Have you ever heard the phrase, “Two heads are better than one”? Well, it’s now a proven fact that working with others to resolve an issue is more productive than trying to figure it out on your own.
Professional fields, such as public health, value intradisciplinary teamwork as well as interdisciplinary teamwork. Through collaboration, innovation often emerges to address complex health issues.
But why does this matter for public health as compared to other fields? Let’s take a step back to understand what health actually is.
WHO’s Definition of Health Goes beyond Mere Physical Health
One of the first things we learn in the field of public health is the definition of health. In its 1948 constitution, the World Health Organization (WHO) defined health in its broader sense as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”
This definition takes a holistic view of health, not just the absence of bodily diseases. It implies that health encompasses multiple layers, such as one’s social well-being.
The Relationship of Health and Multiple Influences on Health
How does this definition of health align with the influences on health as described in the socio-ecological framework? The socio-ecological framework illustrates that there are multiple levels of influences on our health, ranging from:
- Intrapersonal/individual factors (genetics)
- Interpersonal factors (culture, family and values)
- Organizational factors (faith-based organizations, schools and community organizations)
- Community influences (neighborhood and healthcare)
- Public policy (laws, media and the food industry)
These influences extend beyond the core public health disciplines of behavioral science/health education, biostatistics, environmental health, epidemiology and health services administration. As public health practitioners, our need to learn and collaborate with other disciplines is paramount.
For instance, interprofessional education and practice can work together to address a specific public health issue like obesity.
Parents and other family members can influence a child’s dietary habits and physical activity. A public health practitioner can consider these collaborations as opportunities.
- How can we work with social workers to understand family dynamics and intervene to promote healthy habits?
- What is the role of sociologists, psychologists or anthropologists in understanding culture and values contributing to healthy habits?
Access to fresh fruits and vegetables can influence one’s ability to eat healthy and prevent obesity. A public health practitioner interested in addressing obesity trends in a particular community ought to consider the following:
- How can we work with local schools to incorporate a school garden, so that children learn how to grow healthy fruits and vegetables?
- What is the role of local religious leaders in promoting healthy lifestyles in their houses of worship?
“Place” matters as the PBS series “Unnatural Causes” eloquently shows. Where an individual lives, works or plays either limits or promotes opportunities for healthy habits (e.g. safety of neighborhoods or easy access to healthy food options).
- How do public health practitioners work with local/city officials and law enforcement to address security issues or other matters affecting healthy activities, like walking or running?
- What is the role of parks and recreation services in ensuring amenities for healthy lifestyles?
Easy access to health care services is a well-known contributor to healthy behaviors. Access to health and health insurance is aligned with socio-economic status. Lower socio-economic status also correlates with obesity trends (for example, cheaper food products are often high in calories and less nutritious).
- How does a public health practitioner work with policy makers to address access to healthy foods for lower socio-economic groups?
- How can we work with the food industry to address childhood obesity?
Even if you are not a public health practitioner, I encourage you to think about how what you do can affect the health and well-being of individuals, communities, nations and the world. Consider also what you can do to support public health initiatives to promote wellness and prevent diseases at all levels of influence, according to the socio-ecological framework.
My first experience with “minority health” came during my Master of Public Health degree program. I served as a member of the speakers’ committee for the annual Minority Health Conference at the University of North Carolina at Chapel Hill.
We sought to raise awareness about issues related to health disparities and how to take collaborative action across different professions. Our participants included academic scholars, researchers, public health practitioners, community leaders, human rights advocates and policy makers.
We often hear the terms “health disparities,” “health inequities” and “social determinants” as they relate to populations, locally, nationally and globally. So let’s start with a few basic definitions:
Health equity means achieving the highest level of health for all people. It requires valuing every human being equally with continuous efforts to address avoidable social and economic inequalities, historical and contemporary injustices. Health equity also seeks the elimination of health and healthcare disparities.
Health disparities are defined as a particular type of health difference that is closely linked with one’s social or economic status. Health disparities negatively affect groups of people who have experienced greater social and/or economic obstacles to health due to characteristics historically linked to discrimination or exclusion. These characteristics include but are not limited to:
- Racial or ethnic group
- Socioeconomic status
- Mental health
- Physical disability
- Sexual orientation
- Geographic location
Social Determinants of Health
Social determinants of health refers to environmental conditions in which people are born, live, work and play that affect a wide array of health and quality-of-life outcomes and risks.
Ways to Observe National Minority Health Month
There are several easy ways to participate in National Minority Health Month. This year’s theme is “Bridging Health Equity across Communities.” During April, consider doing the following activities:
- Learn more about your own family’s medical history and keep a good record of your health conditions and treatment plans.
