacy work that can influence other nurses to follow your lead? What can nurses do?
So I think that there really are two roles for nurses in addressing firearm violence. One is in our scope of practice: as nurses we ought to be talking to people about firearms and about firearm safety. And there are a number of toolkits out there to help guide nurses in various settings, but when dealing with pediatric populations, we should be talking to parents about safe firearm storage. Firearms need to be stored in locked gun cabinets with ammunition stored separately, and children should not have access to these firearms. The number of shootings by children of children because they have had access to a firearm that they shouldn’t have had access to is heart breaking. And that is 100 % preventable, when parents practice good solid gun safety that all gun owners should endorse.
We know that most women who are murdered by a partner have been seen in a healthcare setting and have not had a screening for intimate partner violence. So that again is something that nurses – it’s within our nursing scope of practice – we should be talking to women, asking them about their history of intimate partner violence – and referring them to experts (either social workers with in their own systems or to their state and local and national hotlines) to help connect women to safety planning, so that they can take action to stay safer. So that’s all within the nursing scope of practice.
I think that nurses are also amazing advocates for legislative change. We are credible; people believe us; we have clinical experience; we have stories to tell; and we have the training to read the research and synthesize it and tell our legislators what we want. So as nurses, we ought to be speaking to our members of Congress at the federal level, to our state legislators, and lobbying them to make changes in laws that will keep people safer. This is a matter of public health and something that all nurses should feel strongly about, I think. I think we need to be using our collective power better than we have so far.
Leadership Interviews – 3 Questions with Living Legend Jacquelyn Campbell
Welcome to the Nursing Outlook Blog – “3 Questions” – Timely Interviews with Thought Leaders in Nursing and Health Care Policy
2018 American Academy of Nursing Living Legend – Jacquelyn C. Campbell
Dr. Jacquelyn Campbell is a widely respected leader in research and advocacy in domestic and intimate partner violence (IPV). She holds a joint appointment in the Bloomberg School of Public Health and is the Robert Wood Johnson Foundation (RWJF) director of the Nurse Faculty Scholars Program. She has received numerous awards and recognitions including: Pathfinder Distinguished Researcher by the Friends of the National Institute of Nursing Research (FNINR); the 2011 Sigma Theta Tau International (STTI) Distinguished Research Award; the 2005 American Society of Criminology Vollmer Award; the IOM/AAN/ANF Scholar-in-Residence appointment for 2005-2006; the Health Care Heroes 2005 Nurse Hero Award; and the Maryland Network Against Domestic Violence 2004 Education Award. In 2018, she was named a Living Legend in the American Academy of Nursing (AAN) recognizing her outstanding contributions to the field of research in violence against women.
Dr. Campbell’s work is extensive and her commitment to supporting victims of domestic violence is ubiquitous. She was appointed by Congress to the U.S. Department of Defense (DOD) Task Force on Domestic Violence and has worked extensively with the DOD, using her research to impact policy including legislation related to gun violence and the Violence against Women Act (WAVA).
Dr. Campbell served on the Board of Directors of the House of Ruth Battered Women’s Shelter and three other shelters. Internationally, she co-chaired the Steering Committee for the WHO Multi-country Study on Violence against Women and Women’s Health. With over 200 published articles, 7 books, and as Principal Investigator on 10 major NIH, NIJ or CDC research grants, she has been a tireless champion for women and an active leader in nursing.
We interviewed Dr. Campbell, focusing on her domestic violence research and its implications in health policy using our “3 Questions” format. She speaks about leadership as an exemplar of how nursing can rise to affect women’s health in general and IPV specifically.
Veronica D. Feeg, PhD, RN, FAAN
We invite commentary that is thoughtful and provocative! Join the online dialogue!
JACQUELYN (JACKIE) C. CAMPBELL, PhD, RN, FAAN
ANNA D. WOLF CHAIR, THE JOHNS HOPKINS UNIVERSITY SCHOOL OF NURSING
NATIONAL PROGRAM DIRECTOR, ROBERT WOOD JOHNSON FOUNDATION NURSE FACULTY SCHOLARS PROGRAM
Question 1. Can you talk about the DoD work, VAWA and other domestic violence research in your career that helped you make the policy differences that you have made?
I have been very fortunate to be able to work on a number of policy initiatives. One of the earliest national policy work I did was with the Department of Defense (DoD) when I was named to a task force to address domestic violence in the military. There was a number of us, it was an interdisciplinary group, I was the only nurse on board, and we went around the country getting input from both the victims of domestic violence. We also talked to offenders who had been identified as using violence against their partners. We also talked to the military personnel on Marine bases, on Army bases, on Air Force bases. We actually went to Japan and talk to people on the bases from the Navy in Japan.
So, we really got a broad picture and we came together on making some recommendations in terms of how the military could address domestic violence, and how there could be a better coordinated response. The military took us up on a number of those suggestions in terms of doing a better job of coordinating things amongst different parts of the military – doing a better job when a case would come before them – and they would recommend that the offender go to an offender intervention program, and then the offender got deployed to some international post. So what’s supposed to happen then?
We really think we made a difference. We wanted the military to do an anonymous survey every couple of years in all the branches to really determine the prevalence and to see whether or not these new policies were effective. They have never put that part into place. So, the research part, they didn’t do, which we’ve always thought was a shame that it didn’t happen. But it did allow me to see, first of all, that working together with other disciplines, using research to inform what we were talking about to the military. One of the things I was able to do was to make sure that the healthcare providers that served military population did a better job in terms of asking about domestic violence and addressing that in health care settings; used some of my research about the effects of domestic violence on health to inform them about that. That was very important for them to hear the evidence.
And the same kinds of things in terms of my work on the Violence against Women Act (VAWA) (the original one back in the 80s) and the reauthorizations. I haven’t actually testified per se on behalf of the Violence against Women Act, but I have provided research evidence to others who have testified.
And again, you can’t be concerned about you being in the limelight all the time, but rather informing those who do testify what the latest research says.
I especially have research on both risk of homicide in domestic violence cases and I have research on those physical and mental health effects. I was asked to testify on the issue of guns and removing guns from known domestic violence offenders. Not to get too far into the weeds, but closing the boyfriend loophole. People may have heard about it; it’s still an issue that we haven’t been able to do nationally. Many states make orders of protection apply to dating partners as well married or cohabiting partners. And the boyfriend loophole says that unfortunately in many states, those laws in terms of removing guns from known domestic violent offenders don’t apply if it’s a boyfriend rather than a husband or someone that you have children in common with.
So that’s something we’ve been working on for a long time. As I said, many states have passed laws to address that. But there are some states that never will, given their current makeup of their representatives on the state level. And so unless we do some of these things on the national level – the true reduction in domestic violence/homicide with guns – we won’t be able to see nationally.
The work has been very rewarding. I continue to be asked to weigh in on various policies, to educate legislators about some of the laws that are under play, the newest re-authorization of the Violence against Women Act has been passed by the House of Representatives. It has not been passed by the Senate. And that is an area that I continue to work on.
So the work doesn’t end. And, doing the research is very important – to make policy recommendations be informed by research findings be evidence based.
Question 2. Can you talk about the importance about mentoring scholars in violence and trauma in nursing as well as other disciplines?
One of the things that I’m the most proud of, and one of the things that I love doing the most is mentoring young scholars – especially in nursing but also in any discipline – who are interested in doing violence research and who I can help guide toward doing meaningful research. One of the things I always say when I present is I have hundreds of research ideas – research that needs to be done. I don’t have time. What I love the most is when there’s a PhD student who wants to actually do one of those ideas for a research study I have. And I have been very fortunate to have a mechanism (a T32) which is an NIH funded pre-and post-doctoral training grant. The current version of it is in trauma and violence, and funded by NICHD. And that allows me to not only do my mentoring but also to be able to support with a stipend and with some small additional research funds that students can use to go to conferences etc.
The T32 actually allows me to actually support them to do that work, and attracts them to come to Hopkins. One of the things about Johns Hopkins as with many institutions – we have violence researchers in all of our departments. So our T32, the pre-doctoral fellowship has us supporting three students from the School of Public Health as well as two Nursing doctoral students. They all come together in a seminar – a violence research seminar – that I get to teach and arrange to have other members of the faculty of the T32 to come and present their research to the students. That way the students all learn together, they get to know each other, they work in an interdisciplinary network that they can use for the rest of their careers to support each other – to cheer each other on (which is an important part) as well as that I can provide some mentoring for all of them. But I can also arrange good mentoring, advisor matches, within their own school – within their own discipline.
The other thing I’ve been very fortunate that I was able to be the National Program Director for the Robert Wood Johnson Foundation Nurse Faculty Scholars Program. Now, not all of those scholars were doing research in violence, but some of them were, and some of them had gotten their PhDs in a violence related field, so I particularly reached out to them and said “be sure to apply” – not that I could guarantee them being accepted. But I was able to get a number of them who do violence and trauma work at various stages, to be part of nurse faculty scholars. And that’s another network where people support each other, where people talk about their own area of research and other people seek connections with theirs, and they can do some work amongst different nursing researchers.
The other thing we were able to do with the Robert Wood Johnson Foundation funding in conjunction with the Foundation, and with our wonderful steering committee, executive committee, was to actually do some evaluation of the kind of mentorship we provided. Part of that mentorship was my vision, Angela Barron McBride was my co-leader (she was chair of the national advisory committee). We worked together a lot on providing this mentoring scheme. And of course I used what I had learned in the T32, which I’ve had for a total of now almost 20 years. So I was able to put some of what I had learned into the Nurse Faculty Scholars mentorship model, and was able to learn from that mentorship model for making our T32, the pre- and post-doc program, that much better.
