Forging into the Future: Innovations and Transitions

UPfront Magazine - Fall 2013

Transitions are well-known in nursing. As nurses, we care for people who move from illness to wellness or chronicity or from one stage of life to another. The healthcare system, too, will be going through a major transition as millions of Americans join the ranks of the newly insured and will be entitled to preventative and curative interventions. Increased reliance on technology in educational and healthcare systems will change the landscape. And, as millions of baby boomers age, necessitating a new emphasis on managing chronic conditions, nursing and healthcare will undergo more seismic shifts. In short, we are in the midst of many transitions.

Anticipating and recognizing these transitions, we at the School embarked on instituting many innovative changes in our educational and research programs. First, we made substantive changes in our undergraduate curriculum (now in its third year of implementation). Next we launched a new simulation laboratory integrating creative simulating experiences throughout the undergraduate and graduate programs. Our state-of-the-art Helene Fuld Pavilion for Innovative Learning prepares students for real-life nursing experiences using the most advanced simulation equipment and instruction to provide challenging but safe opportunities to review and assess their critical thinking skills, diagnostic instincts, and effectiveness.

In this issue of UPfront, we showcase many examples of innovations that advance research, practice, technology, and education – both nationally and globally – that have generated companies, patents, grants, awards, apps, and groundbreaking research.

Empower Nurses to Make a Difference

Someone is finally listening to the cries of rape in the military. And his name is President Obama.

Obama threw down the gauntlet on May 24 in a commencement address at the U.S. Naval Academy: “Those who commit sexual assault are not only committing a crime, they threaten the trust and discipline that makes our military strong. That’s why we have to be determined to stop these crimes. Because they’ve got no place in the greatest military on Earth.”

Actually, I add, they have no place in any civil society. It’s about time to proactively act and implement all measures to deal with this problem for women and girls (and men and boys).

A study released by the Defense Department prior to President Obama’s speech estimated that reports of unwanted sexual contact in the military, from groping to rape, rose 37 percent in 2012, to about 26,000 cases from 19,000 the previous year.

In recent weeks, there has been a flood of troubling allegations and they come in many forms. Two members of military sexual-assault prevention units – one for the Air Force and one at the Army’s Fort Hood in Texas – have been accused of sexual assault. A sergeant at West Point was charged with secretly videotaping female cadets in the shower. And there have been many reports that superiors have advised sexually abused women to drop their charges.

President Obama’s commitment to end this abuse of women in the military has been echoed by Secretary of Defense Chuck Hagel and resulted in a variety of legislative proposals from members of Congress designed to improve the Pentagon’s handling of sex crimes.

Legislation would create sexual assault nurse examiners

While there are many different ways to confront this crisis that are under discussion, one interesting approach affecting the nursing profession was proposed in May by Rep. Dan Lipinski (D- Ill.). Lipinski’s bill would require the armed services to provide professionally trained sexual assault nurse examiners (SANE) to assist in investigations and provide specialized medical attention and care to victims. Lipinski said the SANE Deployment Act will “help give victims more confidence to come forward knowing their cases will be handled with greater professionalism and sensitivity.”

Under the bill, the nurse examiners would be available to collect evidence during the critical early stages of any sexual assault investigation and provide care for victims of sexual assault. The congressman said the position would be filled by a nurse who is qualified through education in sexual assault forensics and in how to best care for victims of sex crimes.

Nurses and other medical personnel are on the frontlines of this fight and in position to provide care and other assistance, but they clearly need the help and support of the military brass to do their jobs.  

GAO finds nurses, doctors given inconsistent guidance on handling sexual assault cases

Unfortunately, the military leadership may not be moving fast enough to deal with this problem. Earlier this year, the Government Accountability Office (GAO) released a report that found the Pentagon has not even established consistent guidelines for the treatment of injuries stemming from sexual assault.

“Military healthcare providers do not have a consistent understanding of their responsibilities in caring for sexual assault victims because the department has not established guidance for the treatment of injuries stemming from sexual assault – which requires that specific steps are taken while providing care to help ensure a victim’s right to confidentiality,” the GAO said.