- Read, watch or listen to local news about emerging health conditions in your community.
- Obtain details about culturally and linguistically appropriate services.
- Attend a local event.
- Join community-based organizations or a local health department task force on minority health.
- Use and share the resources from reputable organizations.
- Use social media groups that engage in discussions about minority health and help spread the word.
- Sign up for OMH newsletters to receive email updates on Office of Minority Health and health disparities issues.
- Contact the Department of Health and Human Services if you have questions about National Minority Health Month.
Public Health Involving Minorities Is a Global Concern
National Minority Health Month recognizes health disparities in the United States, but coping with public health issues involving minorities remains both a local and a global problem. Fortunately, there are local public health events that address issues disproportionately affecting minorities, such as the Houston Heart Failure Management Conference, Save a Life and the Adult Congenital Heart Symposium.
In addition, international organizations have addressed global public health issues affecting minorities. The national ministries of health in the African region, the Centers for Disease Control and Prevention, and the World Health Organization/African Region are evaluating Ebola outbreak response capabilities, which have been strengthened through my collaboration.
The best way to teach more consumers about public health – and especially the health of minority groups – is through education. Staying informed, getting involved and getting connected are powerful ways to raise awareness and learn about the health problems affecting minorities.
Overdose deaths related to prescription opioids have quadrupled since 1999, according to the Centers for Disease Control and Prevention (CDC), which has made it a topic of dinner conversation as well as a top priority in health care. Nurses can play an important role in reducing these deaths, as well as addiction problems, through their assessments and monitoring of patients. But it’s also important for nurses to be well aware of steps they can take to help protect themselves from possible legal action stemming from opioids.
Scope of the Problem
The depth and breadth of prescription opioid abuse is far reaching. In 2014, almost 2 million people in the United States abused or were dependent on prescription opioids. At least half of all opioid overdose deaths involve a prescription opioid. Every day, more than 1,000 people are treated in emergency departments for misusing prescription opioids.
The most common drugs associated with prescription opioid overdose deaths are methadone, oxycodone, and hydrocodone. According to the CDC, prescription opioid overdose rates between 1999 and 2014 were highest among people aged 25 to 54.
Role of the Nurse
A 2016 study published in the Journal of the American Medical Association (JAMA) by Baker and colleagues notes that there is significant variability in the amount of opioids prescribed, and the most commonly dispensed opioid was hydrocodone (78%), followed by oxycodone (15.4%). Interestingly, a 2015 study in the American Journal of Preventive Medicine reported a decrease in the rate of prescribing opioids (-5.7%), perhaps indicating that more health care providers are becoming aware of the addiction issue.
Nurses are well positioned to detect patients with substance misuse. One simple screening tool is the National Institute on Drug Abuse (NIDA) Quick Screen. If a substance use disorder is suspected, the nurse should remain nonjudgmental while referring patients for further evaluation and treatment, so they receive the care they need.
One model for follow-up of possible substance abuse is Screening, Brief Intervention, and Referral to Treatment (SBIRT) from the Substance Abuse and Mental Health Services Administration. SBIRT is a method for ensuring that people with substance use disorders and those at risk for developing these disorders receive the help they need.
Assess the Patient Carefully
Pain medication should be matched to the individual patient’s needs. This begins with a detailed history, including a list of currently prescribed and past medications. Ask about a history of substance use or substance use disorders in the patient and the patient’s family. If opioids are being considered, assess the patient’s psychiatric status.
A physical exam should also be completed, keeping in mind signs and symptoms of possible substance abuse such as advanced periodontitis, traumatic lesions, and poor oral hygiene. If patients are already being managed for chronic pain, the nurse should consult with the appropriate provider.
Apply Evidence-Based Pain Management
To provide optimal patient care, as well as to protect themselves from legal action, nurses should practice evidence-based pain management. That includes considering non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, as first-line pain medication.
NSAIDs have been shown to be at least as effective (if not more so) than opioids for managing pain, particularly in combination with acetaminophen. Before patients begin taking NSAIDs, verify that they are not taking other anticoagulants, including aspirin, and check for hepatic or renal impairment.
Nurses should complete continuing education courses in pain management, and document they did so, which can provide evidence of their knowledge in event of legal action.
Nurses have an opportunity to educate patients about the role of pain medication in their care. This education should include pain medication options and the reasons why non-opioids are preferred.
Verbal and written instructions after the procedure need to contain name of drug, dosage, adverse effects, how long the drug should be taken, and how to store it. Results from a 2016 survey published in JAMA Internal Medicine found that more than half (61%) of those no long taking opioid medication keep it for future use, so patients need to be told to dispose of unused drugs and how to do so. Patients can search for places that collect controlled substance drugs through the Drug Enforcement Administration at www.deadiversion.usdoj.gov.