I also mentor other students, other PhD students in nursing as an advisor who are not part of the T32. We just finished the dissertation and one of my mentees, she just graduated. She did research about how strangulation from partners ought to be dealt with in the emergency department. So she’s going to be coming out with some practice guidelines. It’s very exciting work! I’m more than happy to support her, her help get those practice guidelines in good places. She did work, she did the research, and here’s another person who’s been trained to do violence related research from a nursing perspective with nursing outcomes.
I’ve also mentored some of the junior faculty in our School of Nursing who are going toward their own research careers. One of the things I’m proudest of being part of the journey of one of our first – actually our first Native American faculty member in the School of Nursing, who now has a PhD, and she just got her first R01. I’m only a small part of her journey, I’m one of her mentors. But it’s exciting to see. Her research is on historical trauma and Native American children being exposed to ACES (adverse childhood experiences), and what that combination of adverse childhood events plus historical trauma has to do with the suicidal ideation that so many Native American youth are experiencing, and where we see rates of suicide amongst Native American youth being higher any other racial-ethnic group.
So that’s the kind of thing that I’m proudest of – is when the people I have mentored go on and do even better research than I could have ever thought to do. That’s incredibly exciting.
Question 3. How do you describe the big picture visions in your science now?
I am always amazed at how much there is to learn about violence, how we can prevent violence, how experiences of violence affect people’s brains. We in nursing, I think, come at this in a way that is especially important. We’ve always talked about and done our research from what we call a holistic perspective. And this is, I think particularly relevant in issues about violence and trauma, because we are learning more and more that, especially early experience of violence when you’re a child or adolescent, actually makes changes in one’s brain. That the more traumas and violence that person experiences, the more their brain is affected and the more we see profound mental and physical effects (that’s all in the same brain after all) in those people who’ve experienced violence. And we need to use this new brain science in helping people who have experienced violence heal: designing and testing interventions that can actually make a difference in that traumatized brain. We can think about it from a nursing perspective, as I said from a holistic perspective, and we can work on making those interventions culturally appropriate.
My favorite example is: we have found that yoga, can be helpful for people who have been highly traumatized in terms of doing some of that healing work on their bodies and on their brains. But I always think of the schools that I work with in inner-city Baltimore, and I always have a little chuckle to myself thinking that we could go into those inner city schools, middle schools and say: “would all the young people who have experienced violence in their homes – who have seen their father hit their mother, or their mother hit their father, or have seen a dead body in the neighborhood, or have been abused themselves or sexually assaulted themselves – would you all please report at 3 o’clock for yoga.” And having a little chuckle to myself, thinking nobody wants to do yoga in an inner-city middle school!
We need to design some interventions that do the same kind of good things, but that are culturally appropriate, are relevant, make kids excited to be part of that intervention. I’m sure there are some out there – we just need to develop them and work on them. I’ve done a little bit of work myself with an arts-based intervention for dating violence, but that kind of work needs to continue and we need to test those interventions and really be able to show that it is, indeed, helpful.
As I mentioned, most of the brain science work has been done in terms of mental health responses, that people who have experienced a lot of trauma, as I said, especially as a child or an adolescent. Often times they develop what we say PTSD. In the popular vernacular, we talk about people being triggered, which is really what happens when you have PTSD because you can re-experience events if somebody says something or does something to you that reminds you of when you were horribly afraid in a situation of very serious violence or trauma. And we need to expand that vision to physiological effects, because those happen too and we know that when people have developed PTSD, when they have been highly traumatized, their HPA Axis (Hypothalamic Pituitary Axis), the stress response, gets compromised in various ways, and that the immune system, which is connected to that stress response, also can get compromised.
And when I say compromised, we talk about immune system dysfunction, it can either be over-activated or under-activated. And they can both happen at the same time, as a matter of fact. And if it’s under- activated, they may be more susceptible to infections. If it’s over-activated, we can have the immune system contributing to things like chronic pain (an overactive immune system), or to things like BMI being increased and it being much harder for those people to be able lose weight with normal means.
So it helps you understand why you see certain health problems more often with people who have experienced child abuse. For instance, the Nurses’ Health Study showed that nurses who had experienced child abuse were more likely to have problems with diabetes. We found that women, African-American women who were abused were more likely to develop hypertension early, and find it more difficult to control it.
So these are very important connections that are just beginning to be explored, but they’re being explored in sort of silos in different areas of science. And I think the beauty of nursing is we can see it all together. And we can see things like how the effect on one’s physiology and one’s mental health can contribute to HIV – to people both acquiring HIV and also having trouble keeping their CD4 counts under control, and developing the kind of viral load that disappears over time that makes them no longer infectious. So I’ve been doing some work with other researchers in the HIV world in terms of addressing the kind of cumulative trauma that we see so often in people who contract HIV or acquire HIV, and then have trouble decreasing their viral load to non-detectable, which is the goal now for HIV.
So, it’s this big vision kind of piece that is something that I think I’m particularly good at. Maybe it’s because I’ve done and read so much research by now in many different fields that my own brain is bursting with ideas of ways to apply that and think about things differently. So that we can indeed, and in the end, what we want to do is both prevent violence from happening so much in our country and in the world (there’s also the global vision to think about). But also to help people who have experienced violence, because unfortunately violence in our world is not going to go away in the next few years; to help people who have experienced violence heal so that they don’t, as adults (these children and adolescents) become the ones who are using violence against other people.
3 Questions – Living Legend Nancy Fugate Woods
Welcome to the Nursing Outlook Blog – “3 Questions” – Timely Interviews with Thought Leaders in Nursing and Health Care Policy
2018 American Academy of Nursing Living Legend – Nancy Fugate Woods
Nancy Fugate Woods is one of the nation’s most distinguished scholars of women’s health and a pioneer of research on the women’s health and wellness, who has received accolades from across disciplinary circles beyond nursing. Her early work as a scientist that spawned her curiosity around the menstrual cycle, reproductive health issues and peri-menopausal health concerns of women were foundational to a career noted by induction into the American Academy of Nursing (AAN), the American Nurses Foundation (ANF) Distinguished Contribution to Nursing Award in 2003, the Pathfinder Award from the Friends of the National Institute for Nursing Research, and elected to the Institute of Medicine, now the National Academy of Medicine. In collaboration with other colleagues, she launched first NIH-funded Center for Women’s Health Research at the University of Washington. Her long tenure with the Center and continuing involvement in the Seattle Midlife Women’s Health Study (click here for “The Seattle Midlife Women’s Health Study: a longitudinal prospective study of women during the menopausal transition and early postmenopause”)continues to be a snapshot of an extensive career that resulted in being selected a “Living Legend” in the American Academy of Nursing, an organization that she served as president.
Dean Woods presided over ten years of the University of Washington’s number 1 ranking in U.S. News and World Report magazine. Her research legacy also involves substantial service to her profession and to federal agencies as a nurse scientist, policy activist, women’s health advocate, and nurse education leader, winning numerous awards and serving in U.S. National Advisory and Washington State Health and Education Committees. We interviewed Dr. Woods, focusing on her extraordinary accomplishments and renowned research on women’s health. As Dean Emerita of the University of Washington School of Nursing, Co-Director of the de Tornyay Center for Healthy Aging, and past president of the American Academy of Nursing (AAN) and other noted societies, we wanted to hear in her own words what wisdom she could share with aspiring nurse leaders and scientists in our “3 Questions” format.
We invite commentary that is thoughtful and provocative! Join the online dialogue
Nancy Fugate Woods
Dean Emerita, University of Washington School of Nursing and the de Tornyay Center for Healthy Aging
Question 1. Can you tell us more about your recent work related on healthy aging in women and how your early body of research has informed your continuation of research with the study participants from 20 years ago?
Thanks for that great intelligent question. As I look back over the early work that I did and understanding young women’s health, I found myself being very interested in the symptoms that women experienced, and then the episodes of illness – days that were troublesome for them because of their symptoms. I was really looking at this part of a lifespan and what women were doing in the 1970s when women’s roles were changing pretty dramatically. At the time, women were entering the labor force and they were staying employed while they had babies and raised their children. And up to the time of that research there had been very little work at all, very little research on the effects of the kind of work women did. There was much on the health of their husbands, so what was the consequence of women’s work being employed, that is, outside of the home, on the health of their husbands and the health of their children! But there is very little being done to understand the consequence of being employed on the health of women themselves.
So, we were finding at that time that there was a huge untold story! And of course we saw that this was a major oversight, not having looked at the consequences of women’s work in their own lives for their own health. We did find that women’s employment didn’t have a major effect on their health as long as they had support for what they were doing, so as long as they were being supported in their parenting and their employment roles from their partners or spouses, and as long as they believed that they were doing what they should be doing.
The experiences with that study really made me curious about other questions that hadn’t been addressed related to women’s health and I found myself increasingly interested in what was happening with women’s health related to their physiology. In the late 1970s, colleagues and I at Duke University – and then later at the University of Washington School of Nursing – started a study that involved several hundred women both in the Raleigh/Durham area and in the Seattle area that attempted to understand the menstrual cycle in relationship to women’s experiences of symptoms and how the context of their lives – the challenges they were experiencing in daily living, the demands of their roles whether it was parenting or employment and the personal and social resources they had to bring to bear on these – how these all affected their experiences of symptoms. This was a very revealing project: as it turned out, to my surprise, it was the first large prevalence study of menstrual cycle symptoms that had been done in the United States. It was very much a turning point in some of this work.
We then continued to think more, my colleagues and I, about looking at development of women and their health over the lifespan. And, when we began looking through a feminist lens, we realized that we needed to start with women at the very center of that work with their defining what mattered to them and moving on from there. So at that point we enlarged our lens to look at health during the young adult years, during mid-life and menopause and then eventually, in relationship to aging.