As a result, the GAO said, the various military branches have their own protocols for handling sexual assault cases, and these rules sometimes conflict. The GAO reports that some bases did not give doctors or nurses directions on how to keep sexual assault cases confidential or in other instances had rules that interfered with their ability to do so. The report warned that without assurances of privacy, that “sexual assault victims who want to keep their cases confidential may be reluctant to seek medical care.”

The Pentagon surely has a great deal of work to do to put a stop to this growing problem of sexual assault against women. While there are many steps that must be taken to address this disturbing problem, nurses and other healthcare professionals must be given clear and consistent direction on how cases should be handled, the proper training and the full backing of leadership, from Washington on down to base commanders and those in charge of medical facilities.

Our job is to prevent assault, to make sure victims feels safe to report the assault and to help the victims heal. Our mission is to join the voices demanding change in the military. To do that we need to be empowered; put nurses in leadership positions to do what they do best, protect and enhance the well-being of people.

Violence Against Nurses

We are reading more about violence against women in different parts of the world and some are wondering whether there is an increase in violent incidences. However, I believe two of the reasons we are reading more about it are, women are responding to it more and the public is more aware of it.

Survey after survey has documented that nurses are frequently exposed to violence from patients, patients’ families and visitors that can take the form of intimidation, harassment, stalking, beatings, stabbings and shootings. Unfortunately this is not true about workplace violence against nurses.

These acts of violence however minor or major have major psychological effects on nurses who are trying to provide quality care and undermine their trust in an infrastructure that does not protect them. Recruitment and job retention of nurses suffer as a consequence. Job absenteeism has also been reported due to violent acts.

Violence in the workplace is wide-spread

One survey of 7,000 emergency room nurses taken from January 2010 to January 2011 found that 53.4 percent of nurses reported experiencing verbal abuse and 12.9 percent reported experiencing physical violence over a seven-day period.

The study by the Emergency Nurses Association found that a patient’s room was the most dangerous place for an emergency nurse. In most cases when there was an assault, the study said nurses did not file a formal report, but did notify someone.

In another report released in 2011, The Bureau of Labor Statistics said that in 2009, there were 2,050 assaults and violent acts reported by RNs requiring an average of 4 days away from work. Of the 2,050 non-fatal assaults and violent acts, 1,830 were inflicted with injuries by patients or residents; 80 were inflicted by visitors or people other than patients; 520 RNs were hit, kicked, or beaten; 130 RNs were squeezed, pinched or scratched requiring days away from work; and 30 RNs were bitten.

There is no federal standard for workplace protection against violence for nurses, although a number of a number of states have laws that require establishment of a comprehensive prevention program for healthcare employers, as well as increased penalties for those convicted of an act of violence against a nurse.

Make violence against nurses a high priority

Six years ago,  the National Advisory Council on Nurse Education and Practice issued a report on violence in the nursing profession, and came up with a number of recommendations that are still relevant today, and need to be adopted at hospitals and  other institutions across the country.

These recommendations include the establishment of  clear standards for  workplace safety; institutional support for a culture of open communication and reporting among nursing staff, faculty, health care personnel and students regarding violence in the workplace; management training in the workplace; and the availability of clearly defined support resources, such as legal and psychological services, to nurses in violent situations, or at risk of facing violent situations.

It is time that the issue of workplace violence against nurses be given a higher priority, and that health care managers take steps to better protect nurses in the workplace.

More Information

• http://www.theamericannurse.org/index.php/2011/12/05/workplace-violence-against-emergency-nurses-remains-high/
• http://nursingworld.org/workplaceviolence
• http://www.hrsa.gov/advisorycommittees/bhpradvisory/nacnep/Reports/fifthreport.pdf

Rape Within the Ranks



Former Marine Officer Ariana Klay (right) addresses rape
in the military in The Invisible War.

The eye-opening documentary The Invisible War exposes an ugly truth: Rape by colleagues is an occupational hazard for women in our armed forces. Statistics in The Invisible War assert that military women serving in Iraq or Afghanistan are more likely to be raped by fellow military personnel than to be killed in the line of fire.