The same survey found that about 20% shared the opioid with another person, so education material should mention not to do this. Nurses should also discuss the perils of driving or undertaking complex tasks while taking an opioid. Document in the patient’s health record that this information was provided and the patient acknowledged receipt and understanding. An office visit can also provide the opportunity for nurses to address opioid abuse on a larger scale.
Refer Patients as Indicated
Nurses need to closely monitor patient use of controlled drugs to avoid overdependence or potential addiction, and refer chronic pain patients to a pain management center or specialist. Be sure to document the referral in the patient’s health record. Nurses also should consider referral for patients who seek opioids beyond when they are likely to be needed.
Pain Medications Cautions
Below are some considerations for the use of pain medication in patients:
- Use non-steroidal anti-inflammatory drugs (NSAIDs) as the first option. Consider a selective NSAID to avoid increased risk of bleeding. Know that using acetaminophen in combination with NSAID may have a synergistic effect in pain relief. (Do not exceed 3,000 mg/day in adults.)
- Provide patient education.
- Document patient communications, education, and referrals in the health record.
Protecting Patients and Nurses
Nurses who assess and monitor patients for treatment of pain are encouraged to be mindful of and have respect for their inherent abuse potential. Doing so helps protect patients from harm and nurses from potential liability.
Disclaimer: This article is provided for general informational purposes only and is not intended to provide individualized business, risk management, or legal advice. It is not intended to be a substitute for any professional standards, guidelines or workplace policies related to the subject matter.
This risk management information was provided by Nurses Service Organization (NSO), the nation’s largest provider of nurses’ professional liability insurance coverage for over 650,000 nurses since 1976. INS endorses the individual professional liability insurance policy administered through NSO and underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to [email protected] or call 1-800-247-1500.
Hospitals have dedicated tremendous resources to create an integrated clinical environment that results in better patient care and outcomes, reduces readmissions, and increases hospital utilization, in hopes of reducing the overall cost of health care.
Unfortunately, health IT projects either fall short of business and clinical goals or are completely abandoned at an astonishing rate. Studies vary, but failure-rate estimates range from 35% to 75%.
Overrun budgets and functionality problems are often cited as the primary culprits of doomed implementations. However, the failure to include direct-care clinical staff—including nurses—in the evaluation, implementation, and training of new technology should not be overlooked.
It’s easy to consider a new hardware or software solution and imagine its transformative potential. Health care trade shows brim with thousands of devices, enterprise systems, and software applications marketed as painless solutions for any clinical challenge facing a hospital or care unit. But a poorly implemented system that did not evaluate the impact to the clinical workflow can just as easily exacerbate inefficiencies and reduce the overall quality of patient care.
Equipment that doesn’t work properly or causes needless redundancies in daily tasks is enormously frustrating. The lack of sufficient training and vendor support increases the chances of mistakes or encourages direct-care staff to either work around a new solution or outright revolt at go-live.
A Shared Vision
Many of the doomsday scenarios associated with technology adoption and implementation can be mitigated with adequate planning, training, and collaboration. By listening to, engaging with, and educating front-line staff, hospitals can dramatically increase their chances of success with technology adoption.
For example, consider medical devices with alarm capabilities. Nursing staff are charged with the proper setting of the alarms and the prompt response when any of the devices send an alert. As the presence of alarm equipment continues to grow, nurses find their workflow and ability to engage with patients disrupted as they chase down hundreds of (often non-actionable) alarms. Without proper education and implementation of alarm devices, it’s all too easy to imagine clinical staff arbitrarily adjusting alarm settings—or even turning them off entirely.
Involving direct-care staff is critical to the success of any new technology. How will this new technology impact how nurses deliver patient care? What adjustments in workflow and practice need to be made—at go-live and beyond? Starting with these questions fosters buy-in from the staff who will be utilizing this equipment. If end-users are not involved in the selection, adoption, and implementation of a technology, then the likelihood that they will become owners of that product is significantly lower.
Environmental and Workflow Assessments
Hospitals each have their own unique characteristics, culture, and needs. Identifying and documenting those attributes are critical to any successful health IT implementation. To achieve measurable progress in health IT adoption requires that hospitals identify and support internal champions in all relevant departments.