So, for me the study of women as they aged was a natural outgrowth of having studied the younger women, having studied women during midlife, and throughout the entire menopausal transition and then moving on to study women as they aged.
Question 2. Tell us more about the Seattle Midlife Women’s Health Study that was a foundational component of the Center for Women’s Health Research. Did your clinical connections to the research shape its trajectory?
We had the great fortune to have Ellen Mitchell, who is a PhD nurse and who practiced for many years as an Advanced Registered Nurse Practitioner caring for women in a primary care setting, as a collaborator. Ellen’s clinical wisdom as well as her preparation as a scientist with a PhD in nursing science enriched our research. She really ensured the clinical consciousness in all of our studies. For me as a nurse I found the integration of our focus on women’s biology during the menopausal transition, as well as the personal and social context for women’s lives, really clinically relevant as well as intuitively appealing; and one of the things that I was particularly pleased about was when I presented our work at interdisciplinary meetings. People often asked whether I was a physiologist, a psychologist or a sociologist, because of the integrated approach we took to the research we were doing with the midlife women’s health study. When I would tell colleagues that I was a nurse with graduate degrees in nursing and epidemiology, many were surprised and this often gave me an opportunity to talk about nursing science and our discipline’s particular orientation to integrative human health and health ecology. I was certainly flattered by colleagues who asked whether I was a Nurse Practitioner. I’m sorry that I can’t claim that identity. I was not educated as an advanced practice nurse but clearly Ellen Mitchell’s influence rubbed off and really profoundly shaped the kind of research we did.
I would say in relation to that statement about the clinical awareness another kind of awareness that was really an important part of our work was inviting women to advise us, on not only the Seattle midlife women’s health study, but every study that we’ve ever done. At the end of interviewing women we always would ask: was there something else we should have asked you that we failed to ask or is there anything else that you’d like to tell us in relationship to the interview we’ve just done? And often this would be the time when women would contribute incredibly valuable observations by saying “well I was surprised you didn’t ask me about…” (and then fill in the blanks) with what their current concerns were. Often Ellen and I would go through those data, we would talk with the research assistants who might have conducted the interviews after they completed them in a debriefing session, and we would add or modify a research approach to include some of the great ideas that women were suggesting to us.
It was key to me and Ellen that we tried to make sure that the research we were doing was in fact relevant to the concerns of the women who were participating in it.
Question 3. What advice do you have for aspiring nurse leaders and scholars to be able to connect their clinical interests, personal passions and professional goals?
That’s a great question. I think that the passion for the substance of what one is studying is absolutely essential to sustain us in that work. Otherwise, it’s a lot of very hard, very exacting work. But to imbue it with meaning related to really caring about the topic and the population one is studying is extremely important. I was so fortunate in the 1970s to be beginning work as a young nurse and a young scientist at the height of the women’s movement and its intersection with the popular health movement in the 1970s. Together these two events fueled my desire to contribute to work on women’s health that could inform healthcare and the kind of healthcare that would put women at the center of care and also at the center of the inquiry in research.
I have really loved the research that I have done over the course of my career and I still find myself looking forward to taking time to write and think about topics related to women’s health, so that passion continues. For me, it has been a privilege to get to understand, to be privileged to understand the life and health experiences of now thousands of women that our team and in particular Ellen Mitchell and I have talked to over the years to really say there is no substitute for being passionate about what you’re studying.
3 Questions – Carole Kenner on the Policy Brief “Reducing Preterm Births in the United States”
Policy Brief: Reducing Preterm Births in the United States – AAN Expert Panels on Maternal Infant Health (MIH), Child, Adolescent & Family (CAF), and Women’s Health (WH)
There is an alarming rate of preterm births (PTB) (less than 37 weeks gestation) in the United States that has escalated in recent years and brought with this rise the associated public health problems of infant mortality and morbidity. While the richest country in the world, the U.S. ranks among the top 10 nations on preterm births. What is most troubling is that premature births were declining in the last decade, however more recently, in three consecutive years, preterm births have been steadily increasing to more than 400,000 U.S. babies born prematurely in 2016. The corollaries of PTB are associated with wider use of assisted reproductive technologies and clear racial and economic disparities. Representatives of the Expert Panels of the American Academy of Nursing including Maternal Infant Health (MIH), Child, Adolescent and Family (CAF), and Women’s Health (WH) convened and developed a Policy Brief on Reducing Preterm Births in the United States, published in the September/October issue of Nursing Outlook.
We asked Carole Kenner, the Carol Kuser Loser Dean and Professor in the School of Nursing, Health, and Exercise Science at the College of New Jersey to offer insights into this problem. She served as co-chair of the group of authors of the Policy Brief in Nursing Outlook. Their brief supports the evidence from several Institute of Medicine (IOM) reports relating the complex interplay of social, economic and environmental influences on maternal health in general and the rise of preterm childbirth specifically. In addition to limited access of maternal child health services, the brief includes discussion around the multiple underlying causes of preterm birth related to changes in obstetrical practices including increased rates of elective cesarean births, delayed childbearing, greater use of infertility treatments, illicit drug use, tobacco use, maternal mental health, maternal co-morbidities and chronic illnesses like diabetes, obesity, and hypertension. Although survival of premature infants has improved, morbidity has not followed. Babies born prematurely have a higher likelihood to have increased health-related and neurodevelopmental delays. These are shameful problems that our nation should address in a constructive way to find solutions.
The Policy Brief describes the problems and contributing factors of PTB and proposes policy recommendations with specific interventions that include advocacy for continuation of Medicaid to support maternal child health and action to support of the PREEMIE Reauthorization Act of 2018,with guidance from the March of Dimes.The American Academy of Nursing finds the rising prematurity rates in the U.S. unacceptable and urges the health care providers, policy makers, and the public to focus attention and resources to address this national health issue.
Contributors include (Maternal Infant Health Expert Panel Members): Carole Kenner, PhD, RN, FAAN, FNAP, ANEF, Co-Chair and Deborah S. Walker, PhD, CNM, FAAN, FACNM, Co-Chair; Kristin Ashford, PhD, RN, WHNP-BC, FAAN; Lina Kurdahi Badr, DNSc, RB, CPNP, FAAN; Beth Black, PhD, RN, FAAN; Joan Bloch, PhD, CRNP, FAAN; Rosalie Mainous, PhD, APRN, NNP-BC, FAAN, FAANP; Jacqueline McGrath, PhD, RN, FAAN, FNAP; Shahirose Premji, PhD, RN, FAAN; Susan Sinclair, PhD, RN, MPH, FAAN; Mary Terhaar, DNSc, RN, FAAN, ANEF; M. Terese Verklan, PhD, RNC, CCNS, FAAN; Marlene Walden, PhD, APRN, CCNS, NNP-BC, FAAN; Rosemary White-Traut, PhD, RN, FAAN; SeonAe Yeo, PhD, RNC, FAAN; Linda B. Zekas, MSN, APRN, NNP-BC, CPNP-PC, CWON, FAAN.
Joint expert panel contributors include: Elizabeth A. Kostas-Polston, PhD, APRN, WHNP-BC, FAANP, FAAN, Co-Chair, Women’s Health Expert Panel; Cindy Smith Greenberg, DNSc, RN, CPNP-PC, FAAN, Co-Chair, Child, Adolescent & Family Expert Panel, and Marina Boykoba, PhD, RN.
Acknowledgement: The authors of the Policy Brief wish to thank the members of the Maternal & Infant Health Expert Panel, Ellen Olshansky, PhD, RN, WHNP-BC, FAAN, American Academy of Nursing board liaison to the Maternal & Infant Health Expert Panel, Cheryl Sullivan, Chief Executive Officer, American Academy of Nursing, and Kim Czubaruk, Esq., American Academy of Nursing staff liaison to the Maternal & Infant Health Expert Panel.
We interviewed Dr. Kenner, the Carol Kuser Loser Dean and Professor of the School of Nursing, Health, and Exercise Science at the College of New Jersey, focusing on the policy brief that she co-chaired, to speak about the brief using our 3 Questions format!
Veronica D. Feeg, PhD, RN, FAAN
We invite commentary that is thoughtful and provocative! Join the online dialogue!
Carole Kenner, PhD, RN, FAAN, FNAP, ANEF
Carol Kuser Loser Dean/Professor
School of Nursing, Health, and Exercise Science, The College of New Jersey
Question 1. Why are the preterm birth rates rising in a high resourced country such as the U.S.?
Well first of all, thank you for the opportunity to share a topic that I feel very passionate about. I’ve been a neonatal nurse in maternal child for a lot of years and do a lot of global work. It’s very concerning to me (and I have to say the opinions that I’m going to express here are mine and not the American Academy of Nursing from my background and expertise) but it’s a real concern to me that we look more like low resource or developing countries in terms of our prematurity rate and especially with the rise in prematurity births, preterm births in the last two years in this country. As far as why – I think there is a multitude of factors. I think it’s the structure of our insurance coverage for women in this country. And I think it’s certainly the rise in delayed childbirth, the use of assistive reproductive technologies in this country. But the other thing is the fact that we have underrepresented women that don’t have access to care; don’t have access to maternity leave if they have jobs necessarily; and they, unfortunately, as our policy briefs mentions, in thirteen states in particular really represent the bulk of the premature births.
That’s a concern! So I think it’s insurance coverage, coverage access to care, a use of reproductive technologies, as well as the fact that we have underserved, underrepresented populations that continues to show disparities in in this area. And the lack of maternity leave – I can’t stress that enough – that women get very stressed in thinking about the fact that they have no maternity leave; and some women would normally take and start taking leave prior to a delivery, and now they’re working up to the time of a delivery. Well you might say, why does that contribute to preterm birth that they’re working up to delivery? – Because they’re delivering early because they know they might not even have any kind of leave available to them after the birth at all.
