Infectious disease specialists at the CDC and other organizations are placing an increasing emphasis on the use of contact tracers to rein in a resurgence of the virus as states reopen businesses and reduce social distancing measures. Speaking to Stat News, Tom Frieden, president and CEO of the nonprofit Resolve to Save Lives and a former director of the Centers for Disease Control and Prevention, describes contact tracing as a series of “four key actions: test, isolate the infected, contact trace, and then follow up the contacts. And each of those four things needs to be going really, really well and at a massive scale.”
Good contact tracers have emotional intelligence, close listening skills, caring combined with straight talk, and a flair for patient education. Of course, these are also key characteristics that inspire so many Americans to place their trust in nurses. In a country that regards privacy as an unwritten constitutional right, it is essential that contact tracers be capable of inspiring trust, so it is not surprising that boards of public health across the US try to fill these positions with people who have nursing experience.
School nurses sidelined by school closures, nurses on furlough due to holds on elective medical procedures, and a wide range of former nurses are lending their skills to the massive public health effort. Massachusetts contact tracer Celia Gillis was clearly drawing on her past as a nurse in Boston when she spoke of her new job to Boston Magazine: “It’s been eye opening. You have to sort of establish a relationship with them before you start asking for names and phone numbers, because sometimes people don’t want to share that information with a stranger. So you start with a larger conversation. What are their symptoms? What difficulties are they having? What can we do for them? We’re asking so much of them. Like, “We just need you to stay home for 14 days.” That’s a lot to ask for some people!” She’s helped people obtain medications, food pantry deliveries, and even diapers, and says, “By the time you get to the part where you’re asking about contacts, they’re more comfortable with you and they understand that we’re here to help, too, we’re not just trying to get something from them.”
Out-of-work school nurses are often key players on contact tracing teams. Their availability owing to school closures has turned them into a prized commodity, and many are now working as contact tracers for public health departments serving communities in states such as Alaska, Ohio, and Maryland. Patty Comeau, a former school nurse in Methuen County, Massachusetts, told Boston 25 News that she’s on familiar ground in her new job: “School nursing is very similar to public health nursing in that we manage outbreaks of contagious diseases and we contact parents and we send out notifications.”
With communities attempting to reopen, contact tracers are in greater demand than ever, as their ongoing efforts help to reduce the spread of the virus before it imposes an unmanageable strain on hospital systems. Looking toward summer, Abram Wagner, research assistant professor of epidemiology at the Michigan School of Public Health, notes, “Robust contact tracing will be a key component of returning to work, school, and other aspects of life safely before a vaccine is developed.”
I recently visited a friend while they were in the hospital and during my visit, I stopped by the coffee shop. As I sipped my coffee, I listened to the calls the nurses were receiving on their unit-specific mobile phones. While I can appreciate that a phone makes for better communication between the nurses and hospital staff, I can also appreciate that the same staff are unaware that the phones are inadvertently putting patients at risk.
During the hours I spent with my friend, I was inadvertently present for phone conversations, all on speaker, regarding what patients required pain medication and their room numbers, whose test results were received and their result, what patient was being combative and needed sedation, and who required pain medication. I heard patient names, room numbers, physician names, and patient conditions. And I learned that the wife of the gallbladder in 100B called. Needless to say, it was an interesting and enlightening time. Let me just say that when HIPAA became de rigueur, nurses would have been fired for less illicitly passed information than I learned that afternoon. You weren’t allowed to utter a patient name or room number anywhere where other patients or family members or the public in general were located. If overheard or reported by fellow staff, you were terminated.
The nurses carrying on these conversations were on a break from their units, attending a Nurses Week event, but I’m sure these conversations occur all day long, no matter where the nurse is… in report, at the bedside, at lunch, even in the bathroom. While I’m sure the latter is at most inconvenient and intrusive, the prior is downright dangerous. I’m sure if they even get a break off the unit, the phone goes with them and so does the stress.
We teach students and new nurses to prepare medications where they are not distracted, to check everything multiple times. We never tell them “OK, let’s see if you can titrate this medication while a disembodied voice is telling you about another patient who urgently needs you.” We also don’t teach them that while they are attempting to complete complex therapy requiring their undivided attention while keeping a field clean or sterile, that they will be called multiple times about multiple patients. Several studies have noted that these distracted nurses are at higher risk of committing a medication error or an error of omission.
