Nurses across the globe are innovating new approaches for addressing social determinants of health (SDOH) and improving health equity; collaborating with a wide variety of partners across disciplines and sectors; and implementing programs in communities, hospitals, schools, and other venues. The Future of Nursing: 2020–2030: Charting a Path to Achieve Health Equity describes how health outcomes and access to health care are inextricably entwined with the conditions in which people are born, grow, live, work, and age, known as SDOH. These social, economic, and environmental factors, including race, education, employment, housing, the physical environment, and wealth, are strong predictors of health and life expectancies. Nurses are increasingly using their expertise, their connections with communities and individuals, and their ability to collaborate across professional boundaries to address SDOH and give everyone an equal opportunity to live a healthy life. The following vignettes describe nurses’ work in this area; the vignettes are divided into sections on
- prioritizing SDOH,
- strengthening the nursing workforce,
- innovating in health care,
- mental health and substance abuse,
- community-based health and social care,
- leading on gender equity, and
- the power of leadership.
PRIORITIZING THE SOCIAL DETERMINANTS OF HEALTH
Rush Surplus Project: A Three-Pronged Approach to Addressing Food Insecurity While Reducing Waste
Hospital kitchens may not commonly serve as incubators of great initiatives, but for Jennifer Grenier, DNP, RN-BC, CNML, CENP, director of clinical operations for the cardiac service line at Rush University Medical Center (RUMC) in Chicago, Illinois, they have been just that. In 2015, while employed at Rush Oak Park Hospital (ROPH) in Oak Park, Illinois, Grenier became aware of the vast quantities of food being thrown out by the hospital cafeteria each day. To reduce this waste while simultaneously addressing the needs of patients and local communities living with food insecurity, she, along with Nicole Wynn, DNP, RN-BC, and a team of community leaders founded the Rush Surplus Project. The program began as a partnership between ROPH and the Oak Park River Forest Food Pantry (recently renamed Beyond Hunger), an organization that provides food and other services to 13 zip codes throughout the Chicago metropolitan area.
In Cook County, where Oak Park is located, food insecurity is pervasive. Shortly after the partnership with Oak Park River Forest Food Pantry was formed, the local YMCA also became a recipient site. And in 2017, after moving to RUMC, Grenier and Wynn expanded the program there, this time partnering with Franciscan House, a homeless shelter on Chicago’s West Side. The model works as follows: after becoming certified food handlers, volunteers from the hospital staff, including nurses, social workers, kitchen employees, and administrators, repackage the cafeteria’s unused prepared foods, labeling the containers with the date and any potential allergens. Finally, volunteers from the pantry transport the food, which must be consumed within 24 hours of delivery. Since its inception, the Rush Surplus Project has provided more than 700 meals per month, or approximately 8,400 meals per year. Furthermore, each meal has reduced landfill waste by approximately 1 pound (or 8,400 pounds annually). The project has also strengthened volunteerism, thus reinforcing community bonds.
With the help of Robyn Golden, MA, LCSW, assistant vice president for population health and aging at RUMC, the Rush Surplus Project has spawned two other initiatives. The first, launched in 2017, is a partnership with Top Box Foods—an organization that provides the employees of RUMC and ROPH, many of whom struggle with food insecurity, the opportunity to purchase, at a discounted rate, a 15-pound box of produce, picked up at the hospital. The second initiative, Food Is Medicine, is a collaboration among the Rush Department of Food and Nutrition Services, the Greater Chicago Food Depository, and the Surplus Project. Upon admission to participating ROPH units, patients are screened for several social needs, and those who screen positive for food insecurity receive within 48 hours a bag of such nonperishable foods as oatmeal, canned proteins, and peanut butter, along with recipes and diet instructions for
specific conditions. Food-insecure patients are also encouraged to apply for other forms of nutritional support and are enrolled in NowPow, a database that upon discharge connects them to local resources, including shelters, food pantries, and transportation options.
The burden of liability could create barriers for organizations trying to donate to the project; however, the Good Samaritan law removes those barriers by protecting organizations that donate food to nonprofit organizations. A smaller obstacle was pushback from the cafeteria staff members, who initially interpreted the initiative as reproach for wasteful practices; soon, however, they understood the mission and got on board.
The Rush Surplus Project has proven popular, and various institutions serving low-income individuals in Illinois have already adopted the model. To facilitate replication, Grenier and her team created the Surplus Project Toolkit. According to Grenier, key to the program’s success is inclusivity. “Anyone who gets certified to package food can participate,” she says. Food Is Medicine has not yet spread to other institutions but has quickly been adopted within RUMC. Grenier notes that though the program requires an additional screening, enthusiasm remains high among nurses because they see the tangible results of their efforts. “We send the units monthly data so they know how many patients they screened and how many bags they delivered. We even have a little race going; the unit that delivers the highest number of bags gets a pizza party.”
To encourage replication, Grenier and Wynn regularly post video tutorials on social media and provide PowerPoint presentations at conferences. While both agree that running the programs on top of the demands of their full-time jobs can be challenging, they believe the rewards far outweigh the hurdles. “We do this because we love it,” Wynn says. “And we believe in doing what’s right.”
CAPABLE: Helping Older Adults Thrive at Home
Early in her career, Sarah Szanton, PhD, ANP, FAAN, cared for migrant farm workers in rural Pennsylvania, some of whom were living in reconstructed chicken coops. Later, as a nurse practitioner (NP) making house calls on homebound older adults in west Baltimore, she realized the extent to which people’s health and quality of life deteriorate when their homes do not accommodate their disabilities or frailty. Those early experiences led Szanton—now endowed professor for health equity and social justice and director for policy at the Center for Innovative Care in Aging at the Johns Hopkins University School of Nursing in Baltimore—to co-create a program called CAPABLE (Community Aging in Place—Advancing Better Living for Elders), designed to help low-income seniors age safely in their own homes. Two key program components are an em-
phasis on a person’s physical functioning at home and the concept that housing is health care.
CAPABLE is based on the ABLE (Advancing Better Living for Elders) model created by Laura Gitlin, PhD, FAAN—a home-based intervention that employs occupational and physical therapists (OTs and PTs) to address the needs of functionally vulnerable older adults. CAPABLE includes a focus on the management of pain, medications, and depression, along with communication with primary care providers and home repair. To accomplish these goals, a registered nurse (RN), an OT, and a handyman work in tandem. Szanton notes that while CAPABLE’s initial priority was safety, she soon realized that to truly improve the health and lives of older adults, the program had to focus on their priorities and tap into their motivation for change. She explains that after home adjustments are made, residents adopt behaviors advised by their clinicians; for example, they quit smoking or better adhere to a medication regimen. People using CAPABLE, she adds, have described it as “life-transforming.” One participant reported, “I used to crawl up and down the stairs on all fours. Since the railings I can walk up and down the steps standing up like a lady.”
CAPABLE costs approximately $2,825 per person but is associated with $30,000 in savings per year, mainly in reduced emergency room (ER) visits, hospitalizations, and long-term support services. This cost-saving potential has fueled the program’s spread. Yet, despite its proven effectiveness, CAPABLE has faced several challenges:
- The health care system’s persistent focus on disease. Because of that emphasis, payment policies seldom support CAPABLE’s emphasis on functional improvement.
- Training. CAPABLE requires clinicians to relate to residents differently, focusing on their goals.
- Providing CAPABLE to people with cognitive impairments. Working with a human-centered design expert, Szanton hopes to adapt the service for those requiring the assistance of family caregivers.
CAPABLE is offered at 29 sites in 15 states, as well as in Australia. Thus far, the model has been adopted by such organizations as Habitat for Humanity, Meals on Wheels, the Visiting Nurse Service, accountable care organizations, and others. Hospitals, too, are getting on board. Trinity Health—a nonprofit Catholic health system—is offering the program to complex care patients in Muskegon, Michigan.
According to Szanton, if the nation is to leverage the strengths of an aging population, policy changes will be needed to (1) redirect the health care system’s focus from disease treatment to functional improvement, (2) make programs such as CAPABLE more readily available, and (3) authorize that every other annual Medicare wellness visit be conducted at someone’s home to assess housing and
functional needs early on. A shift is needed, she asserts, from a biomedical model to one that appreciates the value—both human and financial—of helping older adults age at home, safely and with dignity.