Question 2. What strategies can we use to raise awareness of the problem of an escalating rate of preterm births?
I think building on what the March of Dimes started several years ago when they created the campaign around “every pregnancy and every baby deserves a full 40 weeks.” It really was one of those awareness campaigns that grabs the attention of people across the spectrum – meaning from lay public through to professionals and to legislators. I believe that we have to do the same thing here with preterm births. People in general don’t realize the dangers that occur even with having late preterms – that means that babies that are born at 34 to 36 weeks gestation out of a40 week pregnancy – that those babies act much more like preterm babies than they do term babies. And yet for a number of years we’ve thought in this country “Oh! We’ve got all the neonatal intensive care units! We’ve got all the technology to support these babies!” But the truth of the matter is: they may have some life-long problems. Not all, we have done a good job of providing neonatal care. But the families also have burdens, not only of just the stress of having a baby that’s born preterm, but the fear – even if everything worked out all right – of what’s going to happen with that baby and how that financially may impact them (again, depending on how much insurance or what kinds of insurance coverage – if any that they have).
So, strategies! Strategies are creating that awareness. Every time that I go to speak someplace, I always bring up the fact: Did you know that the US is really up there with India in the top ten countries in the world that have prematurity rates that do not compare with other high resourced, well developed countries? Bringing those key messages to legislators anytime we have the opportunity! Not waiting for an Op Ed! Not waiting for this blog (which is a great way to do it to raise the awareness!) Getting things out in social media now, and using that to see how impactful just key awareness statements are! When you say that there are research studies that support that paid maternity leave does impact preterm birth rates, that’s insightful! But we always tend to wait until we can write a full blown paper to get this out in the literature.
And instead, I think, we have to go the opposite and strategize around getting the message – that means that we also (those of us that were involved in writing the policy brief in particular) have an obligation now to work with other organizations. To partner. To make sure that this is integrated into conferences, into workshops, into blogs, into other areas, so that you’re hitting with as much impact as you can – hitting all levels of stakeholders. And I think that something that we haven’t really been good at in the past in terms of looking at different modalities of getting that word out: going to for example, that I have done, to Women League of Voters and talked about some reproductive issues – talked about some neonatal issues. Not just talked about voting issues! Bringing up some of the successes that other countries have had when they have put more funding behind maternal and infants’ health.
And also recognizing that this is an area of great opportunity for researchers to look at what are the strategies around combating preterm birth rates. So why is that a strategy in terms of raising awareness? Because in the research community, at some of our research meetings – our regional nursing meetings and other research meetings – we should be bringing up this topic within the context, especially those of us that do maternal-child research! Bring up this rising prematurity rate within the context of our research and the gaps that are out there!
Question 3. Your group proposed that targeted campaigns should be a high priority to protect those that are most vulnerable, pregnant women and children. What does this mean for nursing?
I would definitely say to nurse leaders, nurse educators and nurse researchers that we need to know the data. We need to bring those data to the awareness of the stakeholders in our organizations. So as an educator, right now, I work with public health undergraduate students, I work with nursing students and graduate nursing students. And I have said, “you know … this is a real problem!” With my maternal child faculty, we’ve had discussions about this and the fact that we need to begin to talk about the US’s role in contributing to preterm birth rates globally and also contributing to neonatal mortality globally. These are not conversations that we normally have. Nursing leadership, both in the practice side, in the education and in the research side needs to know this. We tend to gloss over this if you’re not very intimately involved in maternal child. We know that we’ve got increasing disparities in this country in terms of women’s health and concern over the cuts (the proposed cuts) for funding for women’s health services and what that might do – but not generally looking: is there a linkage with preterm birth rates and what that may do if they continue to rise? – why it’s an embarrassment, in my view, for the US with all the resources we have, to be in this position of one of the top 10 countries in the world with rising preterm birth rates.
So again, nursing has probably the greatest opportunity to impact this problem by working within some many of our own specialty organizations, but also, now that nurses are on many interdisciplinary boards, bringing that to the attention of those boards and saying “this is the time when we need to band together to play together in terms of a strategy.” This is not a strategy that nursing in and of itself can take on. This is a strategy that should involve insurance agencies or Centers for Medicare Medicaid Services (CMS) for the legislators to be involved, such as a passage, just now, of the Preemie Re-Authorization Act – iIt has gotten through the Senate; it now has to go through the House) to begin to strategize together with nursing taking the leadership, because we’re at the grassroots we’re at the bedside! we’re in the NICUs! we’re in the prenatal areas! The nurse midwives, they are seeing, also, complications in their practice and know how important it is to do good pre-conceptional and pre-prenatal discussions about the risks – raising the awareness at every level and then encouraging our researchers, especially our nurse researchers, to look more closely in terms of even health services research; looking at health systems, and how that could impact the preterm birth rate and what that could mean for us.
So, I really believe that nursing is at the (what I always say) is “at the bleeding edge” because we become the interface between policy issues and the public that we serve. We also become the interface between taking our stories of what it’s like to have a family that you are working with that experiences a preterm birth and everything that goes along with it, as well as the journey of the child, because I believe it’s the stories that grabs the public’s attention and grabs the legislator’s attention. It’s not about just data. We have to have the data; we can’t just have the passion. But we have to bring to the table the stories, so that we can advocate and be actively involved in reversing this course.
Leadership Interviews – 3 Questions – Living Legend Linda Cronenwett
2017 American Academy of Nursing Living Legend – Linda R. Cronenwett
Dr. Linda R. Cronenwett is a widely respected leader in advancing inter-professional initiatives to improve healthcare quality and safety. She was instrumental as Chair of the American Nurses Association (ANA) Congress on Nursing Practice and her leadership role on the NIH National Advisory Council for Nursing Research in developing advanced practice nursing and its integration with research. She co-chaired and co-edited the Josiah Macy, Jr. Foundation’s inter-professional work on who will provide primary care and how they will be trained, and she served as President of the Founder’s Committee of Eastern Nursing Research Society (ENRS).
Among her numerous leadership roles, Dr. Cronenwett focused her work on the mission of improving healthcare quality and safety. She co-chaired the Institute of Medicine (IOM) Committee on Identifying and Preventing Medication Errors and served on the board of directors of the Institute for Healthcare Improvement (IHI), on the path toward one of her most recognized accomplishments – launching the national Robert Wood Johnson Foundation (RWJF) initiative “Quality and Safety Education for Nurses” (QSEN), which has been integrated across nursing education programs nationally. QSEN has made its impact on healthcare by influencing national and international revisions in accreditation standards and curricula. Dr. Cronenwett received the American Academy of Nursing (AAN) Presidential Award in 2013 and was named a Living Legend in 2017.
We interviewed Dr. Cronenwett, focusing on her QSEN accomplishments. As Professor and Dean Emeritus of the University of North Carolina – Chapel Hill, and Co-Director Emeritus of the RWJF Executive Nurse Fellows Program, Dr. Cronenwett speaks about leadership as a thought leader using our 3 Questions format!
Veronica D. Feeg, PhD, RN, FAAN
We invite commentary that is thoughtful and provocative! Join the online dialogue
LINDA R. CRONENWETT
Professor AND DEAN EMERITUS
University of North Carolina – Chapel Hill, and
CO-DIRECTOR EMERITUS OF THE RWJF EXECUTIVE NURSE FELLOWS PROGRAM
Question 1. You were one of the founders of the movement to change quality and safety education. Why was that initiative so important and is it still important today?
It certainly is! Colleagues and I began seeking funding for an initiative to change quality and safety education soon after the first Institute of Medicines reports on healthcare errors came out. The magnitude of the problems related to quality and safety were fully at that point in the public consciousness and receiving a lot of attention, and we knew that people were being harmed by medical error with really alarming regularity. Yet, new health professionals were still graduating thinking that the solution for them was just to study hard and be vigilant – that the source of quality was in themselves. In nursing, we even had students who might be expelled from school for a clinical error, rather than learning that all humans make errors and that they needed to know how to learn from errors. They weren’t taught that our job as professionals was to build the systems that would minimize those errors and build the reporting systems that were fair and just that would help us to learn. Almost 80% of the errors involve failures of team communications, and yet, our curricula rarely focused on anything other than nursing team with students really rarely, if ever, having meaningful communications with physicians prior to graduation. And students might have learned about evidence based practice but they rarely knew anything about quality outcomes achieved in the sites where they practiced. And if they did see a gap between best practice and where they were currently practicing, they had little knowledge about what to do to improve quality in that system to close that gap.
So sadly, although there have been great strides in curriculum change in many schools, there is much work that remains yet to do, particularly in the areas of graduate education and in inter-professional education. Also, sadly, the rate of medical error continues to be alarming. We just had a recent study where it’s the third leading cause of death still.
And so, although much more attention is paid to quality and safety metrics in healthcare environments, the methods we’ve used to date to incent quality improvement leave a lot to be desired, in my view, often leading to feelings of burnout among health care professionals. So yes, I think there is much more to do for sure.
Question 2. What were the biggest challenges/barriers/ to achieving the curricular change outcomes that QSEN leaders proposed?
That is a good question. We faced a number of barriers as our project which was called QSEN began. First, nursing and really all other health professions faculty too didn’t fully appreciate that there was a problem in curricula. When asked if they taught quality and safety competencies they uniformly said “yes” because that’s all they did was teach to make their new graduates safe. It wasn’t until we described the specific knowledge, skills, and attitudes that we knew new graduates needed that they would admit: ”… oh, no, we’re not teaching that!” So, there was work to do to build that burning platform for change.