Do they change gloves and wash their hands after handling the phone? Do they ignore the calls when they are in the middle of changing a dressing or toileting a patient? A 2009 study in Turkey found that 94.5% of health care workers’ cell phones tested positive for bacteria including the MRSA. Further, it was found that mobile phones were only cleaned per policy 10.5%. That leaves a staggering 89.5% that were NEVER cleaned! You don’t need to be an infection control nurse to figure out that the mobile phones carried by nurses and other staff are contaminated with nosocomial pathogens that place both the staff and their patients at risk. So along with the importance of hospital staff washing their hands after patient care, they must also be mindful of hand hygiene between patient care and handling of their mobile phones.
Although many hospital systems have implemented policies with regards to mobile phone use, hopefully to increase patient safety and confidentiality, they need to be reviewed and reinforced periodically. It is easy to become desensitized to our actions and those of others in the health care field and it is pretty glaring when violated. Policies should include when the phone should be in silent mode, when and how phones should be cleaned, and how calls to nurses should “roll over” to the nurse’s station—especially when staff are involved in patient care activities. The policy should also include enforcement and the consequences of policy violation.
I knew something was wrong when she was late for work. She hadn’t called out and hadn’t texted anyone where she was. I peeked into her office. I wasn’t looking for any clues about where she was or anything; I was looking for her in an empty room. What struck me was how neat the otherwise messy work place was. It was as if she was going on a trip and wanted to leave the office orderly in case anyone came in while she was gone. The loose ends were tied up. Thankfully, she was not successful in her suicide attempt.
Everyone claimed to not know anything, but we knew the whole story, pieced together from social media posts. We were all quiet and looking at each other like we were examining each other to see if anyone else was at risk for committing suicide. One nurse said, in typical off-color nursing humor: “We know what we are going through ourselves, but you never know if the person next to you is circling the drain.” We all nervously giggled. The comment hurt to hear…but it was accurate, stripped down to the basic cutting truth. We really don’t listen to the answer of a tossed out “how are you”? We are so concerned with ourselves and our own issues that we rarely take the time to reach out to someone else.
Prompted by what happened, the hospital presented education on suicide prevention. I didn’t want to attend. Why bother? I’d been depressed after my mother died, I’d been through treatment, and you couldn’t tell me anything I didn’t already know, but a friend of mine did attend and she was very moved by what she had heard. She shared with everyone on the unit what she felt was the most important takeaway: do not be afraid to ask someone if they want to harm themselves or commit suicide.
During a private conversation, this friend came right out and asked me if I ever thought of commiting suicide, if I’d ever been depressed. I didn’t look her in the eye when I said that in the past I had thought of what the world would be like without me in it, particularly after my mother had died. I told her that I had felt like I was surrounded by blackness, like I was sitting in the bottom of a well and I couldn’t get out. I had sought help and was diagnosed with depression. When I saw tears in her eyes I immediately regretted what I had said because I didn’t want anyone to know that I had been depressed—that there was a chink in my armor. She told me that she had learned that people who are depressed verbalize that they are in a very dark place, feeling like they are surrounded by nothingness and blackness with no way out. My friend kept looking at me like she was really seeing me and asked me to make her a promise. She made me promise that if I ever felt like that again, that I would tell her. My mental fingers were crossed. Strong people don’t reveal weaknesses and we certainly don’t share feelings—we just tamp them down, deny them, and keep going. I didn’t need help and besides, I was thinking, what could you do for me? But the concern and the tears in her eyes really stayed with me.
The truth was that I was sitting at the bottom of that well. Work and life and just the energy required for living were becoming too much again, but my friend had opened the door to the darkness and a little bit of light had shone in. Several weeks went by and we were talking on the unit about work related issues and I causally asked my friend if she remembered making me promise to tell her if I ever felt like I was sitting in the blackness. Tears filled her eyes again when I told her that I was back in the well again. I watched as she went to the computer, made an entry, and handed me on a piece of paper: the link to the employee assistance program at our hospital. She stayed with me while I contacted them and I was seen by a counselor the next day.
am aware that we all do not know someone we feel comfortable talking to, but in
our busy days of being a nurse and caring for patients and caring for ourselves
and our families, we need to be able to recognize when one of our colleagues is
reaching out, however silently, for our help.