Housing First: Meeting Basic Needs to Improve Health
Cyrus Batheja, EdD, MBA, PHN, BSN, RN, followed an unusual path to learning about the role of housing in health and well-being that led to his current role as vice president of policy and clinical solutions at UnitedHealthcare Community & State (the Medicaid division of UnitedHealth Group). After moving from London to Minnesota, Batheja’s family faced many hardships. Upon learning about a program to address a nursing shortage in the United States, his mother pursued a nursing degree as a way to secure a green card—a path Batheja himself eventually followed. “Through the program and my mother’s inspiration,” Batheja says, “I gained a passion for the profession,” and he began contemplating the track he wished to follow, which, he says, “was around making the health system work better.” To this end, he continued his studies, earning a bachelor’s degree, followed by a public health certification, a master of business administration (MBA) degree, and a doctorate.
In 2001, Batheja, along with his mother and wife (a behavioral health professional) purchased a home that they then turned into a supportive living service (SLS) facility, where they would receive vulnerable patients with complex medical or behavioral conditions, including physical and verbal aggression. This was followed by the purchase of a second home, also converted to an SLS facility. “We provided highly dignified housing,” says Batheja, “housing that we would feel comfortable living in.” Batheja has assisted residents with building life skills, returning to school, getting jobs, and finding their own housing. “What we really pride ourselves on,” he says, “is being able to help individuals reach their highest levels of functioning.” He adds, “We’ve made sure that people understand that this is their home. We don’t think of it as our house. It’s their home and we stay there with them.”
In 2009, Batheja joined UnitedHealthcare with the aim of taking his model to the national level. He eventually assumed a position that enabled him to build, across 30 states, local and community programs that could impact quality indicators for the company, including adolescent well checks, immunizations, and diabetes management. In these programs, Batheja emphasizes, the focus was on strategies that built on each population’s strengths. For example, he discovered that in Brooklyn, New York, among Hassidic Jews, the Sesame Street dolls and other trinkets that were being distributed as incentives for pediatric well checks
and immunizations were ineffective. “So we pivoted away from that strategy,” says Batheja, “and partnered with their local synagogues, rabbis, and cantors.” Batheja worked to establish relationships with his company’s Medicaid leadership that, he believes, “helped change their perspective.” As a result, he was able to work with them to develop a strategy based on SDOH, including a “Housing First” approach focused on removing such barriers as previous evictions, substance use, or criminal backgrounds to provide vulnerable populations with dignified housing, along with trauma-informed services.
The initiative not only has been beneficial to vulnerable populations but also has reduced health system costs. One homeless and unemployed UnitedHealthcare member, for example, had in 2 years made 254 visits to the emergency department (ED) and had 32 hospital admissions, accumulating more than $294,000 in health care costs. Four months after moving into a supportive housing unit, he was able to stay out of the hospital and was beginning to set life goals. “At scale,” Batheja asserts, “the program demonstrates that this approach is creating a significant impact compared to traditional case and disease management programs aimed at complex populations.” As of March 2019, UnitedHealthcare had provided more than 4,500 new homes in 80 affordable-housing communities across the United States and had plans to expand its housing program in all of its markets.
Nurses interested in doing similar work, Batheja says, need to “pivot away from transactions, checking boxes, and assessments, and [turn to] relationships.” Instead of asking a patient, “What’s wrong with you?” he adds, nurses could be asking, “What happened to you?” Batheja believes two factors are essential to the success of such efforts. First, he advises, “Don’t be afraid to link your personal values with your professional work.” And second, “Think big, start small, be bold.” Now that the Housing First project has been scaled up nationally, he is thinking of innovative policies and meaningful clinical solutions for the company’s 7 million Medicaid recipients. “Empowering people to have their basic needs met,” he says, “ultimately will lead to both their physical health and their mental health. As people have that opportunity to feel included … they gain purpose and start to contribute back.”
STRENGTHENING THE NURSING WORKFORCE
Multi-Employer Training Fund: Reducing Educational and Income Disparities
In 2018, the U.S. Bureau of Labor Statistics projected that within a decade, jobs in the health care sector would increase by 14 percent, outpacing other occupations. Yet, not all of these jobs are lucrative, and the lowest-paid workers in
health care are likely to be struggling with unmet social needs, including access to education. Before 2008, the Taft-Harley Act allowed unions to bargain for a fund for education and training as an employee benefit. But recognizing the limitations of a single-employer training fund, Diane Sosne, RN, MN, president of SEIU Healthcare 1199NW (a union representing 30,000 health care employees in Montana and Washington State), became one of the founders of the SEIU HealthCare 1199NW Multi-Employer Training Fund. Formed in 2008 as a partnership between the union and multiple employers (nine in 2020), the Fund pools employer contributions and provides an opportunity for additional financial support from federal, state, and foundation sources. The education and training employees receive through the Fund enhance their career mobility, thereby reducing education and income disparities.
The Fund supports the nursing workforce in numerous ways:
- Career advancement. The Fund supports nonlicensed workers in pursuing a profession or certification that can lead to a new position and higher wages. Some become licensed practical nurses or RNs, and existing RNs can apply to complete their baccalaureate, master’s, and doctoral degrees at any accredited program in the country. Service workers can gain apprenticeships in high-demand specialties and become, for example, medical assistants and surgical technicians. Subsequently, a surgical technician can pursue a nursing degree and work as an RN in this high-vacancy specialty.
- Access to convenient educational programs. Because the Fund represents so many employers and employees, it can influence curriculums and negotiate on a variety of factors, including program content and the time and location of courses. As a result of its efforts, many nursing programs now teach contextualized prerequisites. “[If you are taking] math, examples would be related to medication dosages,” Sosne explains. “Or in English, you would be asked to write a paper about interacting with patients and consumer services.”
- Support services. Students can take advantage of English-language classes, as well as tutoring in such areas as English, math, and writing. In addition, they can turn to “navigators” who provide career and educational counseling, or connect with a 24/7 online tutoring program for immediate support.
- Skills and equipment. As members move into positions requiring additional skills—including using electronic health records—members who have had limited experience with computers can take a computer literacy course. Sosne adds that some students have even received Chrome Notebooks and other equipment they would not have been able to afford.
- A caring community. Sosne explains that the Fund has evolved into a “cheerleading squad,” helping members overcome the self-doubt result
- ing from long-standing experiences with racism and discrimination. This sense of camaraderie is strengthened—particularly for older members who might be less comfortable in a classroom filled with 18-year-olds—when members enroll as a cohort. Those who earn their nursing degree and move into a new position can benefit from an RN mentoring program that helps them acclimate to their role, address ethical issues that may arise on the job, and build self-confidence.
For employers, the program fosters loyalty, as employees who use the Fund are obligated to remain with their employer for a specified period of time. Sosne stresses, however, that this is rarely a hardship. “Once people get the benefit of education and experience these wraparound services,” she points out, “they feel loyal to that institution.” While the Taft-Hartley Act requires that employer-contributed funds be allocated only for union members, there is no such stipulation for monies received from other sources, such as grants. Sosne is therefore excited about a new venture that involves reaching out to low-income populations and communities of color to encourage careers in health care. “I strongly believe,” she says, “that the best way to address health care disparities is through a diverse workforce.”
Rhode Island Nursing Institute Middle College Charter High School: A Pipeline to Health Equity
Although ethnic or racial minorities represent almost 40 percent of the U.S. population, they make up only about 20 percent of the nursing workforce. Rhode Island struggles with this disparity, having a population that is 80 percent non-Hispanic White but a 91 percent non-Hispanic nursing workforce. In 2010, recognizing that reducing barriers to nursing education for minorities is key to promoting health equity, leaders from the Rhode Island State Nursing Association decided to respond. Pamela McCue, PhD, RN—at the time director of the Rhode Island Board of Nurse Registration and Nursing Education—was asked to lead this effort. McCue, while pursuing her doctorate at the University of Rhode Island, chose to research the profession’s diversification through the precollegiate pipeline. What emerged from her research is the model for the Rhode Island Nursing Institute Middle College Charter High School (RINIMC), located in Providence.
RINIMC—the first charter school in the United States dedicated to nursing and the first “middle college” in Rhode Island—is an innovative, comprehensive high school whose mission is to prepare students to successfully pursue a nursing college major immediately after high school. It has a supportive learning envi-
ronment, meets federal and state education requirements, and targets adolescents from disadvantaged neighborhoods.
McCue describes four design elements of the school:
- An innovative curriculum called the Nursing College and Career Preparation Program. The curriculum includes rigorous college prep and college-level courses infused with nursing and health care topics, which allow students to earn up to 20 transferable college credits.
