Dr. Gloria McNeal, Dean of the School of Health and Human Services at National University. A nurse whose role is to oversee three departments. Department of Nursing, Department of Community Health, Department of Health Sciences. This includes 4100 students, 300 faculty and 17 programs from Baccalaureate to Masters and soon a Doctor of Nursing Anesthesia Practice.
Dr. McNeil Talks Person Centered Care
What we have done is embedded person-centered principles into all of our curriculum of study and in addition to help the students really get hands-on experience, we have developed a nurse led clinic. There are five of them in the Watts community in Los Angeles, South Los Angeles. Our students can both virtually and on-site deliver primary care services to the patients that we serve. We currently have been in operation for three years. We have 600 patients in our caseload and we are bringing primary care services to a community that pretty much has limited access to care. So, our students learn firsthand person-centeredness and how to address the needs of patients who typically have been disenfranchised.
Cultural Competency: Effective Care Delivery Among Diverse Populations
Many of the patients in our South LA area are Spanish-speaking, in the 60s or so was mostly African-American demographically, now it is mostly Latino and Hispanic. So we have ensured that our clinicians are bilingual that they can speak Spanish as well as English and assist in translation and interfacing with the community. By putting individuals in this community who look like, talk like them, it makes it more receptive.
The other thing we've done is most grants will not support capital expenditures, so we couldn't build the clinic, so what we did is we embedded ourselves inside of churches, Salvation Army locations and drug rehabilitation centers so we've gone to each of the CEOs of these entities and asked if there was space, they gave us a room and we converted the room into a clinic and that's how we see our patients. We are where they live, we are in their community, we are at their place of worship, so they can trust us because we're in a facility that they recognize and that they go to. They go to the Salvation Army, they go to the drug rehabilitation centers, and they go to church.
Track Record of Working with Telemedicine in Underserved Populations
In the early 1990s this nation was hit with a horrible measles epidemic that killed 167 children and put 3,000 others in intensive care units unnecessarily, these children were not being properly immunized. The Clinton administration put out a call for a summer of service initiative and requested that we identify a problem within a city that we wanted to address. The caveat was that it had to include students in high school, in college and so forth. So, working with the Department of Health in the city of Philadelphia, we identified the immunization rates were horrific, so we put a summer of service together to immunize children ages 0 to 5.
There were eight schools of Nursing involved, at the time I was associated with Thomas Jefferson University and we were one of the mobile entities, so we put an old bookmobile into service gutted it, turned it into a clinic and traveled around this immunizing children and putting the children into the database within the Department of Public Health to finish their vaccine schedule. We did that for a while and I thought to myself, you know what, if we can do this for immunization, what about if we did it for full-scale primary care services.
I became the director of the emergency care mobile healthcare project. I had four mobile units, we traveled around Philadelphia and the surrounding counties delivering primary care services. This was a nurse led model, all of the nurses aboard the vehicle were advanced practice nurses. We did that for a few years and then I had opportunity to come out to California, I was recruited to National University, and at that time I thought, you know what, the mobile vehicle is nice, but it doesn't have all of the trust and support, it's not deeply embedded into the community. So, with this model I elected not to use a mobile unit but to make the health care clinicians mobile.
The team moves from place to place, the five locations where we're located and we added one more piece, telehealth technology, so now we're able to monitor the patients remotely. If we want to know what someone's blood pressure is doing, what their weight is doing, what their oxygen is doing, we could get all of that information. They don't have to leave their community and that information is transmitted to the cloud and we download it and put it into our medical record. So, that's the piece that I think is innovative, it's a mobile healthcare team, it’s using telehealth and it's embedded deep within the community.
Cost Effective Ways of Combating Resource Limitation to Serve High Need Populations
I found a startup company that was interested in showcasing their products, for a fraction of the cost, because telehealth technology is very expensive. So for a fraction of the cost we were able to purchase five units that included the blood pressure of the pulse oxygenation, blood glucose monitoring, body weight, heart sounds, lung sounds, and a 12-lead EKG package we could put in each of our locations. The individuals simply had to go to a place where they normally go anyway and we could monitor their vital signs. We don't yet have the capability of putting the equipment in the home and that will be our next iteration when we have more funding. I do believe that to improve access health care will be delivered in cyberspace in the future and at that point everyone will have an opportunity to experience great health.