The health care community is turning to interprofessional care teams to deliver the highest quality of care and increase quality outcomes. Through this model, a well-rounded team of clinical experts work from the same evidence-based playbook to collaborate on an effective treatment plan—caring for the patient in holistic way. A team of health care professionals from EBSCO Information Services (EBSCO), based in Ipswich, MA, explore this rising model and why it’s taking the health care community by storm.
Is there clear evidence that demonstrates how interprofessional health care collaboration leads to better outcomes?
Earlier this year the National Academies of Practice, an interprofessional organization dedicated to fostering collaboration and advocating policies in the best interest of individuals and communities, published a white paper examining the state of interprofessional collaborative practice. The paper included a review of the literature on the relationship between interprofessional practice and outcomes. More than 20 studies are summarized in the report. Overall, interprofessional collaborative practice involving different teams of health care professionals in a variety of settings and patient populations was associated with improved outcomes, including decreased length of stay and admission rates.
Describe how interprofessional health care supports the Quadruple Aim.
Outcome improvement has been a priority focus in all clinical professions for decades. National and international quality groups have taken leadership roles in support of health care improvement. The Institute for Healthcare Improvement (IHI) introduced the Triple Aim Framework in 2007 with the goal of improving the lives of patients.The Quadruple Aim, which is geared towards the well-being of clinicians, evolved from the Triple Aim, which is focused on patients.
No single clinical discipline working independently can meet the
expectations of the Quadruple Aim. An interprofessional team, working in
collaboration across the care continuum, provides the best hope in achieving
the improvement outcomes associated with the Quadruple Aim components listed
Patient Experience of Care
Clinicians have a keen awareness of health system challenges and
the reality of sometimes “missing the mark” in attempts to provide an
exceptional patient experience. An interprofessional team, working to uncover
the patient’s unique situation and health status, can effectively facilitate a
shared plan focused on the patient’s individualized needs, thus enhancing the
Reducing Per Capita Costs
Health care spending continues to rise, especially in the United States, and there is consensus that the current level of spending is unsustainable, according to a recent JAMA study on health care spending. With the shift to value-based care, reimbursement models are now risk-based, causing hospitals and health systems to re-evaluate care models and associated costs for defined populations. Interprofessional strategies are also effective in value analysis, collaborating to evaluate research findings and make recommendations for supply utilization, pharmaceuticals, and other costs associated with care variation.
Population health challenges the health care system to base strategic decisions on an understanding of population needs and then structure services and care teams to serve those needs. Patients within the defined population deal with social determinants of health such as poverty, access to health care, educational level, and other environmental and personal factors impacting outcomes, according to a study in the American Journal of Public Health. Population health strategies require team-based care, community collaboration and integrated practice expertise in the provision of health services, chronic disease management, and culturally competent care.
Care team satisfaction is a predictor of patient satisfaction and clinician well-being is essential for safe, high-quality patient care. However, every discipline across all specialties and care settings are experiencing alarming rates of burnout and associated conditions such as depression, emotional exhaustion, and suicide rates that are two times higher than the general population. In 2017, the National Academy of Medicine launched the Action Collaborative on Clinician Well-Being and Resilience, a network of organizations committed to reversing trends in clinician burnout.
Collaborative has three goals:
baseline understanding of challenges to clinician well-being
visibility of clinician stress and burnout
evidence-based, multidisciplinary solutions that will improve patient care by
caring for the caregiver
By fostering a healthy culture of interprofessional teamwork, supporting joy in work, and decreasing burnout for all disciplines, organizations can improve the quality of care provided to patients.
What are some of the national interprofessional initiatives that support this model?
In addition to the National Academies of Practice, there are other national organizations focused on advancing interprofessional health care.
The National Center for Interprofessional Practice and Education (IPE) was established in 2012 at the University of Minnesota. Funded by the Department of Health and Human Services, along with private foundations, the National Center serves as a coordinating body for the advancement of IPE and practice.
The American Interprofessional Health Collaborative advocates for and advances the alignment of interprofessional educational programs, the importance of interprofessional health care delivery, and research programs that facilitate examining these education-practice linkages towards better outcomes for health and health care.
What are the implications of interprofessional health care for nurses and nurse leaders?