Second, we were pretty sure that students wouldn’t develop the QSEN competencies unless a large percent of their faculty were reinforcing the learning in every course. So this wasn’t content where the school could assign one person to become an expert, and then that would suffice. They had to teach enough faculty so that these competencies and the knowledge, skills and attitudes undergirded what a student did in simulation labs, in the clinical area, in written assignments, in unfolding case-studies in class and in inter-professional courses.
So, we had to develop many methods to assist broad scale professional development. And we worked on online self-study modules, a website, and a forum – national forum for sharing with each other, we worked on train the trainer conferences, in addition to, it seemed, very many, many, speeches and publications.
Among other barriers, we also faced the reality that we had to develop QSEN competencies among all nurses. And that meant that at the basic practice level, we were concerned with all types of entry-level education programs; and at the advanced practice level, we were likewise concerned with competency development for both masters and doctoral students.
Patients deserve to have all their nursing professionals prepared for work in high-reliability systems of care. So, it really meant we had to change the whole world of nursing education.
Question 3. What advice would you give future nurse leaders who take on the challenge of launching a movement involving changes of this magnitude?
First of all,I think you have to build partnerships. You can’t assume this is a solo activity. You need clinical partners and inter-professional partners at the table with you each step of the way if you are going to make a major change. Nothing kept the school of nursing faculty focused on QSEN sufficiently on this big challenge as well as the constant realities of what clinical partners and patients were needing or expecting from their graduates. They had to be hearing that voice at the table all the way along.
Second, I think, including all the relevant professional organizations at the table as well, we really focused on co-creating the future together – not coming in with the right answer – but co-creating it. And only with that level of involvement do the ultimately acceptable answers evolve.I think you have to plan from the start for how to help each individual faculty member who might listen to a speech and be turned on to the idea how they would make the changes they need to make. So you need to develop strategies to attract people who are innovators and early adopters. You want to have places for them to share and meet each other. But you can’t forget to plan for the needs of the majority, who are happy to help if you make it as easy as possible for them to do so.
And then finally you also need to plan strategies to attract the laggards because in some cases nothing helps achieve that last curricular change more than accreditation requirements or licensure or certification exams. I think you have to not worry about who gets the credit. If you’re going for big change, you need everyone in the profession be a part of it. So you need to let everyone be a part of it and have credit where it’s deserved, and realize that there is more than enough work and more than enough credit to go around.
I guess last I would say you, you have to prepare for the long haul. I’ve had multiple people call me and say: “you knowI want to make sure this gets into nursing curricula…could you give me the easy way you got QSEN into curricula?”It’s not just like that. If you really only want to give a few speeches or write a few papers, that is not how major professional change occurs.
So prepare for the long haul, build your partnerships, don’t worry about who gets the credit and just have fun!
Leadership Interviews – 3 Questions – Living Legend Linda Burnes Bolton
2016 American Academy of Nursing Living Legend – Linda Burnes Bolton
Dr. Linda Burnes Bolton was the President of the American Academy of Nursing (AAN). In 2016, she was recognized with the AAN’s “Living Legend Award” for her many contributions in nursing and her extraordinary leadership roles including as the President of the National Black Nurses Association and is a Member of the California Strategic Planning for Nursing Committee on Diversity, the Institute for Nursing and Health Care and the National Advisory Council on Nursing Education and Practice. Among her many appointments including chairing the Veterans Nursing Commission at the request of the U.S. Congress, and among other board appointments including the Robert Wood Johnson Foundation (RWJF), Dr. Bolton served as vice chair of the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine (IOM). This report has been one of the most influential documents of our time.
For over 20 years, Dr. Bolton has played a vital leadership role in raising issues of diversification in nursing education and practice. Her expertise includes nursing and patient care outcomes, cultural diversity and inclusion within the health professions, and population health.
We asked Dr. Bolton to inform us on what problems she believes are most likely to impact nursing and healthcare. Her numerous leadership recognitions make her an outstanding role model for aspiring nurse leaders on the major issues facing nursing leadership today. She points to several major issues and followed up with solutions to engage nurses in team science to achieve a “Culture of Health,” part of the RWJF vision and framework for improving health, equity and well-being in America.
We interviewed Dr. Bolton as a “Living Legend” and thought leader using our 3 Questions format!
Veronica D. Feeg, PhD, RN, FAAN
We invite commentary that is thoughtful and provocative! Join the online dialogue
Linda Burnes Bolton, DrPH, RN, FAAN
Chief Nursing Office and
Vice President of Cedars Sinai Health System and Research Institute
Los Angeles, CA
Question 1. What are the major issues facing nursing leadership now and over the next five years?
The top three issues facing nursing leadership are in some ways similar to the issues that we have faced in the last 20 years, and that is: how do we meet demands? What is different in terms of meeting demand, is that we are more focused on: how do we meet health needs as just acute care needs? And to meet health needs, we are going to need to have a workforce that is perhaps more prepared to deliver clinical care and to be part of the team of individuals that are helping to engage consumers as equal partners in healthcare. That’s different from the demand that was focused on how many critical care nurses you have or how many pediatric nurses you have. It’s really, we will need more nurses engaged in this work of population health management.
The second issue has to do with: how do we place the leadership talent? If you look at the aging of the nursing workforce, we are coming to a period of time when a solid 20% of the workforce might be leaving and those are the individuals who have the most knowledge and the most experience. So, the aging of the workforce is a concern and how do we deal with that concern is to make sure that we have a pipeline of people who are ready to take our places to succeed us. And in that succession, it may not be exactly how the way we have done it and it and how we have performed as nurse leaders, but they will be prepared to rethink – what does it mean to be a leader in a broader perspective in terms of being part of teams?
Question 2. How can nurse leaders advance the engagement of other health professionals to promote team science?
Team science is very important in terms of achieving health goals. It’s going to take more than nurses to achieve those health goals. We may have the most volume of health professionals, you know we are the largest group, but like trying to describe a camel and having three blind men, each having their hands on different parts of the body, that’s exactly how it is in relationship to this work of engagement of other health professionals. Each comes with their own body of knowledge. Let’s take physical therapists as an example. The work that we’re doing to try to get more movement, physical movement, of consumers as a way of not only treating health issues that have arisen, but preventing health issues. Wow, getting nursing and physical therapists together as team members and adding a podiatrist, a physician member, adding someone who is an expert in looking at different ways of conditioning one’s self. What a great team to be able to address the staggering information that we’re continuing to receive about how little people are engaged in walking, running and other types of physical actives. So that’s just one example.
Another example has to do with the whole issue of science itself. So, on the road to discovery, it’s not something that should be just left to one particular clinician – so not just nurses. But how do nurses discover with physicians? How do the nurses discover with consumers? How do they discover with health educators? So, promoting team science is critical to the engagement of health professionals and to what aim? Because we will have better patient care outcomes, that’s the work that nurse leaders should be pushing forward.
Question 3. How do we promote more consumer engagement in achieving a “Culture of Health”?
The work of health and health professionals is aimed at trying to improve outcomes for consumers. One of the things we haven’t done as good a job as we possibly could, is adopting what Dr. Don Berwick said as he created and lead the Institute for Healthcare Improvement. When you’re talking about you want to do something to improve how people are assisted, how we prevent illness, how do we help individuals? – “Nothing about me without me!” So that’s his famous statement. If we can’t hope to achieve a culture of health where everyone has the possibility to achieve and sustain health; regardless of their age, sex, their ethnicity, their sexual preferences; regardless of the income distribution. We can’t hope to achieve that for everyone without engaging the individuals who would benefit. So, consumer engagement is essential to achieving a culture of health. We can’t decide that health – just as health professionals identify it – is the right thing to do. It has to be done with consumers and with consumers focused on not just diversity, but inclusion. They’re a part of the discovery of the answers to the question: how to we achieve a culture of health?
Leadership Interviews – 3 Questions – Living Legend – Elaine Larson
2017 American Academy of Nursing Living Legend – Elaine Larson
Elaine L. Larson, PhD, RN, CIC, FAAN is Associate Dean for Research and Anna C. Maxwell Professor of Nursing Research, School of Nursing and Professor of Epidemiology at the Mailman School of Public Health, Columbia University
Elaine L. Larson, famous for her hand hygiene research, has focused her career on the ultimate goal of controlling and preventing infections. For this work, she is known globally, and its impact has been foundational to what we understand today about preventing infections.
Dr. Larson began her work with curiosity about how preventable infections were more common than many had noticed, and with the growing problem of microbes that are increasingly resistant to treatment, she gained a prominent place in demonstrating that personal and environmental hygiene was the key. She was one of the co-authors of the WHO and CDC evidence-based guidelines for hand hygiene in the health care setting. Her work on infection control and general patient safety stimulated her interest in bioethics, and she serves as chair of two institutional review boards (IRBs) in addition to the research she is conducting on informed consent. Dr. Larson was Chair of the White House-appointed CDC Healthcare Infection Control and Prevention Advisory Council and served on the President’s Committee for Gulf War Veterans’ Illnesses.
As Associate Dean for Research at Columbia University and Professor of Epidemiology at the Mailman School of Public Health, Dr. Larson is currently involved in efforts to bridge the divide between clinical nursing practice and nursing research. She directs the Center for Interdisciplinary Research to Prevent Infections at Columbia University and has been Editor of the American Journal of infection Control since 1995, along with other leadership activities that connect collaborators from different disciplines outside of nursing. With over 400 journal articles, four books and numerous book chapters, she deserves the distinctive accolades reserved for nurse researchers with stellar programs of study in an area that has become synonymous with her name and reputation related to infection control.
We asked her to elaborate on her leadership lessons in connecting clinical nursing practice and nursing researchby answering 3 Questions!
