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Leading by listening

Nurses excel in public health efforts

Martha RyanDecember 2014 -- Nurses' roles in handling the global Ebola outbreak drew media attention in the second half of 2014, but during this same period, press reports also showed nurses taking autonomous leadership roles in other efforts to improve public health. On June 24, National Public Radio ran a piece by Sarah Jane Tribble describing the work of Ohio county health department nurse Jacqueline Fletcher to vaccinate patients in response to a measles outbreak in the state's largely unvaccinated Amish community. On December 19, The Huffington Post ran Nico Pitney's profile and interview of Martha Ryan, the San Francisco nurse who founded and directs the Homeless Prenatal Program, which has helped hundreds of women rebuild their lives. On December 29, the Des Moines Register had a short item about efforts to reduce drunk driving during the New Year's Eve period that focused on Sioux City nurse Carla Granstrom, who distributes cocktail napkins discouraging the deadly practice as part of a long-running program based at her hospital. And on December 30, the Sydney Morning Herald posted an item by Stephanie Gardiner about child and family health nurse Sue Colville, who discusses her work to help families manage post-natal depression and the stress of modern parenthood. These reports show nurses practicing in very different settings. But all the reports enhance public understanding that nurses play key roles in developing and implementing health initiatives, sensitively addressing community needs that others may overlook. We thank those responsible.

No scare to us before

Thousands of homeless pregnant women

Bar napkins to combat drunk driving

You're allowed to say "this sucks"

No scare to us before

Jacqueline FletcherThe online version of the NPR piece is headlined "Measles Outbreak In Ohio Leads Amish To Reconsider Vaccines." The report says something changed in the traditional rural Amish community when a woman reported cases of the measles to the Knox County Health Department in April 2014. Nurse Jacqueline Fletcher and her colleagues responded, collecting samples and confirming that it was, as Fletcher puts it, "textbook measles."

The rash. They had the conjunctivitis in the eyes, their eyes were red. They don't want the light, they sit in the darkened room, wear dark glasses. I mean they were just miserable. High temperatures, 103, 104 temps. So this was the measles.

measlesFletcher was soon on a call with the U.S. Centers for Disease Control and Prevention, which she says advised the county to "get ahead of" the outbreak. The piece reports that the cases are part of the largest outbreak in recent U.S. history, and at the time of the report, Ohio had most of the 341 confirmed cases, which included eight hospitalizations. With the virus spreading in the Amish community in the center of the state, "Fletcher started organizing door-to-door vaccinations, and set up vaccination clinics at various locations." The piece describes one of these in "a store that usually sells construction supplies," as a stream of Amish families form a line outside the door. Many Amish are not against vaccines, the piece says, but an Amish father named Ervin Kauffman says that they may have been too relaxed about the need for them: "I guess there was no scare to us before." Amish getting vaccinesHe notes that the outbreak has delayed weddings and curtailed church services. The piece quotes Knox County Health Commissioner Julie Miller as saying that "we still don't know what the number is of who has the potential to be sick," in part because it is not clear how many Amish live nearby. The piece says Ohio State researchers estimate 33,000 live in the six counties where the outbreak began. About 8,000 people in those counties had been vaccinated at the time of the report. Miller says she is concerned the disease may continue to spread because there is still resistance to vaccination; the piece closes with a brief interaction with a father of 11 whose family is getting the measles vaccine now, but who is unsure about other vaccines.

Jacqueline FletcherThis piece does not have a lot about nursing, but what it does have is helpful. Fletcher appears as a central figure in the Ohio county's response to the measles outbreak, from the initial testing to conducting vaccinations. Her quotes reveal her to be knowledgeable and able to explain the condition clearly in lay terms, which may enable members of the public to recognize the disease, thereby helping to contain it better. Our only complaint is that although the piece quotes county health commissioner Julie Miller, it fails to note that she too is a nurse! Miller has a masters in nursing and a career of leadership in public health departments. It's not clear if the reporter knew of Miller's professional status and did not think it was worth mentioning, maybe because she did not think Miller was practicing "nursing" any more (which would be erroneous). But in any case, it was a missed opportunity to show that nurses can be public health leaders. 

