Nursing Outlook TALK

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).

Link: To hear her testimony to the United States Senate Judiciary Committee on July 30, 2014, click here).

(Link: To hear her testimony within the full hearing related to domestic violence and child abuse [go to 1:36:45] click here).

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.

(Link: To hear in her own words about her commitment to the importance of nursing leadership in domestic violence research, click here).

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
Editor/Moderator

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.

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

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
Editor/Moderator

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.

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

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.

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

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?

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

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.

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
Editor/Moderator

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
Boston College

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.

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

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
Editor/Moderator

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.