- Real-world, authentic work experiences. “Practice partners” mentor students and provide credit-bearing internships at their health care organizations.
- A culture grounded in care and nurturing. Students often come from underserved communities and experience the chronic stresses of poverty, inadequate housing, and unsafe neighborhoods; many have also been victims or witnesses of trauma and abuse. “We recognize the significant challenges students have outside the classroom,” McCue says, “and … help [them] develop coping skills, resilience, and self-efficacy.”
- Partnerships for seamless higher education. While graduates can continue their education at any college, RINIMC entered into agreements with the Community College of Rhode Island (CCRI), Rhode Island College, and The University of Rhode Island in 2018 whereby RINIMC students are automatically admitted as a cohort to CCRI’s nursing program—tuition-free—then continue seamlessly to the latter 4-year colleges for the RN-to-bachelor of science in nursing (BSN) program and can be BSN-prepared in less than 4 years.
RINIMC’s first class graduated in 2014; there have since been a total of 290 graduates. Of these, 73 percent enrolled in college within the first year of graduation, and 79 percent did so within 2 years. These college enrollment rates contrast with a 52 percent enrollment rate for economically disadvantaged students in all of New England and an average enrollment rate of 55 percent for the region’s Hispanic and Black students. McCue and her colleagues have a vision of replicating this model and developing a national network of schools working together to prepare a diverse group of students to become the future nursing workforce and leaders in their communities. She is currently working with nursing leaders in Albany, New York, to open the next nursing middle college.
At the same time, McCue adds, the challenges should not be underestimated. The first is a lack of understanding of the impact of social determinants on education. Funding has been another obstacle. RINIMC receives the same local, state, and federal funding as other public schools—an amount that does not cover the unique aspects of the model, including the essential support services it offers, the nursing experiences, the workforce certificate training, and the costs of the building itself. To make up for this lack of funding, the school relies on grants and
donations. These and other challenges notwithstanding, McCue is hopeful about RINIMC’s future and a network of similar schools. “I think [our school] will have a big impact not only on [increasing] diversity in the workforce, but also [on creating] a new model of education that encompasses health and addresses social determinants of health.”
INNOVATING IN HEALTH CARE
Complex Care Model: Partnering for Transformation
Lauran Hardin, MSN, CNL, FNAP, FAAN, learned a valuable lesson about model design nearly a decade ago when a chief executive of Mercy Health Saint Mary’s Hospital in Grand Rapids, Michigan, jokingly told her she was accountable for a $2.6 million revenue loss. As the hospital’s complex care clinical nurse leader, Hardin had successfully reduced health care utilization by palliative care patients and had been asked by the administration to extend her work to patients with high utilization of services outside of palliative care. Without additional staff or funding, she designed a model of care for patients with complex health problems—the high utilizers of health care resources—that centered on the question, “What do patients need most and how do we create an efficient system to provide it?” Her Complex Care Model worked, reducing 300 patients’ use of services by more than 60 percent in 1 year. Although the model saved money for the health system, it impacted the hospital’s bottom line by reducing income on fee-for-service patients.
Hardin partnered with the chief executive and soon proved that the hospital’s financial stability and the reduction of unnecessary health care services were not mutually exclusive. Over subsequent years, she replicated her model in the Trinity Health System—the parent company of Mercy Health, with institutions across 22 states. Currently, as senior advisor for the National Center for Complex Health and Social Needs in Camden, New Jersey, she is helping institutions throughout the country adopt the model and best practices from the field of complex care, including considering people’s social needs and communities’ SDOH.
Hardin describes the Complex Care Model as “a whole-person model of intervention for complex populations.” Organizations can adapt the model to their own needs and circumstances, which ensures commitment and sustainability among local organizations and the community. Five elements are essential to the model’s successful adoption:
- Using data to find the most vulnerable populations and developing a viable business model. Identifying patients with repeated ED visits and
- frequent hospitalizations is crucial, as is knowing the characteristics of the population being served.
- Using a comprehensive whole-person assessment. The focus of care needs to be on the root causes—medical, behavioral, social, and systemic—that lead to a patient’s instability.
- Identifying everyone in the patient’s care team and developing a shared care plan. This includes people outside the health system, such as those working with social services, law enforcement, and nonprofit organizations.
- Using each patient’s story to improve care delivery. “Built into the model,” Hardin says, “is a responsibility to not only help the individual, but also translate the lessons learned into broader system improvements.”
- Building community collaborations across sectors. For example, hospitals, emergency medical services (EMS), police, and social agencies can form a collaborative to develop an evidence-based approach to help people with alcoholism, whose repeated visits to the ED may be driven by lack of housing and access to care.
Hardin points out that this work taps into challenging issues involving ethics, health equity, and social justice. Examples include
- contending with policies such as those that prevent former felons from obtaining public housing or employment, or assessing the effects of not having health insurance;
- securing resources for long-term sustainability, including for staff care delivery, data analysis, and research;
- developing new competencies, including care coordination, cross-sector partnership, data analysis, and a focus on population health; and
- addressing myriad systems-level barriers, including messages that undermine nurses’ ability to become leaders in the area of complex care management.
Hardin’s model has been shown to reduce ED use, hospitalizations, lengths of stay, and costs while increasing primary care visits, stable housing, and health care coverage. Examples include
- Mercy Health, where declines were seen in ED visits, hospital admissions, CT scans, and lengths of stay, all of which contributed to a 43 percent decrease in direct expenses and a 45 percent reduction in gross charges, along with improvements in contribution and operating margins;
- Project Restoration, an initiative Hardin helped implement at Adventist Health in Clearlake, California, which formed a collaboration with the
- police, EMS, the fire department, behavioral health services, the faith community, and law enforcement to identify the system’s most vulnerable users, who were often the same ones across multiple sectors, and address such issues as lack of stable housing that are major drivers of service utilization; and
- Regional One Health in Memphis, Tennessee, which worked with Hardin to launch ONE Health to help uninsured patients with chronic illnesses—including behavioral health problems—navigate the health system and access social services, thereby reducing ED utilization, hospitalizations, lengths of stay, and health care spending.
Beyond the financial gains represented by these examples, Hardin emphasizes that the initiatives are transforming lives, stating “people are experiencing a different kind of respect and stability. They report feeling seen and heard, and having a sense of renewed hope.” She adds that the initiatives are helping not just patients but also their families, their communities, and the entire health care system by improving relationships, social circumstances, and care coordination. She notes further that Adventist Health is developing metrics to better measure the impact of this work on community well-being as it moves further upstream to address specific SDOH. Providers, too, are benefiting, reporting that they find the approach effective or highly effective, and that they value the ability to improve patient outcomes through meaningful collaborations.
“Transformation occurs,” Hardin says, “when the system is equitable and organized around each person, and when it integrates that person’s community into the care plan.”
The Pause: A Moment to Honor, Recognize, and Reflect
In 2006, Tim Cunningham, RN, DrPH, FAAN—then an actor and professional clown—was invited to cheer up patients at a pediatric hospital in a rural Haitian town. While he was there, a premature infant died because the mother had had no access to quality prenatal care and nutrition. This experience of the inequities of the health care system led him to pursue a career in nursing. Three years later, having earned his nursing degree and working in the ED at the University of Virginia Medical Center in Charlottesville, Cunningham met his mentor, Jonathan Bartels, RN, who introduced a practice that became known as “The Pause.” When a patient with cardiac arrest died despite resuscitation attempts, Bartels asked everyone to pause in order to honor the person’s life and recognize the team’s efforts.
This simple practice, which Cunningham describes as “a tool that we’re all capable of practicing even when everything else seems to have fallen apart,”
further ignited his passion for health care that is anchored not only in science but also in human relationships, eventually leading him to assume a position as the director of the University of Virginia’s Compassionate Care Initiative (CCI). After receiving a grant from a private donor to research self-care and resilience, Cunningham and his team at CCI chose to study The Pause to investigate whether short-term self-care practices could offer benefits similar to those provided by such long-term practices as yoga and meditation. Cunningham has since expanded his research on resilience-building practices to Emory Healthcare in Atlanta, Georgia, where in 2019 he became vice president of practice and innovation. “We find ways to scale best practices in culturally appropriate ways,” he says, “and make them available to a wider audience.”