Thousands of homeless pregnant women

Martha RyanThe Huffington Post item, by senior editor Nico Pitney, is headlined "Nurse Has Helped Thousands Of Homeless Pregnant Women Rebuild Their Lives." The short introduction focuses on the results nurse Martha Ryan has achieved with the Homeless Prenatal Program (HPP). Unfortunately, it does not mention that she is a nurse, that she founded HPP (which now has a staff of 80), or even that she is the group's director, although readers may deduce that from the focus on her and from her sense of authority over the work. The piece does note that Ryan's "clients" "achieve extraordinary results," even though they are pregnant, homeless, and in many cases battling addiction or domestic violence. More than 90 percent of their high-risk pregnancies end in healthy babies, better than the national average for all births. HPP also helps them find jobs and permanent housing. The piece says HPP's approach is modeled on Ryan's aid work long ago in East Africa, where she trained female refugees to be health care providers, empowering them and at the same time gaining providers with no cultural barriers. At HPP, more than half the staff are former clients. Ryan explains that she had been getting a masters in public health at Berkeley and planned to return to the developing world. But when she volunteered at a local shelter, she "saw the developing world right here in America." She argues that pregnancy is "a special window of opportunity for at-risk women," evidently because their desire to help their babies motivates them to improve their lives.

Introducing the long Q&A, the piece says Ryan was asked "to share some life lessons -- about parenting, regrets, relationships, and her life's work." Some elements are relevant to nursing. In response to questions about the influence of Ryan's parents, we get the only direct statement that she is a nurse, when she is describing her history as a volunteer: "I volunteered at St. Anthony's Medical Clinic here in San Francisco while I was working full-time as an ICU nurse." She also suggests that her parents may have made assumptions about her, since "I was not the greatest student in the world, and I didn't do well in school, so there was a sense that I wouldn't do anything in life. I think that now my mother's quite surprised at what I have done with my life, and she's very proud of what I do." Ryan cites that as a lesson for HPP, to "never give up on anybody." The piece asks her to explain her "kindness," which seems to be the quality the author finds most striking about her, citing client anecdotes about her great patience when the clients are "being difficult." Ryan emphasizes the importance of conveying to those in poverty that everyone is "worthy," because "that's the beginning point of helping somebody heal and move in the right direction." And "if I give a hug to somebody, I get a hug back." As for HPP's high success rates, she cites the trust that comes from having a staff that is mainly from the community, the sense of hope clients get from HPP's "beautiful" facility, and their policy of not judging and conveying belief that clients' lives can be turned around. Ryan explains that people become homeless for many reasons, including violence in the home. As for pregnancy as a "unique window of opportunity," Ryan returns to the importance of not judging:

[Some people] see a poor woman or a woman who doesn't have housing, a homeless woman, and they say, "Why? She shouldn't `[have a baby]." But she should. I believe in family planning too. It's important for us to provide access to family planning, to prenatal services, to healthcare services. Healthcare is a right; it's not a privilege.

Finally, Ryan discusses her concern about HPP itself getting too big, but she also expresses her interest in seeing "other people model our program in different cities around the country."

To the extent readers understand that Ryan is a nurse and the HPP director, the piece is generally helpful. It presents a strong, sophisticated, visionary leader, someone who supervises a large staff and has achieved high success rates in providing holistic care to an at-risk population that faces great challenges. Her quotes are also helpful. A few show strong general health policy advocacy (e.g., "healthcare is a right") and many more show advanced psychosocial skills, as well as an admirable candor about matters including the benefits that return to a care giver (the "hug back"). It's also helpful to know that Ryan pursued a masters in public health at Berkeley, which will presumably balance the information that she was not a good student early in life; it reinforces her own message that people can change. On the downside, the nursing element is certainly not prominent, and many could miss it, especially since it is limited to the passing reference to Ryan "working" as an ICU nurse long ago. No effort is made to link Ryan's current work to the profession and there is no suggestion that nursing encompasses this kind of community health work. Finally, in the focus on her kindness and patience--non-technical virtues traditionally associated with nursing--it would be easy for readers to overlook that this is a public health leader who has spent decades building a large and effective health organization. On balance, the report is probably a net gain for nursing, although it could have done a lot more.

Bar napkins to combat drunk driving

bar napkinsThe Des Moines Register piece, which apparently originated with the Sioux City Journal, has a catchy headline: "Sioux City using bar napkins to combat drunken driving." It reports that Mercy Medical Center's "Reality Education Alcohol Prevention Program" (REAP) "plans to distribute 36,000 bright yellow bar napkins that encourage people to avoid driving after drinking in the nights leading up to New Year's Eve." The piece includes a photo of the center's "education coordinator" Carla Granstrom holding one of the napkins, which reads: "Friends do whatever it takes to stop friends from driving drunk." Granstrom is reportedly "spearheading" the bar napkin distribution effort, passing out fliers "urging people to use a designated driver or call a cab around St. Patrick's Day." The piece notes that Granstrom starting "working" at Mercy in 1973 as an emergency department nurse, and she "played a key role in the establishment of the program about 20 years ago." It includes substantial quotes from her:bar napkins