Sexual assault is the most under-reported crime in the nation, so the precise number of cases within military ranks is uncertain. A 2011 report from the U.S. Department of Defense itself estimates 19,000 cases in fiscal year 2010 alone.

And men are far from immune. According to the Department of Defense, the percentage of male victims of sexual assault within the military increased from 8 percent in FY 2010 to 13 percent in FY 2011.

Further, victims of rape within the military report facing disbelief and threats of retribution.

Rape and PTSD

Rape, like war, is a trigger for post-traumatic stress disorder. A precursor to the identification of PTSD in rape victims known as “rape trauma syndrome” was first articulated in 1974 by Penn Nursing Professor Emerita Dr. Ann Burgess and sociologist Lynda Lytle Holmstrom. Today, the term “military sexual trauma” describes what too many of our service women and service men are facing.

As nurses, we vowed to identify, treat, and conduct research on the specific health needs of our veterans and service members through Joining Forces, the national initiative launched by First Lady Michelle Obama and Dr. Jill Biden. Understanding and addressing the prevalence of rape perpetrated against members of our military by members of our military must be part of this mission.

What Nurses Can Do

I urge nurses to stress awareness of rape when caring for members of the armed forces and U.S. veterans. Nurses, who always have the opportunity to hear about patients’ lived experiences, are in the best position to uncover stories of trauma and stories of rape, even when their patients seem reluctant to reveal them.

We must intervene wherever and whenever we can through careful, sensitive health assessments, education, and research on military sexual trauma. It is a critical way for us to join forces with those harmed and betrayed during their service to our country.

When Sexual Violence Doesn’t Make Headlines

News of violence and injustice against women consumes the headlines every day. "Liberian women battle against ‘sex for grades’ at universities." "Delhi gang rape victim’s tragic death transforms her family’s life." Stories about ". . . the plague of violence against women."

Even amidst this steady stream of astonishing wrongs, I think about every woman and girl facing violence and injustice quietly and without notice. Too many remain invisible.

Global Health Starts With Women

This week, academic leaders from around the world are coming together for the 4th annual global health conference of the Consortium of Universities for Global Health. Nearly 1,400 members of the academic community (including some 500 students) from 751 institutions in 56 countries seek to identify a multi-sector, multi-disciplinary, interprofessional approach to improving global health.

An important aspect of the conversations is that any approach to global health must start with women and girls. Taking care of women is taking care of the family which is taking care of the community which is taking care of society.

In any dialogue about social welfare and development, there is global recognition of this centrality of women. The United Nations’ Millennium Development Goals aim to improve the lives of people around the world and ensure their basic human rights, particularly women’s issues, including poverty, education, maternal and infant mortality rates, and infections. The formation of UN Women and the appointment of Melanne Verveer as the U.S. ambassador for global women’s issues by President Barack Obama are indications of recognition of the vital role of healthy and educated women.

Progress and Need

But, as Ambassador Verveer wrote, “. . . we have indeed seen progress in protecting the human rights of women. . . . [but] there is no getting around the fact that progress is fragile in many places and barely measurable in others.”

Similarly, President Obama’s recent reauthorization of the Violence Against Women Act is an important marker both of our progress and of the continuing, deeply rooted need for attention to the health of women and girls.

As we come together this week, my partners in the Consortium of Universities for Global Health will:

• Consider novel ways to make academic institutions transforming forces in global health, expanding our moral commitment to translate knowledge

• Assemble best practices from different parts of the world. Universities are not just exporters of innovation, we are importers too.

• Share a united vision of global health, one of equity and justice, the elimination of violence, the courage to tackle world problems, and truly measurable impact.

Those are headlines I would like to see.

Now Is the Time

We are living in a world with guns. As much as I would like to change that, as would so many of us, I need to focus on what I can change – and what you and I as members of the largest group of healthcare professionals in the nation can change. I have committed to the following, and I urge you to do the same.

Encourage and conduct research on gun violence.

In a pivotal move to decrease gun violence, President Obama directed the Centers for Disease Control and other scientific agencies to research its causes and prevention. The President’s directive lifts a de facto 17-year ban on federal research on gun violence research. “We don’t benefit from ignorance,” he said in releasing his plan “Now Is the Time”. “We don’t benefit from not knowing the science of this epidemic of violence.”