Foster Change by Incorporating Young People in Decision Making Processes
Young people, just by definition of being young, they're very visionary and they want to make change, they really do. All you have to do is give them the avenue, so when I set up these mobile units and all of that and made it available to the young people, they were right there, I didn't have to coach them or anything. They wanted to be where the action was and they wanted to make a difference. So even now with my nurse managed clinic, I can't hold the students back, I don't have room for all of them, because it's 4,100 people. They gravitated to it naturally and they come up with amazing ideas about how to change the system. Ideas I had not thought about because of their youth and their interest in changing the world, it's just a natural entity that they have.
If You Weren't In This Career What Would You Be Doing Instead?
I always wanted to be in healthcare, I never had an interest in any other career, not that I was not exposed to the other careers. I saw them, but I didn't see them making the commitment to underserved populations and really helping people develop their health because health is everything. If you don't have your health, it's very difficult to exist. The other disciplines weren't oriented in that direction.
Who Has Impacted your Professional Journey?
Early on, I was guided by my mother, she was a single parent and we lived in an underserved environment community, she was a very visionary woman. She wanted her children to go to college, she herself did not have skills but I watched her develop an affinity for Nursing and so she started out and as a nursing assistant. She was so interested in advancing her skills, she was able to at that, apply for a waiver license for vocational nurses and there was an exam, an interview. She passed when she became a licensed vocational nurse and so I watched her manage patients, and the love that she had for the profession. She wanted me to be a nurse and so I was able to, with her guidance.
She worked three jobs to put us through school and I was able to successfully graduate from the Villanova University with my undergraduate degree. I was interested in assisting her in paying for the tuition and so forth so I joined the Navy. The military paid for my education, my last two years I was a commissioned officer. When I left Villanova and I was stationed at Philadelphia Naval Hospital where I was promoted two more times to a lieutenant and gained critical care experience. From there when I transition to the civilian world.
I wanted to continue my education so I acquired a master's degree in nursing at the University of Pennsylvania and continue to work in critical care areas as a supervisor, but I also always liked teaching students. So, I went back to the University of Pennsylvania to acquire a PhD in higher education administration. I knew I'd be a Dean or something, so that's my educational background. Of course being at those institutions gave me some forward-thinking and visionary approaches to what I do now.
Legacy in Health Care
I like my legacy to be, recognizing what it takes to address the healthcare needs of underserved populations and to be where the person is, to not impose and to recognize that we're all different and we have different ways of living and experiencing life. Not to be judgmental, to try to be where the person is to address their health care needs. If I can imbue that understanding in my students as they go out into the world, I think I will have left a legacy.
This interview was recorded at #Planetree18
"Patient centered care is achievable; it might be difficult but it is attainable. Nurses have to go in and say, this is the reason I came into this business, to make a difference in my patients lives" Joy Chin, BSN, RN.
I’ve been a nurse for 27 years, I have graduated from Loyola University in Chicago. I’ve worked on med-surgical floors- special procedures, which is for arteriograms. I’ve gone into pre-op, where I’ve worked with getting patients ready for surgery in the perioperative area which I’m currently in the pre-admission testing.
A Day in the Life of Nurse Joy
I make sure patients paperwork are in order, ensuring patient don't cancel on the day of surgery, so if they need any kind of clearance i.e cardiac clearance that's where I come in and make sure all of that is taken care of. Now usually when my patients come in, we have a little office which is kind of nice that because you get to sit down with a patient face to face. When patients come in to who are having their procedure, firstly, you want to make sure that patients know why their there. Question; Why are you having this surgery? Did you have a second opinion? Did your doctor explain the procedure to you when you first met him or her?
It's important to make sure that the doctor is talking to the patient not a medical assistant, or event a nurse practitioner or a physician assistant should not be explaining the procedure to the patient the first time. The surgeon should be the one talking to the patent because they are the ones performing the procedures. I ensure that the patient is aware of what's going on, we ask questions about after surgery.
Where are your recovering? If the individual is having a joint replacement; Are you going to have rehabilitation? Are you going to have someone coming to your home for rehab? That's important, you want to find out if the patient lives alone. If the patient lives alone and their going home that same day, they can't go home by themselves. That needs to be told to the doctor. Questioning, did you arrange for the patient to have a 23 hour observation? Is the patient going to have a family member coming in from out of state etc.