Those engaged in the profession of nursing are in a unique position to assume a leadership role in advancing interprofessional education and practice. Nurses work in diverse positions of influence within health care systems, academic organizations, government agencies, and industry. Because of this broad influence, nurses have many avenues to get involved and have an impact including:
Stay informed on recent interprofessional initiatives and advances
Seek to understand interprofessional colleagues’ unique scope of practice to improve clarity, collaboration, and coordination of patient care
Join interprofessional national/international groups and participate in initiatives
Share interprofessional best practices with others through education, publication, and presentation
Advocate for and implement interprofessional approaches through committee work, research, or policy/standards development
Influence policymakers, businesses, and health system boards, advocating for the advancement of interprofessional education and practice
Most clinicians say they chose health care as a career to make a difference and give back to humanity. If nurses can individually commit to action, the profession can collectively make a significant contribution in advancing interprofessional education and practice.
It is no surprise there is often confusion between the concepts of experience and engagement. Tack the word “patient” to the front of either, and you’ll likely become even more confused as to the difference in meaning between the two. The difference, however, becomes significant when we look at the current state of health care. The reality is, participants in the health care industry are dedicating significant resources to enhancing the patient experience.
Equally, investments in technology and labor are being made to
improve engagement with patients, both prospective and current. This shift in
patient engagement has stemmed from an increasing number of patients playing a
more active role in managing their health affairs through digital platforms. While
both patient experience and patient engagement contribute equally
to patient loyalty, there are key differences worth noting.
Patient experience can be summed up as the cumulative experiences a patient encounters throughout their dealings with a health care provider. This begins with the initial phone call and continues right through administering care to the patient and the routine after-care checkups. A patient’s experience is a journey that is often comprised of:
The initial phone conversation or online booking made to schedule an appointment with the health care provider.
The patient’s visit to the premises, including the interaction between the receptionist staff and the patient upon arrival and departure.
The level of care provided by the health care provider to the patient, and the quality of the health care staff who administered the care.
Whether the patient’s experience was comfortable, this includes the gown they were provided with and the appropriateness of the uniforms worn by the health care provider.
The patient’s billing experience, such as the ease, convenience, and flexibility of payment.
The after-stay experience with the health care provider—for example, did they make a follow-up call to the patient to gauge how they were feeling and whether the provider could have improved on any aspect of care?
In summary, every encounter the health care provider has with the patient contributes to the overall patient experience. Patient experience places the onus of care mostly on the health care provider, meaning the provider is responsible and accountable for the patient’s experience from start to finish. Understanding the touchpoints of this experience is critical to enhancing the overall relationship between the patient and the provider.
The Center for Advancing Health defines patient engagement as the “… actions individuals must take to obtain the greatest benefit from the health care services available to them.” Patient engagement puts the onus of health care back on the patient. Patients are afforded an opportunity to enhance their health and well-being through various health care services on offer. However, the patient must act for engagement to take place. This shift in onus from provider to patient is the main differentiating factor between patient experience and patient engagement. Some examples of patient engagement are:
1. Patients and their families engaging in wellness programs, health-based courses, and initiatives provided by health care providers.
2. Patients registering for, updating, and regularly using online health care records. The introduction of online health care records offers significant convenience and control for patients who traditionally would not have documented their health history.
records enable patients to manage their health information,
including advanced care plans or custodian details.
Online health records also allow patients to add personal notes regarding any allergies and allergic reactions they may have previously had and set up text or email notifications to notify the patient that a health care provider has viewed their record.
Patients concerned about security can configure their security settings to restrict access to their records and who can and can’t view their health records online.
3. Provide input into patient engagement surveys or broader initiatives. Surveys on patient engagement have been used previously to gauge the services that can be undertaken by a patient as opposed to health care providers. This, in turn, allows the health care provider to devote resources to segments of the patient experience cycle that require more attention.
Achieving Both Patient
Satisfaction and Engagement – Is It Possible?