Dr. Therese Richmond, our leading researcher on violence, and other prominent researchers at Penn are positioned to work across disciplines to systematically build a science on lowering injury and death from gun violence.

Science can help keep people safe from injury and death by providing data and evidence for policy changes. We have a tremendously effective model in motor vehicle safety. When we learned that people were dying in car accidents, we did not get rid of all cars. Instead, with data and research findings, policies to enhance the safety of cars were implemented and continue to save lives. If we accomplished that with car crashes, we can accomplish that with gun violence. And nursing research must be front and center.

Change perceptions about gun violence.

Gun violence is a health issue and central to what we in nursing should care about. What happened in Newtown, CT, was tragic, and so is the gun violence that kills children and adults every day in every U.S. state. And, it is a hard truth, but when the victims of violence are brown and black, our society doesn’t pay as much attention, yet gun violence is the leading cause of death of African Americans ages 15 to 24.

Gun violence kills Americans in mass shootings that grab hearts and headlines, and gun violence kills Americans one by one every day on street corners and in homes. Four million Americans have been injured by guns in the past 30 years and approximately 30,000 die every year from guns. We cannot view the Newtown school shooting as an isolated event, nor should mass shootings be the only impetus toward action. Gun violence is a daily occurrence in the U.S., as sure as the rising and setting of the sun.

Become familiar with the facts.

Since we are not all experts in this area, what should we know and do? As nurses, we all should be conversant about the facts related to gun violence. Dr. Richmond is research director of the Firearm and Injury Center (FICAP) at Penn. FICAP has developed the fact sheet “10 Things Every Healthcare Professional Should Know about Firearm Injury.” It is evidence-based and a must-read for us all.

As President Obama said, “While we may not be able to prevent every senseless act of violence in this country, if there’s even one thing that we can do to reduce it, if even one life can be saved, we’ve got an obligation to try.”

When it comes to this socially complex, polarizing problem, the worst we can do is nothing. Nursing as a profession and nurses as individuals are committed to health and well-being, therefore a focus on enhancing the safety of people and eliminating all forms of violence, including gun violence, is part of our mission. Now is the time.

We as nurses care for people, families, and communities who trust us. We should employ that trust and data and facts to educate and to change perceptions about injury due to gun violence. We should act by engaging in research programs to reduce injury and death from gun violence. We have the courage to act, the expertise to conduct research, and the compassion and caring to change the world.

Innovative Learning

Providing quality healthcare while maintaining or decreasing costs will depend on how technology is integrated in the fabric of the care given without losing the care and compassion needed for individualized care. This requires changes in educating nurses to embrace innovations in teaching and learning.

Therefore, I am proud to introduce the new Helene Fuld Pavilion for Innovative Learning, a unique educational center where technology meets the science of caring.

On the strategically renovated first floor of Fagin Hall, the Fuld Pavilion expands Penn Nursing’s simulation space to 7,000 square feet, equipped to best prepare students for evidence-based practices they will use as novice and expert nurses. The Fuld Pavilion features:

• Simulation rooms that are designed to reflect different care settings, including outpatient, hospital, and home care

• Interactive mannequins, diverse in age, gender, and race, and the capability for behavioral, live action, and high fidelity simulations

• Rooms outfitted with video systems to record students’ simulation experiences, maximizing opportunities for educational debriefing, evaluation, and reflection with faculty and fellow students

• The renovations include upgrades to the Brunner and general skills labs where students learn and practice nursing techniques in blood draws and patient monitoring.

These state-of-the-art learning tools integrate theory, research, and practice to build essential competencies in our nursing students. Simulations offer challenging but safe opportunities to review and assess the effectiveness of our students’ developing competencies, diagnostic abilities, and organizational and decision-making choices.

As the only undergraduate BSN program in the Ivy League, Penn Nursing leads the way as a model in nursing education. The high-tech, high-touch Fuld Pavilion shapes our students’ experience with the knowledge, the tools, and the best practices to influence care and policy around the world.