The Pause is a secular practice implemented after the death of a patient, offering the care team 30 to 45 seconds of silence to honor the life that has ended and the clinicians and support staff who cared for that life. Any member of the team can initiate The Pause by expressing a variation of the following statement:
Could we take a moment just to Pause and honor this person in the bed? This was someone who was alive and now has passed away. They were someone who loved and was loved. They were someone’s friend and family member. In our own way and in silence let us stand and take a moment to honor both this person in the bed and all the valiant efforts that were made on their behalf.
The Pause is voluntary and should not be imposed, and it is nonprescriptive, allowing team members to be in silence as they see fit. “You are free to think and feel whatever you need to at that moment,” Cunningham explains. A word commonly associated with The Pause among those practicing it is “honor,” for both the patient and the team, an acknowledgment of not only the staff’s physical efforts but also the emotional toll the attempt at resuscitation can take on them. The Pause may also hold the potential to mitigate burnout, an area in which Cunningham is continuing to research. Those practicing The Pause further report that care of the self and the team leads to a “sense of grounding and well-being” that allows them to focus better on the patients who follow, which, Cunningham says, is crucial to improving quality of care and patient safety.
Implementation of The Pause has faced some challenges, one of which has been its potential to be interpreted as a religious practice. However, this perception can be mitigated if the practice’s open nature and adaptability are made clear from the outset. Another concern has been its ability to “stir uncomfortable emotions,” including a sense of failure. Cunningham cautions that The Pause is not a one-size-fits-all practice. “If we allow ourselves to feel failure and we are not able to manage it,” he says, “we could feel even more burned out.” Still another concern is the potential standardization of The Pause, which would defeat its purpose as an opportunity for voluntary reflection and human connection. Finally, The Pause can be viewed as supporting the tendency of health systems
to “pass the buck” to individuals with respect to building resilience. Cunningham stresses that health systems must constantly examine ways to decrease stressors by reevaluating scheduling, for example, or lessening administrative tasks, and not just regard implementation of The Pause as having fully discharged that responsibility.
The Pause has been implemented in 23 locations within the United States and globally in settings that include hospitals, academic institutions, administrative offices, and community health settings. Cunningham describes it as “a grassroots movement” that can be disseminated in various ways, including via clinical training or at the bedside. He adds that many people are already practicing some version of The Pause, but with a different name. “It turns out that you can’t trace it back to any one person,” he says. “And that’s what’s beautiful about it. It reminds us that it’s simply a very human practice.”
What Matters to You?: Focusing on the Whole Person
In 2012, an article in the New England Journal of Medicine by Susan Edgman-Levitan, PA, and Michael Barry, MD, urged health care providers to ask not only “What’s the matter?” but also “What matters to you?” A nurse in Scotland, Jen Rodgers, took up this challenge in her pediatric hospital in Glasgow, and a nurse in Norway, Anders Vege, did the same in nursing homes across that country. What they found was that highest on the list of what matters most were not medical needs but needs related to social issues, family and support, access to food and housing, and safety. The question changed the perspective of these nurses on their work and, in addition to meeting needs related to SDOH, on their contributions in health care. They realized the power of this change in the process of care and felt the need to share it widely. To this end, they initiated a “What Matters to You?” (WMTY) day on June 6 and shared the very positive impact of making this change.
The WMTY idea has generated global energy, and WMTY campaigns are now in care systems in 50 countries. Each year on WMTY Day, 2,000 organizations worldwide participate, and thousands exchange ideas and learning, stories, and more. A WMTY group convenes each month with members from Vancouver to Australia and from Norway to Brazil to share what they are learning and ways to impact the health system to move from a focus on clinical needs and care to encompass the whole person and SDOH.
For more information, see Dang, 2018.
MENTAL HEALTH AND SUBSTANCE ABUSE
The Talking Circle: Addressing Substance Abuse Among Native American Youth
As a Native American with Cherokee, Creek, and Lenape tribal heritage, John Lowe, PhD, RN, FAAN—founding director of the Center for Indigenous Nursing Research for Health Equity and McKenzie endowed professor for health disparities research at Florida State University in Tallahassee—became aware early on of the challenges his community faces. Prominent among those challenges is substance abuse. Substance use is prevalent among Native American youth, who report initiating use at an earlier age compared with other adolescents, with greater frequency, and in higher amounts; by 12th grade, 80 percent are active drinkers and tend to have close ties to substance-abusing peers. When Lowe was just 10 years old, he witnessed a cousin who had returned from the Vietnam War succumb to alcohol addiction and die at the age of 32. Associated with such conditions as heart disease, stroke, liver disease, and cancer, alcohol use may also signal the presence of other risky behaviors, including tobacco use, drunk driving, risky sexual behaviors, and suicidal ideation.
Lowe’s creation of the Talking Circle (TC) intervention in 2000 grew out of his recognition that substance use—along with other frequently co-occurring behaviors, such as drunk driving, risky sexual behavior, and suicidal ideation—is a result of such complex social and cultural factors as poverty, disenfranchisement, dispossession of land and culture, historical trauma, familial fragmentation, unemployment, and lack of access to quality health services and education. The TC manualized intervention was designed to address these factors and thereby prevent substance use among early adolescents belonging to the United Keetoowah Band of Cherokee Indians, the eighth largest tribe in Oklahoma. Once per week, participants engage in a group led by a counselor and cultural expert. The format is a talking circle—a tradition among American Indian/Alaska Native and Indigenous people based on the premise that healing and transformation occur in the presence of others, as all people are believed to be interconnected, and each individual is part of a whole. Lowe explains that TC has at its core three essential questions: Who are you? Where are you? Where are you going?
Group leaders discuss essential aspects of substance use by focusing on a specific related topic each week. One topic, for instance, is stress. Participants are asked, “What happens in a stressful moment? If a bear were to come in here, what would you do? Do you want to run from the bear or fight with it?” Through the example of the bear, the body’s physiological response to stress—including the release of the stress hormone cortisol—is discussed. “Then we talk about what the bear is,” Lowe explains. “Maybe your bear is your parents coming home in a bad way. Maybe [it’s] the bully at school, [teasing you] for who you are. Maybe you did not have a meal last night. Maybe you don’t know where you are sleeping
tonight.” Participants learn that persistent stress, if left unaddressed, may lead to substance use.
However, in addition to discussing challenges, the group examines its own cultural strengths, which stem from the tribe, the community, and the family. An emphasis on the positive is essential, Lowe says, because so often Native American youth are exposed to negative portrayals of themselves. Adolescents in TC groups have been shown to have significantly better outcomes over time relative to those participating in standard substance education programs. The program’s effectiveness is reflected in its recognition by the U.S. Department of Justice’s Office of Programs as an evidence-based program affecting juvenile well-being. The TC intervention is also recognized as an American Academy of Nursing “Edge Runner” evidence-based innovation.
In addition to TC groups in Oklahoma, Lowe has implemented the Virtual Talking Circle intervention to help other Native American communities—including those in Minnesota and North Carolina—provide similar interventions through video conferencing with a facilitator. The United Keetoowah Band of Cherokees tribe passed a resolution to implement the program for youth within their tribal jurisdictional area, and a rural county in which approximately 10,000 Native American students attend the county public schools is working with Lowe to mandate the program in the school system to address an increase in suicides related both directly and indirectly to substance use. Lowe has also helped the First Nations in Canada replicate TC, tailored to their own traditions. Currently, talks are under way with Indigenous people in Australia, New Zealand, and Panama. Strong interest in the program has also been expressed among other racial groups, including African Americans and Hispanics. Despite cultural differences, Lowe believes that the TC format can be successfully adapted to each group’s cultural characteristics.
COPE: Empowering Children and Youth for Mental and Physical Health
At the age of 15, Bernadette Mazurek Melnyk, PhD, APRN-CNP, FAAN, dean of the College of Nursing, vice president for health promotion, and chief wellness officer at The Ohio State University, witnessed her mother’s stroke and subsequent death. That experience left her with severe anxiety and posttraumatic stress disorder that was eventually treated months later with diazepam, but no therapy or counseling. Decades later, Melnyk says, recognition and treatment of mental health disorders are still lagging. “One out of five children, teens, and college-age youth is affected, and yet so few receive evidence-based treatment,” she observes. Delays in treatment are also commonplace. These deficiencies have persisted despite the rise in mental health disorders and the increased rate of
suicide among children and adolescents, with notable racial and socioeconomic disparities.