Patient experience focuses on the steps taken by the health care provider to enrich a patient’s experience, whereas patient engagement centers on the actions taken by a patient to engage in the services provided by the health care professional. While differences between patient experience and engagement are apparent, the two operate hand in hand when understanding the full gambit of a patient’s interaction with health care providers in the modern-day health care landscape. The question is, can a health care provider serve both sides of the spectrum? Can this utopia of patient interaction be achieved? Essentially, the answer is yes, it can, but only by understanding some fundamental levers. Some of these levers are:
Defining the patient. Is the patient one person or should this comprise the patient’s family, friends, and caregivers? When assessing experience and engagement, should experience be focused on the individual’s experience with the provider or on how a patient and his/her family interact with health and wellness programs?
Defining the degree of control. What control does a patient under the “patient engagement” umbrella have in determining their quality of care and level of engagement? When we speak about engagement, how much choice does the patient have? Conversely, does the patient experience relinquish all control, or can there be some middle ground, where the patient can provide input into the patient experience cycle by, for example, completing surveys?
The degree of engagement. If a health care provider has patients who are highly engaged, completing most tasks themselves, is this the ideal degree of engagement? For example, is having patients schedule appointments themselves, leverage technology to pay for bills, and update their health care records the proper amount of engagement? Some believe so and argue patient engagement allows that other elements of care, such as the actual health care service, should be left to the patient experience cycle.
There is undoubtedly an opportunity for health care providers and patients to work within the confines of the patient experience and patient engagement concepts. Advancements in technology, such as online health care records and increased availability of health programs, have created the platform for patient engagement and made it easier for a patient or a patient’s family member/caregiver to manage their health affairs. This has reduced administrative dependency on providers, who can now focus on more pressing facets of the patient experience, such as the level and quality of care provided to patients.
Overall, the outlook appears positive and, in time, health care providers and patients will likely find a comfortable medium between bearing the burden of patient engagement and patient experience.
A small sampling of these messages on Facebook found that “anti-vaxxers” had qualitatively different types of arguments that cater to a wide variety of audiences, reported Brian Primack, MD, of the University of Pittsburgh School of Medicine, and colleagues.
The World Health Organization (WHO) lists “vaccine hesitancy” as one of its 10 threats to global health in 2019, and indeed, Primack and colleagues cited the “considerable rise in the rate of nonmedical exemptions from school immunization requirements” in the U.S.
They noted that while prior research has focused on either anti-vaccination content on Twitter, comments in response to celebrity posts, and Facebook groups, the characteristics of individuals posting anti-vaccination content on Facebook has not been thoroughly examined.
Primack and colleagues examined the profiles of 197 individuals who posted anti-vaccination comments on a Pittsburgh pediatrics practice’s Facebook page in response to a video promoting the vaccine against HPV. These were among “thousands” posted over a period of 8 days considered anti-vaccination, “which we defined as being either (1) threatening (e.g., ‘you’ll burn in hell for killing babies’) and/or (2) extremist (e.g., ‘you have been brainwashed’),” the group explained.
Among the 197 randomly chosen for analysis (“in order to feasibly conduct in-depth quantitative assessment”), they found a large majority of these commenters were women, and almost 80% were parents. About 30% reported an occupation and a little under a quarter reported a post-secondary education. Of the 55 individuals whose political affiliation could be determined, 56% identified as supporters of Donald Trump, while 11% identified as supporters of Bernie Sanders.
There were 116 individuals who had at least one public anti-vaccination post from 2015-2017, with posts about “educational material,” or claims that doctors are uneducated and parents need to educate themselves were the most popular (73%), followed by “media, censorship, and ‘cover up'” or the suggestion that pharmaceutical manufacturers, government, and physicians deliberately fail to disclose adverse vaccine reactions (71%) and “vaccines cause idiopathic illness,” claiming kids who are not vaccinated get less illness (69%).
The four overarching themes were more specifically:
Trust: emphasizing suspicion about the scientific community, concerns about personal liberty
Alternatives: focusing on chemicals in vaccines, use of homeopathic remedies over vaccination
Safety: perceived risks and concerns about vaccination being immoral
Conspiracy: that government “hides” information that anti-vaccination groups believe to be facts
Co-author Beth Hoffman, BSc, also of the University of Pittsburgh, said that these groups “caution against a blanket approach to public health messages that encourage vaccination.”
Limitations to the data include that these only reflect commenters who responded to a single pro-vaccination video, and do not necessarily reflect “broader discussions of anti-vaccination issues on Facebook.” Demographic data was self-reported, and could not be authenticated, they noted.