I've just seen, over the years, a lot of suffering that's happened. And it's preventable. ... It's not only the people that are driving that are at risk. You have pedestrians. You have people in their own cars, minding their own business, that can be affected. ... At one point, they estimated that alcohol was a factor in about 95 percent of all the cases that came into the ER after midnight. It's not only the impaired drivers, but it's gun shots, traffic accidents, falls, fires, drownings, assaults, domestic violence. I've seen an infinite number of those kinds of events. Basically, how alcohol has affected all of society and the impact that it's had on a lot of peoples' lives.

Backing these up, the piece notes that the National Highway Traffic and Safety Administration estimates that nearly 10,100 people were killed in "alcohol-impaired driving crashes" in 2013, and that of those, more than 2,700 were passengers and almost 850 were not even in a vehicle.

This piece portrays Granstrom as a public health leader, helping to start and execute this innovative initiative:  Cocktail napkins deliver the message in a format that is likely to catch a bar patron's eye. Granstrom's quotes make significant points about the negative effects of alcohol consumption on driving and a range of other physical activities. Once again, the nursing element is more buried than we would prefer, and there is an implication that maybe Granstrom is not "working" as a nurse in pursuing this health campaign. (We often hear that people are "working" as nurses, as if it was just a job they decided to take rather than a professional career that requires advanced education.) But at least Granstrom's work on the alcohol issue seems to relate directly to her emergency room work. And unlike the Huffington Post item, this piece is not long enough for the nursing link to get too lost.

You're allowed to say "this sucks"

Sue ColvilleThe Sydney Morning Herald item's headline is: "Family health nurse Sue Colville remembers eureka moment." That moment was when Colville saw "a new mother bravely walk[] into a health clinic without her baby," in the late 1980s. The article says the "veteran child and family health nurse" was shocked at the time, but the realization that the mother needed to talk about herself "sparked her passion for supporting the wellbeing of new mothers." Colville, also a "trained midwife," says she believes her most useful skill is listening." Now, with post-natal depression well-recognized and the recent discovery of two abandoned babies in Sydney, the piece asks Colville to discuss "modern pressures affecting parenthood and child development":

People have lost their instinct. There's more books, there's more apps. Mothers in particular don't trust themselves to know what to do with their children. We're trying to get mothers to be the expert of their own children. … There's one apartment block that we go to a lot for new babies and there's a small patch of grass and there's a sign that says 'Do not play on the grass'. As soon as I saw that, I thought 'no'. We can't be all cooped up.

The piece notes that "it is supposed to take a village to raise a child," but today many of Colville's patients have no family close by. And new mothers are often alone with a baby very soon after the child's birth, when the mother's partner must go back to work. So Colville

encourages mothers at the parenting groups she runs at the Hornsby community clinic to create their own villages and talk openly about the realities of parenting. "I always say if they find one friend then I've done a good job. It's about trying to get people to come together and parent together. You're allowed to say 'this sucks' ...  because then we can have a conversation about how are we going to manage it."

Colville also describes male post-natal depression, which can occur when men feel an "overwhelming sense of responsibility like 'suddenly I'm the provider for the family'."

Of all these public health items, this may be the best for nursing, which will not get lost when it appears right in the headline. It's true that the piece does not convey a lot of technical information about nursing, and some may not recognize "listening" as a key skill for a modern professional. But the piece puts that in context by focusing closely on Colville's nursing experience, practice, and leadership. Her nursing status and specialties are very clear. And she is able to describe in lay terms some important aspects of post-natal depression, including why it may be as prevalent as it is today and the measures we can take to address it. So on balance, this report is a valuable snapshot of a nurse as an important local public health leader.


See Sarah Jane Tribble's NPR story "Measles Outbreak In Ohio Leads Amish To Reconsider Vaccines" from June 24, 2014. (pdf archived)

See Nico Pitney's Huffington Post story "Nurse Has Helped Thousands Of Homeless Pregnant Women Rebuild Their Lives" from December 19, 2014. (pdf archived)

See the Des Moines Register article "Sioux City using bar napkins to combat drunken driving" from December 29, 2014. (pdf archived)

See Stephanie Gardiner's Sydney Morning Herald article "Family health nurse Sue Colville remembers eureka moment" from December 30, 2014. (pdf archived)


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