When she became a pediatric NP, Melnyk felt she had limited tools with which to care for the many patients who presented with depression and anxiety. So she designed and tested COPE—Creating Opportunities for Personal Empowerment—a cognitive-behavioral therapy (CBT)-based program that is manualized so it can be delivered by professionals other than mental health specialists, such as teachers and RNs, including primary care NPs. COPE teaches people that how they think relates directly to how they feel and how they behave. Melnyk stresses that a negative pattern of thinking cannot be changed by drugs used to treat depression and anxiety. Instead, COPE supports the development of emotional and behavioral regulation skills. “We teach children and youth to cue in to how they feel, physically and emotionally, when they are starting to get anxious or depressed, and how to turn those thinking patterns around,” Melnyk explains. The method also includes a problem-solving component—an “ABC approach.” “The A stands for activators,” she explains.
They are things that happen in our environment that cause us to have a negative thought. We teach people how to monitor their thinking patterns when stressful events or activators happen. And when they catch themselves in negative thoughts, the belief—that’s the B in ABC—we teach them how to turn that negative thought around into a positive thought, so that they feel better and behave in healthy ways. C is the consequence of the belief or the thought, the emotional change—feeling less depressed and less anxious.
There are several versions of COPE, each with a program manual and a 4-hour training Melnyk provides to session leaders to ensure fidelity. COPE is also being delivered by primary care providers and others in one-on-one or small-group sessions.
COPE has been tested in cluster randomized trials and has been shown to reduce depression, anxiety, and suicidal ideation while improving self-esteem and healthy lifestyle behaviors across various socioeconomic, racial, and ethnic groups. There is also evidence of improved academic performance, which Melnyk believes can reduce educational disparities.
Melnyk reports further that the program has been well received by children and teens and that when one variation of the program—COPE/Healthy Lifestyles TEEN—was shown to diminish obesity and depression, the National Cancer Institute listed it as a research-tested effective obesity control intervention for teens with the highest level of dissemination capability. The cost savings, too, are significant: a recent analysis concluded that COPE could help save more than $14,000 for every mental health–related hospitalization it prevents.
Melnyk has sought to diversify the pool of those who can provide the intervention. She explains that there are not enough mental health providers who deliver CBT, and some of those who do so do not administer its full dose.
Recognizing that payment for COPE would be key to its sustainability and spread, Melnyk examined the Current Procedural Terminology codes until she found one that allowed reimbursement for both individual and group mental health sessions. As a result, primary care providers in 45 states are being reimbursed for delivering the program.
Melnyk notes that while COPE is helpful to children and teens who are already depressed and anxious, she would like to “move from treatment as crisis intervention to prevention,” something that is happening as the program spreads. She reports that COPE and COPE/Healthy Lifestyles TEEN are being delivered by teachers in schools across the United States and internationally, usually in health courses. Others, including counselors, mental health providers, school nurses, and community health workers, are also using the model. COPE is also being used in young adults—for example, in universities to help prevent suicide and reduce dropout rates, as two-thirds of students who leave college before graduation do so because of a mental health issue. Melnyk recently used an adaptation of the program in a new nursing residency program, and reports that after 6 months, participants were less depressed, less anxious, and more satisfied with their jobs.
For more information, see Alegrίa et al., 2015; CDC, 2019; Curtin and Heron, 2019; Gruttadaro and Crudo, 2012; Kozlowski et al., 2015; Lusk and Melnyk, 2017; Melnyk, 2020; Melnyk et al., 2009, 2013, 2015; NCI, 2020; Sampson et al., 2020.
COMMUNITY-BASED HEALTH AND SOCIAL CARE
Mary’s Center: A Multigenerational Sanctuary
In 1988, when Maria Gomez, RN, MPH, president and chief executive officer (CEO) of Mary’s Center, founded the organization in Washington, DC, she did so in the basement of a row house with a $250,000 grant, some donated tables and chairs, and a vision: to provide comprehensive health care and support services to residents facing social difficulties, especially pregnant women from Central America fleeing violence. Thirty-two years later, Mary’s Center has five locations throughout DC and Maryland, along with two senior wellness centers and a program office.
The idea for the center stemmed from Gomez’s own immigrant experience, coming to DC with her mother from Bogota, Colombia, at the age of 13. After earning her nursing degree, she began working as a public health nurse at the DC Department of Health in the maternal and child health unit, where she observed that every Latina woman had a traumatic story. This experience made her want to provide a sanctuary for these women. After taking time off to earn a master’s degree in public health, Gomez, along with a team of nurses and social workers, founded the first Mary’s Center based on “a social change model” consisting of three interwoven components: health care (physical, mental, and dental); social
services (including home visits, assistance with domestic violence, and guidance in such areas as parenting, school preparation, and goal planning); and adult education (including English classes and seminars on economic mobility for families).
For Gomez, “the genesis of health care is about getting to individuals early on and helping them decide whether they want to have families.” Gomez explains that when people are living with such challenges as unwanted children, poverty, or domestic violence, it is impossible for them to maintain their health. “If we at least partner with that first generation to overcome the major elements of poverty,” she says, “[then we can do] everything possible to make sure that that second generation has a chance.” Mary’s Center now serves more than 55,000 individuals, most of whom are low-income women and children, and has become multigenerational. Gomez reports that about 30 percent of the nearly 700 people who now work at Mary’s Center were born through the center’s programs or were served by the center in their younger years.
Despite these positive outcomes, funding remains an ongoing challenge, as many of the center’s social and health education services are not reimbursed by Medicaid or other payers. The center therefore needs to continuously gather data and demonstrate the results of its model to encourage reimbursement—a costly endeavor that is not immune to bias. When the Urban Institute conducted a qualitative study of the center’s social change model, for example, only a handful of the dozens of foundations that had for decades been supporting Mary’s Center were willing to fund it. Still, the center has managed to remain viable through the medical services that are reimbursed by third-party payers, and it continually engages with lawmakers to advocate for policies that address SDOH. Its efforts paid off, for instance, when Washington, DC, created the DC Health Care Alliance—a reimbursement model for undocumented people similar to Medicaid, and covering hospitalization; medications; and specialty, dental, and mental health care.
The center also consistently urges the city to fund more community health services. For example, after realizing that many adolescents were presenting with behavioral problems, Mary’s Center began providing mental health services in schools. Eventually, thanks to the efforts of Gomez’s team, the school system and the DC Mental Health Department began not only funding but also expanding the program. The City Council has even made mental health a priority in schools.
The center is now pushing to make telemedicine part of the standard of care. Doing so, Gomez says, is crucial for homebound patients, those with mental health illnesses who are secluded in their homes, the elderly, and pregnant women on bed rest or too depressed to go to a health center.
For her work, Gomez has received numerous awards, including the 2012 Presidential Citizens Medal, presented to her by President Obama at the White House. She credits her accomplishments to three essential elements: being empathic, listening to people’s stories, and analyzing existing data.
Pine Ridge Family Health Center:
From the Classroom to the Community and Back
Like many cities, Topeka, Kansas, has communities confronting challenges associated with SDOH. Shirley Dinkel, DNP, RN, faculty emeritus at Washburn University School of Nursing in Topeka, learned about some of these challenges when visiting Pine Ridge Prep, a preschool in Pine Ridge Manor—the city’s largest and oldest public housing neighborhood, with a population that is equal proportions White, Black, and Hispanic/Latino. Because Pine Ridge Manor had an on-site wellness center used as a clinical learning site for baccalaureate nursing students, Dinkel and colleague Jane Brown, PhD, RN, wanted to discuss the possibility of having students from Washburn’s NP program perform preschool physicals.
At the same time, the National Center for Interprofessional Practice and Education (NCIPE) at the University of Minnesota announced the availability of a grant for integrating interprofessional education DNP (doctor of nursing practice) students and care delivery. Dinkel saw an opportunity: transforming Washburn’s DNP curriculum to improve the lives of her Topeka neighbors. After receiving the grant, she led an interprofessional team that implemented the Classroom to Community (C2C) Accelerating Initiative, which has since become a case study for interprofessional education and practice, founded on community engagement and a partnership with a housing authority to foster health equity. The interprofessional C2C team consisted of academic leadership from nursing, business, and health communications. The team’s goal was to expand the curriculum to incorporate content addressing SDOH and to bring that content alive in an experiential way in the community.