Most of the time patients are not prepared due to time restraint when their in the doctor’s office. Patients are and I’m sorry to say this but they are kind of (treated) like an assembly line. Basically in the office a medical assistant might come in and talk to the patient, here's your PAT pre-admission testing appointment and they will fill you in. When the patient arrives they are like “can you explain this procedure to me” at which point we’re like no, the surgeon is the one doing the cutting.
We’re not doing a procedure. We’re just making sure, that you’re cleared and that no hiccups will occur on the day of surgery. Usually the patient has to be redirected back to the surgeon’s office or we’re actually being advocate for the patient doctor, and saying “Ms. Smith is still not sure why she's having this procedure, she don't know what type of procedure it will be. Are you going to make an incision, or is it going to be laparoscopic, what are you doing? This patient needs additional teaching. We then have to send the patient back to the office, mostly, their very close. Sometimes, we call a shuttle for the patient to be transported from the hospital back to the doctor’s office.
It's always about getting to the core; Do you know what you’re having? Do you know what’s happening? The patient will then respond “Well the doctor says that I need this surgery”. To which we respond, we need to know what do you think, do you think you need this surgery, do you, did you get a second opinion. We have talk to our patients, we have to build a rapport. We have to make sure the patient feels comfortable, provide a safe and secure, non-judgmental environment for the patient.
When you do that, you'll hear a lot of stuff that you didn't even ask but you’ll find out. You’ll find out that M.s Smith lost her husband a month ago, but no one knew. Then she lost her insurance, and now she's not even taking her medication because she doesn't have insurance to pay for it. Therefore, its not that the patient is being non compliant on purpose, the patient is just not being helped. Finding out, get to the core, listen to the patient.
Realism Vs. Idealism in Clinician’s Workflow.
The majority of nurses, when we come into our profession. We’re coming into our profession with this positive idealistic mindset. Saying we’re going to do good for our patients, we will make an positive impact, and make a difference in their lives. You get on the unit you have barriers. Barriers such as time restraint, we’re always pressed for time.
The nurse to patient ratio is very high, you have six patient to a nurse etc. Clinician face situations with excessive charting, double charting, you’re putting the same information in different places. They do say if it's not documented it didn't happen, however, if its documented once why do we need to have it in three different places? Documentation, high patient ratio, press for time are some of the barriers that I can think of and I’m sure they are more.
Patient centered care is achievable, it might be difficult but it is attainable. Nurses have to go in and say “this is the reason I came into this business, to make a difference in my patients lives. Therefore I’m going to set goals; even If I set goals to meet two patients needs that day. It's better than meeting non. If I go on and make small changes like make eye contact.
For example, I will touch my patient, I’m NOT going in with the computer and talk to the computer while I’m talking to my patient. I’m going to listen to what my patient is saying. I’m going to turn and then and say I hear you I feel your pain, how are you feeling this morning, how are you coping? Is there anything I can do to make your visit much more pleasant? Its about how we attack our day, When we come in and say, I know all of this is happening around me but this is what I’m going to for my patient.
Social Determinants of Health
There are different ways of inquiring about social determinants of health. Finding out where the patient lives, how is the patient living condition at home, is the patient having difficulty providing, funds to obtain their medication? How about food, are they able to provide for themselves? Will they have to use the money that they will be buying their medication to buy food and pay their rent? This is how you find out these things, by communicating with your patient and inquiring about where, the need is lacking.
Social service, case management at work I usually try to always get a consult. Not by discharge, but try to get that ahead of time. By the time of the hospitalization so that they can figure out where the patient will need help. Inquiring about basic needs, family member, neighbors that can help. We just need to facilitate the line between where this patient is coming from and meet this patient at their level, at their preference.
We need to treat the patient to how they can adopt to the healthcare. Not like, okay you’re supposed to be meeting us at this level, so I’m sorry. No, that's not what we’re supposed to be helping patients by asking them how we can be beneficial to them. Getting the patient involved in their decision making, can you share how you would like us to take care of you? What will help in your condition. Finding out where the patient is at.
When the patient comes in and they have a wall up, almost saying, you’re the nurse I’m the patient, and you think I don't know about myself but I do. You a s a nurse is basically going to say, Ms. Smith tell me about yourself. Patients do not want you in their face telling them, this is what you need to do, this is how it's going to be. Instead, do you prefer to have your treatment, in the middle because you tend to be up in the middle of the day?