For hospitals and health systems, especially those that are breaking ground on new technology integration, the first step is an assessment of needs and potential impact to workflow. The formidable task list that comes with any technology implementation requires the input and expertise of a project team, which ideally, should be comprised of leadership from myriad stakeholders, including IT networking, facilities, patient safety experts, educators, informatics nurses, laboratory staff, pharmacists, electrical engineers, biomedical engineers, quality improvement specialists, vendors, and direct-care clinical staff . This team will be responsible for every phase of deployment—evaluation, acquisition, rollout, implementation, and transition to live operations. They will determine the hospital’s objectives and integration goals, as well as vendor evaluations, business and clinical requirements, risk management concerns, patient safety goals, and costs.
The project team will also be charged with identifying the departments or units the integration will first impact. Big bang, enterprise integrations are not unprecedented, but a phased roll out in a single department or set of departments with the highest acuity, such as the surgical suite, allows more time and space for assessments, lessons learned, and best practices, which can be applied as the integration spreads to the rest of the enterprise.
One aspect of integration that is often overlooked is the value of clinical workflow, which can vary among hospitals and individual units. Workflow should not be minimized because it will largely define how data is collected, how it is displayed, and what is displayed. Hospitals should incorporate clinical workflow as quickly and as early as possible in the process.
Designating a nursing champion—or super-user—at the outset allows other nurses and direct-care clinical staff to receive information, training, and support during all phases of adoption. These super-users would be working closely with the interdisciplinary team assembled for the implementation project.
Health IT implementations can be expensive, complex, involve dozens of stakeholders, and are often up against aggressive deadlines. Technology can also be disruptive and bring new uncertainties to the entire organization. However, the quality of the relationship with the vendor supplying the solution can make a huge difference.
Any hospital or health system has business and clinical needs and cultures that make them different from other organizations. A partner with deep knowledge of the unique aspects of your organization not only will help you avoid common mistakes, but also keep you focused on detailed integration points and workflows.
A partner that knows your organization also helps other vendors get acclimated, provides guidance, and ensures everyone stays accountable. A positive and fruitful collaboration allows hospitals to establish benchmarks and ensure that configurations and interoperability are optimized and seamless.
An excellent vendor also acts as a consultant and educator, making hospital staff comfortable with new technology and uncovering strategies for optimizing workflow. The importance of evaluating the vendor as much as the product they are delivering cannot be stressed enough. Vendors that lack expertise, training capabilities and clear steps toward go-live and beyond are critical red flags.
Can the vendor explain their process? Can they share metrics? Do they offer continued training and support after the implementation is complete? Answers to these questions will give your project team keen insights into the potential challenges of a technology implementation.
If your vendor supplies references, ask their customers specifically about their specific challenges and the vendor resolved them. Setbacks are a natural part of any implementation, but the true difference maker is determining the level of support and collaboration provided to overcome it.
A team approach to health IT doesn’t guarantee that technology adoption and implementation will be a success—but it will significantly increase its chances of sustainability. Today’s nurses have neither the desire nor the option to be passive consumers of health care technology. The seamless integration of technology requires that direct-care clinical staff have influence in the design and testing of equipment and applications. Involving end-users in the early stages of system analysis and design specifications can lead to better adoption of new technology, as well as identifying how current technology can be adapted for greater user acceptance.
Hospitals will face a major dilemma if the current federal administration repeals the Affordable Care Act (ACA) without a suitable replacement. The ACA offers millions of Americans affordable health insurance, and hospitals have seen their revenues, and their quality of care, rise as those newly insured citizens access their services. If the ACA goes away, those health care patients and their accompanying insurance payments disappear, putting even more stress on today’s health care labor force. With profit decline comes employee decline, both in number and quality. This will first and foremost affect nursing staff, putting some out of work and others in-over-their-heads.
An Uncertain Health Care Future
Before enactment of the ACA, existing law required (and still requires) that health care facilities provide “stabilizing care” to any person who requests services, regardless of their ability to pay. Medicaid covered these costs. Without ACA coverage, many patients will be forced back to receiving only the substandard “stabilizing care,” and will not receive the services they need to regain their health.
In that circumstance, the medical facility will be forced to balance the volume of unsubsidized, stabilizing care offered against the revenues generated by paying patients, cost reductions, or staff workload increases. If they offer excessive unsubsidized care, they risk declining income levels, staff numbers and possible bankruptcy. If they provide too little, they risk losing their Medicaid/Medicare funding. In both cases, the facility, its staff, and America’s uninsured patients will suffer.
Unpaid Care Is Expensive for the Medical Office …
Every medical consultation generates a series of cost-creating actions, from those of the scheduling secretary to the attending medical professional, and all the way through to the deposits made by the final billing clerk. According to the American Hospital Association, hospitals provided $35.7 billion in uncompensated care to their patients in 2015 alone. When a hospital absorbs these losses, it is also forced to reduce the services it can afford to provide.