The initiative was created in and with the community of Pine Ridge Manor. After conducting a focus group and administering an assessment survey, the C2C team asked the community members what they needed and wanted. Their priorities included better access to high-quality health care, child immunization, and mental health and dental services. The idea of a primary care clinic—the Pine Ridge Family Health Center (PRFHC)—on site at Pine Ridge Manor soon took hold. The clinic would provide rich experiential learning opportunities for the students while improving residents’ access to care. To guide the initiative, the C2C team formed an advisory council that consisted of the C2C team; two DNP students; two social workers for Pine Ridge Prep; CEO of the Topeka Housing Authority; and CEO of THA, Inc., the foundation arm of the housing authority, whose mission is to develop affordable housing for the Topeka community. Residents were also instrumental in the design, implementation, and naming of the clinic and are now represented on a PRFHC Advisory Council formed to ensure continuing community input into the center’s work.
Using information provided by residents and community representatives, a C2C team created 10 learning modules, with an emphasis on social justice,
cultural competence, adverse childhood experiences, and the impact of those experiences on health. To help students better grasp the impact of SDOH on people’s ability to “succeed,” the curriculum team created a poverty simulation, conducted in the morning, followed by roundtable discussions with residents at Pine Ridge Manor in the afternoon.
Evidence on the impact of C2C on students and the residents of Pine Ridge is still emerging, but preliminary findings of an analysis commissioned by NCIPE include the following:
- As of 2018, the clinic had 1,131 visits from 444 unique clients. The sources of referral are expanding, and include local hospitals, community agencies and halfway houses, and other community health clinics.
- Residents who had used the clinic reported that they were highly satisfied with the care they received, and by 2019, the clinic had reduced their use of the ED by 20 percent.
- Students’ perspectives on poverty and SDOH are changing. “Most of our students come from a middle-class, White, Midwestern culture,” Dinkel says, “and we’re having different kinds of conversations than we’ve had in the past.”
Getting the project off the ground was not easy, according to Dinkel. “Bringing all of us together was one of our biggest challenges,” she says. The financial sustainability of the clinic has been another concern, as it is dependent on reimbursement for care from Medicaid, which takes up a great deal of time. An additional hurdle has been the lack of full practice authority for NPs in Kansas, which requires paying for a collaborating physician.
C2C has spread through additional departments at Washburn University, including social work and law. In addition, THA, Inc. has received a local grant to provide transportation for residents who need to get to and from appointments. The clinic also partnered with a food bank to address food insecurity on site, and it is developing its telehealth capacity. The partnership with THA, Inc. continues. Plans are under way for the clinic to hire an RN to perform case management and care coordination for residents of two or three other THA housing units. The model has even caught the attention of the U.S. Department of Housing and Urban Development, earning a visit from the regional office. “Meaningful change occurs from the ground up,” says Dinkel. “I don’t know what we will be doing in a year, but it will be bolder than what we are doing now—I am sure.”
For more information, see George et al., n.d.; Harder + Company Community Research, 2019; Washburn University Alumni Association and Foundation, 2018.
Nurse-Managed Clinics: Partnering to Promote Health and Education
Despite a persistent emphasis in the United States on acute care, some schools of nursing have been prioritizing community-based care. Eileen Breslin, PhD, RN, FAAN, dean of the University of Texas Health Science Center at San Antonio (UTHSCSA) School of Nursing (designated as a “Hispanic-serving Institution”), says that when she joined the university, she was intrigued by its commitment to population health. The faculty, she says, “views health care as an act of social justice,” and the students, who are from the community, “go back and give back.”
Working in tandem with Breslin is Cindy Sickora, DNP, RN, vice dean of practice and engagement and clinical professor. Before joining UTHSCSA, she was the founding CEO of the Rutgers Community Health Center (a nurse-managed federally qualified health center). Recognizing the potential of the Rutgers nursing students and faculty to serve the city’s urban community—one that was struggling with violence, poverty, and other social challenges—she contemplated the creation of nurse-run clinics in the city’s public housing developments. Although her plan was initially met with resistance, her commitment to population health helped her persevere. She attended meetings, asked people in the community what they needed and wanted, built trusting relationships, and then used two grants from the U.S. Health Resources and Services Administration to open a nurse-managed health center that educated interprofessional students about SDOH. “Over time,” she notes, “we were able to demonstrate that an RN who understands community engagement is well qualified, when practicing within the scope of an RN license, to provide [a range of] necessary services,” such as monitoring blood pressure and blood sugar, providing education regarding immunizations, making home visits to ensure medication adherence, arranging essential screenings, and identifying ailments that warrant an ER visit.
To ensure sustainability for the school’s nurse-led initiatives, Sickora formed a partnership with Superior Health Plans—the largest Medicaid managed care plan operating in Texas—to support a mobile health initiative she had developed in the aftermath of Hurricane Harvey in 2017, targeting families living in low-income housing. And in 2018, she opened an on-campus pediatric health center managed by faculty from the School of Nursing, which she sustained with a shared value-based payment model. Many of the center’s patients are foster children, and the program has been recognized by Superior Health Plans as a Foster Care Center of Excellence.
Breslin attributes the focus of the UTHSCSA School of Nursing on population health to several factors grounded in “intentionality,” including
- having a rich cadre of diverse and committed faculty who believe in community service, engagement, and partnership;
- redefining criteria for faculty promotion and tenure to place equal emphasis on scholarship/research accomplishments and on work that improves the health of the community;
- encouraging faculty to practice in the community to model for students a focus on and an understanding of SDOH;
- recruiting and retaining students from the local community and obtaining necessary resources for community engagement through a variety of grants, contracts with agencies, and philanthropy;
- forming strong relationships with community organizations and agencies; and
- having a supportive university administration.
According to Breslin, “our students understand that we are expecting them to view social justice as a vital part of this school’s heritage. That is the future.”
LEADING ON GENDER EQUITY
Ending Period Poverty: The Royal College of Nursing Takes Aim
For the estimated 800 million girls and women menstruating daily worldwide, long-standing traditions, stigmas, and taboos related to periods can carry significant physical, social, and economic consequences. For some girls, for example, lack of running water for hygiene or access to menstruation products may result in regular school absenteeism. For others, limited or no access to toilets may lead to diminished food and liquid intake during menstruation. While access to running water is not a significant concern in the United Kingdom, “period poverty”—defined as the inability to afford such common menstruation or “sanitary” products as pads and tampons—has been an invisible problem until recently. In June 2019, the Royal College of Nursing (RCN), the country’s leading organization for RNs and midwives, committed to removing this barrier to girls’ and young women’s academic and economic development.
Carmel Bagness, MA, RN, CNM, the professional lead for midwifery and women’s health at RCN, notes that period poverty is especially problematic among teenagers whose families may be poor immigrants or residents from countries where menstruation is viewed as “unclean,” and cultural traditions prohibit the use of tampons or menstrual cups. The problem has been noted even in hospitals, where until recently, the National Health Service (NHS) did not provide sanitary products for women except in OB/GYN units or when medical procedures required them. In contrast, NHS hospitals have provided toilet paper,
shaving supplies for men, and other hygienic necessities. Some government action to address this disparity has recently been taken or pledged. Despite these governmental commitments, however, Bagness reports that nurses have become involved to ensure follow-through on these measures and to raise awareness of period poverty. “A lot of people don’t realize this is a problem,” she says, “[and] they don’t recognize the embarrassment that girls experience when they don’t have access to sanitary products.”
In 2017, Nursing Standard, the official journal of RCN, reported that school nurses were increasingly buying sanitary products to keep girls in school. At its June 2019 annual meeting, the RCN membership committed to pursuing three goals:
- Raise awareness of the problem among nurses and midwives, as well as the public.
- Monitor the government’s efforts to remove financial barriers to obtaining sanitary products and end period poverty.
- Encourage national discussion of the problem.
Progress on these goals requires collaboration with various entities, including the government, food banks, and charity organizations. For example, to target poor women and girls outside of health facilities and schools, RCN is working with food pantries, to which for 2 weeks in March 2020 nurses and midwives donated sanitary products.
To raise awareness of period poverty among nurses and midwives, RCN has started a web page, to be featured along with a presentation on the topic at its 2020 annual meeting in June. Bagness notes that because RCN is also mindful of its environmental impact, it is forgoing print handouts in favor of a QR code guiding members to its web page. This awareness of environmental impact also has led the organization to encourage the use of “moon cups”—also known as menstrual cups—along with other reusable sanitary products that collect menstrual blood. However, Bagness says, as these products are not acceptable for unmarried women and girls in some cultures, free pads remain essential.