Veronica D. Feeg, PhD, RN, FAAN
We invite commentary that is thoughtful and provocative! Join the online dialogue!
Elaine L. Larson
2017 American Academy of Nursing (AAN) Living Legend
Columbia University School of Nursing and School of Public Health
Editor, American Journal of Infection Control
Question 1. What do you see as the interface between clinical nursing practice and nursing research?
From the very beginning when I was a nursing student, I always thought that nursing research was an integral part of clinical nursing practice. And in fact I feel so strongly about it that, I feel that it’s our ethical mandate to make sure that as good clinicians, we have to understand what works and what doesn’t work and we have to have a sense of commitment to evaluating what we do. So to me it’s all the same spectrum: I think that you have to have research, you have to have clinicians, and implementation science is sort of, to me, another word for evidence-based practice. The clinician maybe on one end of the research spectrum and the researcher may be on the other, but we’re all on the same spectrum.
Question 2. How did you get involved with doing research?
I remember the first year that I graduated from my baccalaureate program and I had a patient, a young woman who had rheumatic heart disease. In those days that was very common – not so common anymore, fortunately. She was fairly young, she was in her 30s, and she called me into her room and she told me that she wasn’t feeling very well. She couldn’t breathe very well. So, I listened to her heart, I took her blood pressure, took her respirations, did the usual things. She wasn’t in an intensive care unit. She seemed to be relatively okay, so I propped her up with a pillow on her bedside stand and I told her to call me if she didn’t get better. Within a half an hour she died of acute pulmonary edema. As a young nurse, I promised myself that I would do everything I could to make sure that I knew as much as possible about my patients’ disease, their conditions, their ability to cope etc. What I did was I wrote my first paper my first year out of nursing school. I sent it to the AJN. It was about taking care of patients with acute pulmonary edema and sort of my defense mechanism or my way of making sure that I didn’t make mistakes, and learned from every – every – experience that I had was to read all about it. So I wrote the paper. It was published by the American Journal of Nursing many years ago. It would never get accepted for publication now because basically it was a case study and most of my references were from textbooks! But I got a letter from the American Journal of Nursing editor saying “we need more articles that are relevant to clinical practice like you’re doing” and I was hooked! So from then on, I just thought “wow”! An important part of what we’re doing as practitioners is also understanding what we’re doing and learning from mistakes, learning from our experiences From then on I’ve been hooked!
Question 3. How can clinicians and ‘academics’ collaborate more? What are some strategies to make it work?
It’s funny, because over the years “academics” and clinicians have sort of been systematically separate from each other so that hospital nurses aren’t necessarily on the faculty and vice versa. That’s really got to change! I think what’s happened over the years is that nursing went through sort of a period of adolescence where they had to sort of make their own way, divorce themselves from their parents – which at the time were sort of the hospitals – and then make a stand and establish themselves as an academic discipline. Now it’s time for us to get back together because this is not working.
Just a couple of things that we’ve been doing lately that are very exciting and I think are wonderful strategies. One is we produced an academic clinical partnership so that we have staff nurses who are applying, writing a three-page little idea, a problem that they are seeing on their clinical units. So they are writing a little proposal about how they might like to do a project or study or a QA project to try to resolve the problem. Those that are selected are actually given some time on the clinical side and they are linked up with an academic mentor. They are mentored to actually do the project. So they are mentored through the IRB process. We have faculty who are being the mentors and some of the nurse researchers in the hospital. So this is very exciting! We’ve got some exciting ideas: for example, a nurse in the medical ICU was very concerned because they have a lot of ICU dementia (patients who become delirious in the hospital). She wants to look at the extent to which the nursing staff are appropriately documenting delirium. She’s going to do that as a project. That’s one thing – academic clinical partnerships, where faculty link with clinicians and mentor them to do projects that are very relevant to their practice.
Another thing that is very successful that we’re working on now and other places have as well, I think, although it’s still not to the place where it should be is actual joint appointments between academic nursing schools of nursing and hospitals. So we now have four full-time nurse researchers with PhDs. We have a memorandum of understanding between hospital and the school, so they spend 50% of their time in the school, 50% of time in the hospital and are paid by both. And they jointly report to the hospital and to the school. That’s a real win-win because then the researchers who are in the hospital have access to statisticians and other kinds of help and advice writing grants etc. and they can serve as a link between the clinical staff and the academic environment.
So those are just two ideas. We have a project called the link project which does that, in fact, and actually provides to staff and the hospitals some statistical help. I think the important thing is that some of us are appliers of practice and some of us are developers of new ideas. So the idea is to build on the strengths of each. A lot of nurses researchers are sort of “silo-ed” and may not really even have a realistic idea of what the problems in the field are on the ground. And the people on the ground are so busy providing care that they may think of an idea, but if they aren’t trained to follow it through and if they don’t have the resources, they just let it go because they have to! They have to make immediate decisions. The joining of the two I think are strategies for how to make it work!
Leadership Interviews – 3 Questions – Living Legend Ann Wolbert Burgess
2016 American Academy of Nursing Living Legend – Ann Wolbert Burgess
Nursing leaders of our times are recognized by healthcare professionals and the public for their outstanding contributions not only to our discipline, but to the health of the population. The American Academy of Nursing recognizes its distinguished leaders who have given service over their career to a group of selected individuals known as the American Academy’s “LIVING LEGENDS.” In 2016, these recognized scholars, policy makers, educators, researchers and truly dedicated nurses received this highest honor and addressed the audience with humble thanks and inspired all of us in the room with their living stories. For future nurse leaders who may not have been in the room, we believe that their personal viewpoints about leadership ought to be shared online in their own words. This second interview is with Dr. Ann Wolbert Burgess, Professor of Nursing at Boston College.
Dr. Ann Wolbert Burgess is internationally recognized for her contributions in the assessment and treatment of victims of trauma and abuse. Her research has provided significant insight into the links between child abuse, juvenile delinquency, and the perpetrators of serial offenses. Her public service on numerous national committees and councils for victims of serious trauma, including sexual abuse in a variety of settings, has culminated in work that has been applauded at many levels of government and her courtroom testimony has been described as “groundbreaking.” Her focus that includes elder abuse, cyberstalking, and internet sex crimes has been recognized in forensic science classrooms nationally. At the heart of the work is her compassion for victims and victimization on which she has built a distinguished career, receiving numerous honors and numerous highest awards including the Sigma Theta Tau International Audrey Hepburn Award, the American Nurses’ Association Hildegard Peplau Award, the Sigma Theta Tau International Episteme Laureate Award, and named a 2016 American Academy of Nursing “Living Legend.”
Dr. Burgess’ leadership continues in her active work with other researchers and scholars at the Boston College. One of her two most recent projects is the College Warrior Athlete Initiative Project funded by the Wounded Warrior Project (click here for video). The purpose is to assist our nation’s wounded service men and women transition back into civilian life by partnering with an athlete in active physical exercise and socially supported learning activities. We asked her about the project and advice she might offer aspiring nurse leaders who seek ways to channel personal compassion into meaningful research and scholarship.
Ann Wolbert Burgess, D.N.Sc., APRN, FAAN, Professor of Nursing at the Connell School of Nursing, Boston College, is an internationally recognized leader in Forensic Nursing. Her research with victims began when she co-founded, with Boston College sociologist Lynda Lytle Holmstrom, one of the first hospital-based crisis counseling programs at Boston City Hospital.
We asked her to elaborate on the College Warrior Athlete Initiative Project and her leadership lessons in forensics by answering 3 Questions!
Veronica D. Feeg, PhD, RN, FAAN
We invite commentary that is thoughtful and provocative! Join the online dialogue!
Ann Wolbert Burgess
2016 American Academy of Nursing (AAN) Living Legend
William F. Connell School of Nursing
Question 1. Can you tell us about the Wounded Warrior Athlete Initiative Project and how you found the connection with your own body of work and the victims of military trauma?
The College Warrior Athlete Initiative or what we call in shorthand the Wounded Warriors Program is a nurse led health promotion program for wounded vets. It’s our way of having academic nursing to be a part of the wounded warrior trajectory back to health. There had been some discussion about how we, who are in academic situations, could be helpful. What happened is Ada Sue Henshaw, who was Dean down at the Graduate Nursing Program of the Uniformed Services University of the Health Sciences (USUHS) in Bethesda had taken on a high profile military issue for nursing to take the lead – and it was what is called “military sexual trauma.” And at the time that she contacted me it was getting a lot of press as well as Congressional attention. She knew of my clinical and research work in the area of sexual trauma. So she applied for a budget to fund a visiting professor to come to USUHS, advertised it competitively, I applied! And that’s why I got down to USUHS.
Now once I was down there working with Dean Henshaw, I spent some time with Dr. Sue Sheehy who was on faculty. And interestingly enough Sue had been a military nurse and had spent time working with returning wounded warriors coming into Walter Reed Hospital, which is right down there on the campus. And she had made a very compelling point that once these wounded warriors were discharged back home, there were very few resources, often, for them to continue in any kind of rehab program. Now that’s in more of the rural areas, certainly not in the major cities. But she was kind of pondering that and had been thinking about it, and realized that every small community would have access to a nursing program. That’s one thing that we certainly have done very well is that we have our nursing programs scattered nationwide.
So she thought why not test the nurse led program using the “battle buddy” system. Now, the occupational culture of the Army’s “battle buddy” concept refers to an attitude of support during tough times and had at that time never been applied to veteran health promotion. The big health problem outside of any of the medical or psychiatric diagnoses were nutrition for weight control, and strength decline. These seem to be two of the big problems that wounded warriors were having. So, with Sue, there was a decision to design a program with an athletic department and a nursing department to pair a veteran with a college student athlete for an exercise workout program that would also include wellness classes, and lunch – a nutritious lunch.