Consequently, it is not unheard of for doctors to reduce the size of their bills by limiting the services they provide or the number of recommendations they make, based on their perception of what the patient can afford. Other studies confirm that uninsured patients are checked into a hospital for shorter stays, and they are offered fewer interventions for their condition. For the health professionals, these painful decisions are in direct conflict with their oath to provide the best care possible for every patient.
… And Hard on the Staff
One group of hospital workers that will certainly absorb a significant percentage of additional work due to funding cuts are the nurses. Reduced funding often leads to reduced staff numbers; remaining staff end up working longer, harder shifts, with more responsibility and less break time. And nursing is already a challenging job, with a high demand for significant physical labor that also takes an emotional toll. In fact, between 2002 and 2012, nurses have reported the highest stress levels of all health care professionals.
Additionally, long hours may not allow nurses to get the sleep they need. Inefficient sleep has been associated with a deficit in performance, caused by cognitive problems, mood alterations, reduced motivation, increased safety risk, and physiological changes. These effects only get worse with total sleep deprivation, common among nurses who work consecutive shifts.
Additional Stress Factors
Research reveals that the changes in the nursing profession in particular and the health care system in general, contribute significantly to the problem:
- Sophisticated technology offers immense benefits but adds additional layers of responsibility on already overloaded schedules;
- Burnout is common, too. Protocols can change as resources ebb; nurses are compelled to follow evolving practices without the opportunity to add input regarding their patient’s care. A 2012 study published by the Canadian Federation of Nurses Unions found high levels of burnout correlated to lower ratings for quality of care.
- Reduced staff numbers also drive nurses to work even when they are sick. Many choose to potentially infect their patients rather than leave their colleagues unsupported on shift.
The reality for America is that, before the ACA, unpaid hospital bills were often eventually born by other elements of the system, including taxpayers and patients who incurred higher medical care costs. Repealing it won’t save the country money, but instead will add extra stress to the system and further erode the health of millions of its citizens.
Of all the risk factors for heart disease, the areas you have no control over are often the ones that are especially troublesome. While you can make inroads to a healthier diet, more activity and exercise, reducing stress, and even taking appropriate medications, it often feels like there’s nothing you can do to change your family’s track record of heart disease.
As February is American Heart Month, now is a great time to take stock of your own heart health. Knowing that your family carries a higher risk for heart disease is actually a great motivator to keep your own heart as healthy as possible. In many cases, if you ramp up your efforts to control what you can, you can negate some of your family’s health lineage.
Can you change your family’s past? No – if you had a father and three aunts who died from heart disease in their 40s, you need to take that very seriously. But it doesn’t mean you will take the same path.
How can you beat your genetics?
Know Your History
The American Heart Association recommends gathering as much family history as you possibly can. If you are at least able to start with members of your immediate family, that will help you assess your risk.
Look for family members with a history of heart attacks, strokes, high blood pressure, high cholesterol, or congestive heart failure. Find out how old family members were when they were diagnosed and how old they were if they died from the disease. And try to notice any patterns – is the predominant problem heart attack or stroke?
Accept (But Don’t Give Into) Your Genes
There is virtually no way to change your genetic makeup. But if you carry an elevated risk, it can make you feel unsure of what’s to come. So while you can’t change your genetic cards, you can change how you live your life.
A lifestyle that is heart-healthy, heart-friendly, and heart-supportive can contribute greatly to your overall heart health and start to bring your elevated risk into a more normal range.
Talk with Your Team
Talk to your healthcare providers to make sure you are getting all the tests you need to uncover any early indicators of heart disease. Discuss medications and other therapies that can lower your blood pressure and your cholesterol and even get things like triglycerides into normal range.
Some minority populations are more predisposed to heart disease (including African Americans and Hispanics), so go over some of those risk factors. And have a discussion about any other conditions you may have that could put you at a higher risk including diabetes, depression, and even psoriatic arthritis.
Make Heart Health a Priority
No one else is going to put your heart health first, so that’s going to be up to you. Put caring for your heart at the top of your to-do list. That means taking a look at obvious things like your eating habits, your weight, your blood pressure and cholesterol numbers. But it also means making sure you get enough sleep (lack of sleep raises your risk of heart disease over time) and making sure you take the time for pleasure.
Loneliness also contributes to declining heart health, so develop a rich social life and figure out exactly what that looks like for you. Some people want three parties every weekend and others are happiest having dinner with best friends every couple of weeks or a favorite book club every week.
No matter what story your family health patterns reveal, it doesn’t mean that’s your destiny. With some changes and lots of diligence and close observation, you can keep you heart healthy and strong.