How can we work around that to make everything goes smoothly for you”? Do to prefer to go to physical therapy, mid day because your arthritis acts up in the morning?” Or the nurse should be talking to the physical therapist, asking what time they will arrive to tend to Ms. smith. Should we medicate her 30-45 minutes before she goes to physical therapy?
If the patient knows that you’re willing to work with them and meet them at their level. i/e non-judgmental environment, you have to be able to provide that for them. I try to encourage my patients to ask a lot of questions. The department that I’m in, I encourage a lot of questions, because patients tend to say “the doctor said this is how it's supposed to be so that's it.I say question the doctor, don't be afraid to question the doctor, If you don't feel comfortable within yourself ask is this the only choice that I have or do I have a second choice? Do I have to have this surgery now? Can it be delayed, can I have conservative therapy, before actually going into surgery. They will meet you at your level. Have your list, bring it with you to the doctor’s office, and check off questions as they are answered.Don't leave that office, do not leave that office, do not get up out that chair until all of your questions are answered. I try to empower my patients, exposing, we're not trying to cripple you, when you leave and go back to your pre-existing hospitalization state, we're not going to be there with you. I want you to be equipped with this tool. So that when you encourage additional healthcare services you are able to interact and feel at ease with what you have on board.
"The cost of care needs to me more transparent, more predictable and more reasonable. There is nothing like the fear of not being able to afford what you need, or going bankrupted" Danny van Leeuwen, RN, MPH, CPHQ.
How does an individual figure out what works for them?
"I think you learn what works by trying things. The life journey for an individual, for me, for you, is an experiment. The way I look at it is, that I'm trying to accomplish something with my health journey. I have multiple sclerosis, its a progressive disease and I want to progress as slowly as possible.
I'm also a person that's pathologically optimistic, and I don't want to mess with that. Its a real strength to be optimistic, I feel better having a positive attitude. I also play the baritone saxophone, and I don't want to mess with that. Those are the three things that I want to accomplish, so I need to experiment with the things that are going to help me accomplish those health goals.
I can and I do go to research and try to learn what works for populations, or groups of people. Just because something works for groups of people or is likely to work for groups of people doesn't mean it will work for me so I feel like I need to try stuff. If it doesn't work then I need to adjust and try something else, so I think its experimentation".
Suggestions for improving empathy in health service delivery?
"You don't create empathy. There are people who have no empathy, there are people who have lots of empathy and then there are people in between. I think what you can do is foster the situation where empathy can exist and grow. Its very challenging to be empathetic when you have 8 minutes as a clinician, to spend with someone when theres this whole list of things to do.
You're consumed with checkin all the boxes and its hard because empathy requires listening and reflexion, which means you have to pause and think about; what do I see here in-front of me, whats the story I'm hearing, whats behind what their saying. That takes a moment, and when you're really rushed its really hard to do that".
Appeal to policy makers?
"The cost of care needs to me more transparent, more predictable and more reasonable. There is nothing like the fear of not being able to afford what you need, or going bankrupted. The next thing is the availability of information. My information about me, is mine. Right now information is so silo, its so dependent on the platform, i.e electronic record, the setting. Its very difficult to share that information amongst settings.
As a patient I want to have access to all the information there is about me, I'll pick and choose whats important and whats not. But, I want to be able to have access. I also think that the way healthcare is setup is by episode and diagnosis. An episode is a snapshot, its a moment in time. A diagnosis is a label about some aspect of my dis-health. I think policy makers should focus on longitudinal care over time, thinking about me a person, rather than a diagnosis".
Advice to clinicians that are new to healthcare environment?
"It would be good for people who go into the healthcare profession to spend a day in the shoes of people who are living in the setting their in. If their a patient, spend the day in the bed. When I was a young nurse I went to the Rusk Institute in New York City to learn about physical rehabilitation; I spent the day in a wheelchair.
That was a transformative experience, gaining some lived experience, I think that would be one thing. I would encourage networking as a young clinician. Finding people who care about the patients in this manner. Finding out who they are and then meeting with them regularly to share what works and what doesn't. Having that support system outside of the work environment I think is really important".