Now the next step is that Dean Susan Gennaro here at Boston College was able to offer Dr. Sheehy a visiting scholar position. Sue came up, we wrote a grant, submitted it to the Wounded Warrior Project and was one of three projects to be funded. That’s how it all got started.
We just finished our two-year program. We had a total of 50 veterans between Boston College and we had one satellite site at Norwich University. So we had 38 males and 12 females between the ages of 25 and 54, of seven cohorts. And they lost a total of 232.8 pounds and showed very positive changes in their BMI.
The way I got involved is through the military program and these were veterans who were also victims, if you will, of a war, and it seemed to be kind of a natural fit for me to become involved. And our goal is to extend the program to other nursing programs across the country. It’s very low-cost, highly rewarding, certainly for the wounded warriors, certainly for the students, certainly for the faculty who participate, the University and the community. In all it’s a win-win.
Question 2. What lessons did this project and other work you have done teach about nursing and what nursing can do?
Well I think there are several lessons that we can talk about. One is certainly to identify a high profile issue where nursing can take a leadership role. That, I think is critical. For example, one is the current opiate crisis. I’ve just finished analyzing data from over 300 cases where teens died by suicide. And so what we did was to look at the toxicology findings from the medical examiner’s office that identified the drugs in the teen’s system at death. And that’s important – for all that I’ve looked at the problem, nobody says what are the drugs that kids have in their body when they suicide? That will be from the data – that will be a recommendation for nurses on how to prevent teen suicide where prescription drugs and mental health is involved. So I saw that as an example of a high profile issue where nursing really can take a major role…I send that out for all of nursing!
Now a second high profile issue from my perspective is nursing staff violence, especially in the ER. How are we training or responding to violent patients and visitors? Now I know that many are…as we read some of these incredible cases of shootings…I know they are doing that…but is there anything else we can do? And one experience I’ve had that I would pass on is: I was involved in analyzing, doing a psychological autopsy of a mass shooting in the community of Seattle Washington. And the police chief there convened a panel to analyze the shooting and then publish our report on his website for the community to understand. So that is again another place, when they have one of these horrendous cases, nursing should get in there and suggest this – that the police chief can do such a thing. Out of Seattle, they found that very, very helpful.
And a third area I suggest is the cyber security of health records. Everybody knows that ransomware is hitting hospitals and nurses can be key in the solutions regarding records. I think that would be a huge area.
Now to take the example from their wounded warriors, nursing leaders know of nurses’ expertise and how to find them to consult on an issue. We have that published in our Academy notes. So Dr. Henshaw demonstrated that educators need to have a budget for visiting scholars or professors, whatever they want to call them, and also a budget for funding annual speakers. So that would be something that could be done – it doesn’t just have to be academics it can be in hospitals and so forth. And then have working groups on high profile issues. Then you can find some leadership for nursing. And I think that’s the way we get ourselves out in front and show what nursing leadership is.
So those are just some of the suggestions I had for how did I take the lessons learned from the Wounded Warriors project, as a model if you will, and transpose it to different topics.
Question 3. What is Forensic Nursing and what advice do you have for aspiring nurse leaders and scholars to be able to connect forensics with their specialty leadership goals
Well first of all, as a definition, Forensic Nursing is the interface of Nursing and the Law. So any time that a nursing issue, problem, case, etc. comes into a legal arena, that’s what Forensic Nursing is. So nursing has many areas, in fact, I can’t think of a single area in nursing that doesn’t have a potential legal issue to talk about. For example, the easiest ones are abuse cases, trauma cases, accident cases, they all come into the emergency department. That is the most logical place and that’s where, I think, a lot of Forensic Nursing started. My project did. We saw – Lynda Holmstrom and I – saw all rape victims coming into the emergency room over a one year period, and we took that data – and that’s what really kind of bounced my career into the crime victim arena. But I entered the forensic arena before there was such a title. We didn’t talk about forensic nurses back then. In fact I introduced the term and worked with Virginia Lynch as a pioneer in the field at the 1992 ANA annual meeting in Las Vegas. She was the one that really was the pioneer. And we were able to get that onto the annual meeting. So we date it back there.
But one of the official organizations, what we call the International Association of Forensic Nurses, which is the IAFN, was actually formed in Minnesota with the leadership of Linda Ledray and others. If you go to the Linda Ledray website, her definition is: ”by linking the clinical care with forensic care the result is better outcomes for patients” – and that’s Linda Ledray’s message.
And just to give you an example: One of the cases I helped with – because the US Attorney’s Office here in Boston needed a “forensic nurse” – they called me. And I helped by reviewing over 200 case files of meningitis cases where fungus had been introduced through a compounding center (and that was in Framingham Massachusetts). The US Attorney’s Office was handling it. The first trial just came about and I testified at that trial. But that was the case where it was (a) very unclean compounding center that was somehow…a fungus got into it…you could even see the fungus in the test tube! I mean I don’t know how people administering the steroid wouldn’t have seen it! But at any rate that’s just another example where people died – they needed a forensic nurse to be able to help them legally.
So my suggestion is nursing leaders need to be updated on forensics as it applies to nursing care. Nursing homes and even hospitals are facing a lot of what I call sexual exploitation cases, and nurses in risk management really need to know how to manage them. Two cases I was just called on this week: (1) one involved an ICU nurse taking photos with his iPhone of a patient’s breast and genitalia; (2) another case involved a nurse molesting a patient while under anesthesia and surgery was going on! These cases are publicly recorded on the Internet, so one of the things I try to do when I lecture on this is to give the actual cases – as it’s right there on the Internet for people to read! And we need to know how forensics can play a key role in this.
So those are just some of the cases and a definition of how I see forensic nursing as a potential in every nursing specialty.
Leadership Interviews – “3 Questions with Living Legends in Nursing” – Linda Schwartz
Nursing leaders of our times are recognized by healthcare professionals and the public for their outstanding contributions not only to our discipline, but to the health of the population. The American Academy of Nursing recognizes its distinguished leaders who have given service over their career to a group of selected individuals known as the American Academy’s “LIVING LEGENDS.” In 2016, these recognized scholars, policy makers, educators, researchers and truly dedicated nurses received this highest honor and addressed the audience with humble thanks and inspired all of us in the room with their living stories. For future nurse leaders who may not have been in the room, we believe that their personal viewpoints about leadership ought to be shared online in their own words. This first interview is with Dr. Linda Schwartz, Assistant Secretary of Veteran Affairs for Policy and Planning, who received the “2016 Living Legend Civitas Award.”
Dr. Linda Schwartz serves as VA’s principal advisor on all matters of policy, interagency liaison activities and strategic planning to enhance and promise the health of America’s 22 million veterans and their families. She is the former Connecticut Commissioner of Veterans Affairs (2003 – 2014) prior to her Senate Confirmation in 2014. She was a flight nurse and member of the United States Air Force, serving during the Vietnam War and following on Active Duty until 1986.
In her leadership roles, Dr. Schwartz was a strong advocate for issues related to homeless veterans, veteran suicide prevention and women veterans. Among her many awards and honors, she received the National Commendation medal of Vietnam Veterans of America for “Justice, Integrity and Meaningful Achievement”; the Legion of Honor Bronze Medallion from the Chapel of the Four Chaplains; Sigma Theta Tau’ International ARCHON Award “for her leadership and research on the human effects of exposure to Agent Orange.”
In a recent town meeting where she was asked to speak for the VA, Dr. Schwartz gave a response to a journalist known for his aggressive style that changed the tone of the meeting and the negativity in the room. In her poised but passionate response about a particular issue that is near and dear to her heart, she spoke to the audience with her nursing “voice” that said “we’re listening to you” and “this is a new day.” This short video captures that event and teaches nurses about talking to the press, but more importantly, shows how using opportunities to turn to the humanity of our profession can be a skill for nurses who aspire to positions of leadership to develop (click here to view video– courtesy of Elizabeth Leary, doctoral student, Yale University).
As a distinguished leader in nursing today, and with such significant service to country and discipline, we asked her to speak about nurse leaders using opportunities to educate the public about nursing as we face challenges today in health care. For future nursing leaders, we hope to inspire courageous young nurses to find their voices and seek opportunities to make a difference. Here are some of her words of wisdom:
Veronica D. Feeg, PhD, RN, FAAN
Linda Schwartz, DrPH, RN, FAAN 2016 Civitas Award Recipient
American Academy of Nursing
Assistant Secretary of Veteran Affairs for Policy and Planning
Question 1. Awards for leadership are bestowed upon people whose achievements are clear to others. But perhaps some accomplishments from the award recipients are even more meaningful to them that are unrecognized. Can you share with us a past experience that describes from your perspective what others might learn about opportunities that cultivate leadership?
…I think probably saying that you don’t plan these things, they just seem to happen. And the real factor in this is to seize the moment, and be a risk-taker even if it’s just speaking up for your patients and then starting with better care, better programs. I think that naturally nurses are leaders in their own right but they just don’t really see that the things that are the very fiber of our profession are the real hallmarks of what a good leader is.
So, from my own example, I never really in my wildest imagination thought that I would be a veterans’ advocate. But as I saw how the veterans were being taken care of in the VA when I had to use it, I kept thinking there’s a better way to do this! and seeing that in fact a lot of veterans didn’t have the wherewithal to speak on their [own] behalf; and in actuality, that’s how I kind of merged into being able to use my background as a nurse, my dedication to seeing that the right things were happening, that the best was happening for our veterans. I didn’t really realize as I was laboring in this and working for the women who served in Vietnam – working for their recognition – that I was slowly becoming a leader. People had to actually point that out to me, where I was thinking, “well I’m just trying to do the very best I can to move this agenda.” So, you know the old saying that leaders are made not born? I think a lot of that is your investment of yourself into a goal or an issue, and all of a sudden you become a leader in that respect.