Bagness, who sees addressing period poverty as a part of “promoting menstrual well-being,” notes that RCN is still working on strategies for engaging the public in discussions on menstruation and poverty. The organization’s work may serve as a model for other national nursing associations, including those in the United States, where the cost of sanitary products—exacerbated by a “nonessential” or “luxury” tax in many states that does not apply to medications for erectile dysfunction or baldness—contributes to a period poverty rate that may be as high as 64 percent among low-income women.
For more information, see Brickell, 2019; Free Periods, n.d.; Goldberg, 2018; Khomami, 2018; Kuhlmann et al., 2019; Magistretti, 2019; Miiro et al., 2018; Murphy, 2019; Rimmer, 2018; Royal College of Nursing, n.d.; Shearing, 2020; Tull, 2019; Walker, 2019; Young, 2019.
Gender Equity: Focusing on the Whole Woman
Growing up, Sheila Tlou, PhD, RN, FAAN, had looked up to the community health nurses in her native country of Botswana who identified women early in their pregnancy and worked with their mothers and mothers-in-law to ensure that the women received the necessary perinatal care. When she became a nurse in 1977 through studies in the United States, she began to regard gender equity as an important social determinant of health and was dismayed by national policies in Botswana that focused solely on maternal and child health rather than on the health of women in general. To help change these policies, she continued her education and conducted research on such issues as violence against women, documenting its socioeconomic impact on the country. Monetary considerations, she rightly assumed, would capture the attention of the country’s mostly male Parliament, which eventually passed a law in 2008 aimed at reducing gender-based violence.
Tlou shifted her attention to HIV/AIDS as it reached Botswana in 1985, documenting its prevalence and impact among women; promoting HIV/AIDS education; and pressing for such initiatives as making home care available to those with the illness and training nurses and others in HIV/AIDS prevention, care, treatment, and support. And when antiretroviral (ARV) medications became available in 2001, she mobilized her nursing and other colleagues to motivate citizens to go for HIV testing to ensure greater access to treatment. Through her work, Tlou regularly communicated with the president of Botswana and the Parliament, and these interactions convinced her that she could be more effective as a policy maker than as an academic. In 2004, when President Festus Mogae asked her to serve in his cabinet as minister of health and to focus on the nation’s response to HIV/AIDS, she conditioned her acceptance on one factor: receiving 15 percent of the national budget. He topped that and gave her 20 percent. “It was an offer I could not refuse,” she says, adding, “I led and rolled out a comprehensive prevention, treatment, care, and support program that is still a model in Africa now, offering free access to services.”
Tlou was able to keep on shifting the patriarchal culture of Botswana and promote gender equity by linking HIV to policies harmful to women. At the time, she says, 90 percent of women had access to perinatal care. With the money allocated for HIV she built more clinics, bringing the access level to about 98 percent, and the rate of mother-to-child transmission of HIV fell from around 29 percent to 8 percent within 4 years. But Tlou also ensured that the clinics provided a broad range of reproductive and sexual health services, facilitating women’s access to birth control and resulting in a decreased fertility rate. Tlou then became the director of the regional support team for Eastern and Southern Africa for the Joint United Nations Programme on HIV/AIDS. One of her key initiatives in this new role was combatting child marriage in African nations. As chairperson of the Conference of Ministers of Health, Tlou led other African nations’ ministers of health in developing the Sexual and Reproductive Health Framework for Africa, which was then translated into the Maputo Plan of Action 2016–2030: Universal
Access to Comprehensive Sexual and Reproductive Health Services in Africa. And further expanding her work on gender equity, Tlou helped create the International Council of Nurses (ICN) Girl Child Education Fund, which provides support for orphaned daughters of nurses to continue their education.
Through all of this work, Tlou has encouraged her nursing colleagues to be proactive in transforming care delivery and addressing SDOH, including gender equity. Along with Nigel Crisp of Britain’s Parliament, she is co-chair of Nursing Now—a global campaign initiated by the World Health Organization (WHO) and ICN to highlight the contributions of nurses to the health of communities and nations. During her time as a senior lecturer and professor of nursing at the University of Botswana, Tlou educated and trained most of the nurse leaders in Botswana, Lesotho, Malawi, Namibia, South Africa, Swaziland, and Zimbabwe. She serves as a role model and mentor for nurses around the world. Tlou wants other nurses to see themselves as leaders willing to take on the central health and social issues of the day, a task that, she emphasizes, must include political leadership.
THE POWER OF LEADERSHIP
School Nursing: Addressing Health Disparities Through the Public Schools
Robin Cogan, MEd, RN, NCSN, witnesses health disparities daily in Camden, New Jersey, long deemed one of the poorest and most dangerous cities in the nation. Cogan believes public schools are integral to improving this picture. Cogan joined the Camden School District in 2001 and completed the necessary courses to become a certified school nurse. Beyond carrying out the standard tasks of her profession—health screenings, teaching, ensuring vaccine compliance, and caring for children with chronic health conditions—she describes her role as the school’s “chief wellness officer.” In this role, she advocates for children’s health and welfare, including mental health; procures and manages grants for wellness initiatives for students and their families; provides health education; conducts outreach for displaced children and families; offers individual and small-group counseling; refers students and families to health and social services; arranges resources for teachers and other staff for managing challenging behaviors in the classroom; and encourages conflict resolution among students.
Cogan asserts that a school nurse cannot ignore the impact of SDOH on children’s well-being and academic success. After immersing herself in the evidence on adverse childhood experiences, she began to understand why people had so much difficulty looking beyond their immediate lives. “I saw tremendous adversity,” she says. “Much of it was linked to poverty, lack of access, racism,
structural inequity, and language barriers. You do not just snap out of it. This is a systems issue.”
Cogan initially focused her efforts on her own school. She secured a small grant to bring in fresh fruits and vegetables, and arranged for physical education students to organize lunchtime activities for the children. But sustainability, she says, has been a problem. “Once the money runs out … things often end,” and the people running such programs also end up leaving. “It takes a long time for residents to trust that you are not going to be one of those people.”
In 2015, Cogan widened her focus, considering ways to enhance not just her school but also the community. She was accepted into the Johnson & Johnson School Health Leadership Program, along with a team consisting of school nurses from her own and a neighboring district, a representative from the county health department, and a public health official who oversaw health advocacy at the preschool. Their project was to conduct a “community café” to gather parent and community input into pressing issues. Among the topics the team considered was parents’ reluctance to take their children to the pediatrician, opting instead for the ER. The team learned that families using the ER felt the lack of a connection with their provider, and routinely experienced other obstacles, such as translation problems or difficulties making appointments. Working with the Camden Coalition of Healthcare Providers, the team convened a roundtable of pediatric providers and school nurses that meets to improve relationships and communication. And her team continues the community cafés, focusing on such topics as the experience of being an immigrant or the role of fathers in children’s lives.
Based on her experiences, Cogan “felt a moral and professional obligation to change the status quo” by sharing her new knowledge and skills with other school nurses. Accordingly, at the School Nurse Certification Program at Rutgers University School of Nursing, Camden, where Cogan now teaches, she and two colleagues redesigned the certificate program into a master’s program that incorporates a focus on population health, social determinants, adverse childhood experiences, leadership, and health equity. Cogan also has dedicated herself to mentoring, publishing her writings, and speaking at an increasing number of events and conferences.
Among Cogan’s top priorities is the safety of students and staff. To raise awareness of gun violence and school drills, she has been writing, speaking, and tweeting. Cogan’s vision of the school nurse as the chief wellness officer is shared by the National Association of School Nurses (NASN). According to its CEO, Donna Mazyck, MS, RN, NCSN, CAE, “school nurses … influence systems changes and pursue safe learning environments to promote the health of all students.” To reinforce this idea, NASN has published the Framework for 21st Century School Nursing Practice, which includes information on care coordination, leadership, and social factors affecting health.
Cogan sees a shift in school nurses’ perception of their role. “We are talking about health equity. We are talking about mental health in schools.” For the first
time in 2020, NASN will address school gun violence at its national conference, with Cogan presenting. “Stop playing it safe,” she advises. “Disrupt the status quo. Be relentless.”