Question 2. Can you describe your work with some of the significant problems that you have come to know well from your career?
Let me just say that early on, I became involved with the veteran movement especially the Vietnam veterans’ movement, and the women veterans who served. I was struck by the fact that so many women veterans who served in Vietnam had strange and exotic diseases and were dying at a very young age – wondering what all happened to them, maybe in Vietnam. And at about the same time, being an advocate for having women and women veterans in research, I was contacted by a group that was actually doing a study on Vietnam veterans, and they were upset because women veterans were declining to be interviewed. This was probably the first study of the Vietnam Veterans Readjustment study. My circle of friends were mostly women who served in Vietnam or in the military during that time, and this was an effort to try to get them to participate in a study that would actually do a better job of telling their stories or what was happening to them, and maybe to help unravel some of the questions I had.
But intead I became an interviewer for the study and my job was to try to talk people who had been selected to be subjects in the study – who had actually declined – and to talk to them about being in the study rather than not participating. That study was probably the first known health inventory for women veterans; it compared three groups of women – women who served in Vietnam, military women who did not serve in Vietnam, and a matched cohort of civilians. So, my question about health became almost like my passion because you just can’t start a study on Agent Orange and not get really into the nitty gritty of it.
And so, believe it or not, it became part of not only my study – my scholarly pursuits – but also I have a real passion for advocating for veterans and their families, especially for those who are having issues with health conditions associated with exposure to Agent Orange. So it was almost like a dual track of wanting to answer the questions but at the same time having the data, the information that would help answer those questions.
Question 3. What advice would you give to aspiring nurse leaders
For aspiring nurse leaders, I’ve always had a real special belief that nurses have a leadership role, and rightly so, because of the way in which we look at the world, the way in which we use data and information and facts. That’s a lot, not necessarily factored into leadership, per se, or to leading anyone or groups. So, for me, it kind of evolved, and starting out with wanting better conditions for veterans (which is a really vast and prolonged vista from which to choose many different avenues, actually). But the fact that I was a nurse, and wherever I went, and whatever I advocated for, I’ve always been one who believes that you should speak truth to power, even when it is not necessarily the easiest thing to do. When you’re challenging the system, just speaking truth to power really isn’t enough. You have to have your facts. You have to be very conversant in what’s going on with the issue that you’re addressing.
But I also feel that sometimes, for me, the bond that I have with the people I served with in the military is very strong and it doesn’t necessarily have to be people I actually know. It’s the people and understanding of the experience that people go through when they are in the military and keeping faith with them. I was lucky enough to know Virginia Henderson who is maybe is not as well-known today as when I was, when we knew her, it was the fact that she had defined nursing as being, doing for the patient what they cannot do for themselves if they were well and had energy, and all those things, that we have to be the voice of those who have no voice. And that’s kind of been my mantra. Because nurses can so well identify the issue and the arguments and the points that need to be stressed. It’s just the way we learn how to diagnose the problem and look for the solutions.
So, it’s a very natural part of nursing and I think many nurses, hopefully it’s changed, but back in the day that wasn’t something that people wanted to encourage in nursing – that you would be a leader. For me, this kind of quest to look for the justice of the situation: I had exquisite opportunities to be in the halls of Congress, to be before legislators and policy policymakers. And it is not because I said, “I want to be the leader” – it’s because my dedication to the veracity of the information and the authenticity of the information was very important. And often times that doesn’t happen when you’re trying to effect change in public policy. Sometimes the truth is the first victim of the situation.
In many ways, I believe that my nursing profession, my nursing practice, has been a wonderful way to frame my leadership style – that we listen to all people, we allow people to express their opinions, but at the same time our eye is firmly focused on the goal of what we’re trying to accomplish. And in policy and health policy, that’s health, but in some instances, like for example with veterans, sometimes it’s justice. So, I think it’s important for folks to remember why it was they came to nursing in the beginning, and if it was, as it was with me, to be sure to help other people – that’s a common theme. And it certainly gave me great courage to face some of these situations; and I can just say, [in] the film that you have of the symposium on Agent Orange, the emotions that were displayed by a lot of people in the room including some of the sons and daughters of veterans who, at first, had birth defects that are still a challenge for them today, to sit in that room and listen to them – it was listening just as you would listen to someone you were trying to help. And I think that is another aspect of nursing, that we are not necessarily adversarial, we are more of trying to find the common ground and a way forward. So, those are the leadership strengths that I think are natural or embedded in what we do as nurses. It’s just that maybe some nurses need a little confidence that, that also works once you are trying to accomplish other goals in patient care.
Leadership Interviews – “3 Questions” – Health Care of Our Veterans and Military
Healthcare of Our Veterans and Military
In 2011, First Lady Michelle Obama and Dr. Jill Biden came together to launch Joining Forces, a nationwide initiative calling all Americans to rally around service members, veterans, and their families and support them through wellness, education, and employment opportunities. Despite these initiatives that have provided resources to those who served our country, their healthcare has been the subject of numerous headlines and ongoing discussions that warrant nurses’ attention.
In an effort to bring back the “joining forces” momentum – remembering why we did this in the first place and to show the progress along the way – Dr. Morrison-Beedy offers her insights about the special Nursing Outlook focus on military and veterans’ health care in the September 2016 special issue. This series of articles in NURSING OUTLOOK provides a spotlight on initiatives that have taken place with military and veterans’ health over the recent past years. Launched from the Jointing Forces Initiative and Restore Lives Conference at the University of South Florida, nursing educators, researchers and clinicians who shared their commitment and common challenges related to military and veterans’ health in the U.S. and globally, came together in 2015. These articles highlight the work of nurses on issues of concern for veterans and active duty service members and their families (see conference program here).
Dianne Morrison-Beedy, PhD, RN, WHNP, FAANP, FNAP, FAAN is a Professor of Nursing, Global Health and Public Health and past Senior Associate Vice President of the University of South Florida Health, as well as Dean of the College of Nursing. Her work in the area of veterans’ and military health nationally has now taken a global perspective as she has included related issues from other countries. She brought together the papers from the Joining Forces conference in the recent issue of NURSING OUTLOOK. We asked her to elaborate on the series by answering 3 Questions!
Veronica D. Feeg, PhD, RN, FAAN
We invite commentary that is thoughtful and provocative! Join the online dialogue!
Dianne Morrison-Beedy, PhD, RN, WHNP, FAANP, FNAP, FAAN
Professor of Nursing, Global Health and Public Health, University of South Florida (USF)
Past Senior Associate Vice President of USF Health and
Dean, USF College of Nursing
Question 1. What was the impetus for a military and veteran focus special edition of Nursing Outlook?
To listen, click here.
The idea for the issue really was sparked several years ago, around 2012, when Joining Forces became a focus for our Nation. Joining Forces is a National initiative and it focused on education and wellness and employment for veterans. It was spearheaded by First Lady Michelle Obama and Dr. Jill Biden and it really was to support and honor American service members and their families. At that time over 600 colleges of nurses met this initiative head on, and developed curriculum, tool kits, research, webinars and veterans-focused programs.
In my role as the Senior Associate Vice President for USF Health and the Dean at the College of Nursing at the University of South Florida, I brought together leaders in those areas for what has become now a yearly Joining Forces to Restore Life conference. All these approaches were very much needed as there are over 22 million veterans of the US Armed Forces and in fact there is over a million residing in Florida, Texas and California.
So both those who have served and their family members are impacted from stressors of deployment, combat, separation, and frequent moves, as well as employment and education transitions. So it was in essence a time for nursing to do its part, and it was truly gratifying to see the overwhelming response from Nursing Academic Programs across the U.S. to the Joining Forces call.
Question 2. Why do you think this topic is so important to nursing at this time?
To listen, click here.
Over the past several years since the Joining Forces kick-off, nursing academia has been moving these various initiatives forward. As is often the case in nursing, we are quietly making an impact on an individual, unit, or case by case basis. And I thought that editing a special edition issue highlighting just a few of the tremendous steps forward in these areas that have been led by nursing was important to both document as well as to provide an opportunity for us to talk more about these topics.
So I am very grateful for the opportunity for this interview and for serving as editor. And it was over the past few years because of my connections with Joining Forces and the military that I began to partner internationally on several veterans focused initiatives.
Committed partners can do great things together and the result was the International Joining Forces to Restore Lives conference held in 2015 in the UK.
Now it’s really what I saw there, what I experienced, what I learned, really what I felt could be summed up simply as “individuals who came together with a committed passion for making life better for active duty service members, veterans, and their families.”
We shared many of the same challenges and this conference allowed us to put our heads and our hearts together to come up with solutions, support, and strategies to find a path forward for those who have served and for those who are protecting all of us at this moment.
Question 3. What are the “take-home thoughts” you have for readers?
To listen, click here.
I think readers will be very pleased with this issue not only with the content that’s provided but with the ability to see other nursing academics and scientists who are doing work in the area and have the opportunity to connect with them.
We are a very diverse group of scholar clinicians but the common the thread among all of us is a passion and the commitment for active duty military, our veterans and their families.
So whether we’re examining pain management, trauma informed care, how service impacts family members, or reintegration of veterans once they return home, this issue brings together ideas and data and programs from global nursing leaders. The issue highlights both what we are doing and what we can do to meet the physical and the psychosocial needs of those in the military and strategies for education, clinical and scientific innovations.
It’s been a real pleasure serving as editor for this special edition, and even though we have joined forces, we still need to keep moving forward with what nursing can contribute to military and veterans’ health. And I hope this issue just highlights some of the ways that we are doing that.