Healthy Baton Rouge: Collaborating for a Healthier Community
In Baton Rouge, Louisiana, two indomitable nurses have been transforming the health of individuals, families, and communities for decades. Terrie Sterling, MSN, MBA, RN, FACHE, who began as a staff nurse at Our Lady of the Lake Regional Medical Center 35 years ago and served as its chief nurse for 7 years, is the first African American and first nurse to become the organization’s chief operating officer (COO). Coletta Barrett, RN, MHA, FAHA, FACHE, is vice president of mission at Our Lady of the Lake, where she ensures that systems align with the core values of the Franciscan Sisters who founded the organization; she is the first lay leader in this position. Both are in the Louisiana State Nurses Association Hall of Fame. Together, they engage in mutual mentoring as they address SDOH through their health system and a community-based initiative to make Baton Rouge a healthier place to live and work.
In 2013, after the closure of a safety-net hospital that had been part of the Louisiana State University health system, Our Lady of the Lake entered into a cooperative agreement with the State of Louisiana to become a safety-net hospital, absorbing the graduate medical education programs and patients of the shuttered institution. Barrett says that although the public–private relationship “was a noble and bold step,” they soon discovered that there was a 9-month waiting list for 1,200 people in need of primary care—a situation she describes as “unconscionable.” Within just 9 weeks, Our Lady of the Lake had both eliminated the waiting list and decreased costs. Sterling notes that these accomplishments prompted their thinking about systems and structural changes that would align with the community’s needs, such as locating primary care services near other health care services and public transportation hubs. Barrett and Sterling also seized the opportunity for collaboration across hospital systems with the Patient Protection and Affordable Care Act’s expanded “community benefit” requirements for nonprofit hospitals to conduct community health needs assessments and develop plans for addressing priority issues. Barrett facilitated one of the first joint community health assessments and plans, which focused on addressing HIV/AIDS. The current shared priorities are access to care, healthy living (including diet, exercise, and smoking cessation), mental and behavioral health, HIV/AIDS, and addressing SDOH through “anchor strategies” that prioritize local resources.
The focus of this work—rooted according to Sterling in a commitment to compassion and ministry at Our Lady of the Lake—is not just on patients but on
employees as well. After becoming COO, Sterling worked with Barrett to create Upward Potential, a program to help entry-level employees with such skills as financial literacy and understanding access to health care.
In 2007, the mayor of Baton Rouge invited Barrett to chair a task force charged with providing recommendations for making Baton Rouge a healthier community. The result was the collaborative community initiative Healthy Baton Rouge (HBR). HBR had no budget and just one staff person provided by the mayor’s office, but it did have many volunteers. Financial support came from an annual fundraiser and two grants to address food insecurity, obesity, and social isolation. To ensure that Our Lady of the Lake would be contributing meaningfully to HBR, the duo championed such initiatives as the Summer Feeding Program, which offers food to children who are seen for medical appointments. In addition, they worked with the Geaux Get Healthy Program, which provides nutritious foods to people in food-insecure zip codes, to have one of the system’s campuses offer fresh provisions at low prices to local residents. And they partnered with the Big River Economic and Agricultural Development Alliance, an organization that works with farmer’s markets, to bring a Farm-to-Work Program to Our Lady of the Lake. Employees making less than $15 per hour can purchase a $25 box of food for just $10; Our Lady of the Lake subsidizes the difference. Barrett says both facets of the initiative—addressing food insecurity and supporting a local farmer along with migrant workers—are driven by her commitment to social justice.
Their work, Sterling and Barrett agree, is not without challenges. First, because it is longitudinal, it tests people’s patience. Second, the goal of improving the health of whole communities seems unrealistic to some. To counter the skepticism toward HBR, Barrett convinced other organizations’ leaders to focus on such areas as their procurement practices (identifying from which businesses they were acquiring goods and services) and the well-being of their own employees. The third challenge has been confronting stigma and racism, as exemplified by the reaction they initially received to an “opt-out” HIV testing program. Finally, Sterling points out that the “imposter syndrome” is a challenge for the mostly female nurses. “Women are more inclined to say, ‘I’m not ready. Am I really qualified to do this work?’” She has addressed this challenge through her commitment to leadership development.
Barrett and Sterling attribute much of their success to two factors: mentoring each other and staying focused on mission and values. Both believe that the education of nurses on SDOH is crucial. “Sisters in this ministry have been here in Louisiana doing this work for 100 years,” Sterling says, “and this is just [our] little piece of it. We take so seriously the responsibility to continue the care and compassion, and to make the community we live in better.”
The Women of Washington: Nurse Leaders Collaborate to Transform Health
A dean, a legislator, a public health official, a Medicaid director, and a member of the governor’s cabinet—these are the nurse leaders who make up the core of the Women of Washington (WOW), a group that collaborates to transform health in Washington State. In 2018, Governor Jay Inslee appointed Sue Birch, MBA, BSN, RN, to serve as director of the Washington State Health Care Authority, the state’s largest health care purchaser. Birch quickly reached out to other nurse leaders, several of whom had for some time been collaborating informally on shared interests: Eileen Cody, BSN, RN, who since 1994 has represented Washington’s 34th district in the House of Representatives, chairing its Health Care and Wellness Committee; Patty Hayes, RN, MN, director of public health for Seattle and King County; MaryAnne Lindeblad, BSN, MPH, among the longest-serving state Medicaid directors in the country; Azita Emami, PhD, RN, FAAN, Robert G. and Jean A. Reid executive dean of the University of Washington School of Nursing; and Sofia Aragon, JD, BSN, RN, executive director of the Washington Center for Nursing. Emami characterizes the group as a “lifeline” that compounds the success of each individual; Birch calls it “collective conniving” on behalf of Washingtonians because they work together to shift mindsets on the factors affecting health.
The group’s cohesiveness relies on their shared values, which include focusing on equity, whole-person care, population health, cross-systems thinking, multisector partnering, and the promotion of nurses’ roles in advancing health. Various initiatives have emerged from their collaborations, including the following:
- The Nation’s First Public Option. In 2021, Washington will be the first state to offer a public health insurance option.
- Strengthening Primary Care in Washington. Cody, Birch, and Lindeblad have been champions of advancing primary care in Washington State.
- Accountable Communities of Health (ACHs). Lindeblad and Cody collaborated on obtaining legislative approval and funding for the creation of nine ACHs, which bring cross-sector partners to the table to use data to plan and promote health equity, improve health planning, link with community clinical health, and promote health and well-being with a holistic perspective.
- Foundational Community Supports. Through this initiative, Lindeblad, Hayes, and others ensured that the state’s application to the federal government for a $1.5 billion Medicaid demonstration waiver included a focus on SDOH.
- Hep C Free Initiative. Governor Jay Inslee has set the bold goal of eliminating hepatitis C virus in Washington by 2030, a goal supported by this initiative, which includes public outreach, innovative purchasing strategies for curative medications, and a key role for nurses.
- Integrating Nurses’ Voices in Policy. When the state sought to survey physicians for a study of primary care capacity and expenditures, Birch alerted Hayes to mobilize NPs, who requested that they, along with other primary care providers, be included.
- Changing Nursing Education. The group’s involvement with ACH aligns with Emami’s efforts to focus nursing education on population health and provide students with opportunities “outside of hospital walls” to learn about SDOH and health equity and to acquire the skills to put that knowledge into practice.
- Nursing Now. When the University of Washington School of Nursing became a U.S. co-lead of Nursing Now—a campaign run by the World Health Organization and the International Council of Nurses to raise the profile of nursing worldwide1—Emami reached out to her WOW colleagues to ensure a successful launch. Birch and Cody discussed this with the governor and First Lady Trudi Inslee, who became an ambassador for the initiative. “Nurses play a transformational role in ensuring the health and well-being of all communities,” said the governor, who called for an investment in preparing a diverse nursing workforce.
Hayes notes that the group’s work holds promise beyond these areas. One example is a collaboration between Hayes and Emami on King County’s Best Start for Kids, a comprehensive, levy-funded, life-course approach to helping children have a happy, healthy, safe, and thriving environment. At the same time, the work has its challenges, including choosing which initiatives to focus on, coordinating efforts, and not giving up. The group admits that it has not always been successful, especially when attempting to receive funding from the legislature to support such initiatives as improving access to behavioral health services or increasing the nursing workforce. But failure is not in their lexicon. “We never fail,” says Cody. “We back up and take another path.”
1 Nursing Now USA is a collaboration among the University of North Carolina at Chapel Hill School of Nursing; the American Nurses Association; and the U.S. Public Health Service Chief Nurse Officer. It was launched in April 2019. See https://www.nursingnow.org/who-we-are (accessed April 12, 2021) for more information.
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