Clumpiness of Life

Astronomers have found that matter is not evenly distributed across the universe; it's a clumpy distribution. Hence we have galaxies.  I find this a very useful analogy of how human life unfolds: in clumps of business and events. I've been in one of those clumps for the past few weeks. Not oppressively dense, but dense enough to need to stay focused on timelines and deadlines and tasks.

One contributor to the clump was an invitation to return to RWJF in Princeton, NJ, to continue the discussion of the future of public health nursing. We were a small group and spent a full day of identifying barriers and possible solutions to improving and supporting the existing workforce. So, I prepared a little handout for the meeting and made the round trip in two days. I felt as though it was a good discussion and now we will wait and see what RWJF decides to do.

Another contributor the recent clump has been students wanting to meet about their MPH capstone paper. It's usually this time of year that those who want to graduate in May come asking for help. I think of this as a good thing. But, these meetings do fill up the calendar. Thankfully, those I have spoken with seem to be on task, on target and on time. To be honest, the capstone paper is the one activity in which I really work with the students, helping them pull all the content together into a package that will help them get a job.

A third contributor to the clumpiness is the revisions to my textbook. In July I forwarded all the chapters for the 3rd edition. Now, I am getting those files back with questions from the editor. Things like "this url is outdated" and "where does this table go".  Things that need attention to make the book as good as possible. But, these little things take time. There's no glossing over them.

The last clump contributor was the decision to write a grant proposal for a Dec 5 deadline. Although I am not the PI, the research team (more the proposal team) have swung into high gear.  These deadlines have a way of motivating, being a distraction, and generating some anxiety. I'll update the blog with how the project progresses.

Now, that the clump is thinning, a little, I can make my way back to the routine work of HCMR editorship, course instructor, research collaborator, and manuscript writer.  I guess the clumpiness analogy only goes so far; there's no vacuum in my life.

The mostly grey skies over Seattle didn't bother me; I was inside walking around the convention center and attending AcademyHealth sessions. AcademyHealth has grown over the years that I have been attending, and the science has become far more sophisticated and complex in keeping with the health services issues being addressed.

As usual, I made the rounds at the post sessions, scouting out potential manuscripts for the journal. I spent time with previous doctoral students, listening with some pride at their new career achievements. Naturally, networking and planning collaborations was a major activity. It's always difficult to know whether those conversations will prove fruitful. So, this year I am being more proactive than in the past and doing my part to follow-up and actualize the potential.

With the ever shorter time between the release of an RFP and the date due, we all must have a grant ready for minor changes. There is no longer time to generate something new. The shorter proposals are nice, but also harder, requiring a highly advanced skill in writing and explaining.

After AcademyHealth, I spend the morning in Longview WA for the KRISP Project. I did a session with the public health nurses on the PDCA cycle. After a year of bi-monthly meetings, the lights are going on. They began to generate a set of possible, very doable QI projects which would increase their efficiency. They actually sounded excited about the possibilities. After the session, we all went to lunch. It was reassuring to hear them say that they are no longer going merely because they were told to go to my sessions. For at least a moment or two, I felt like we were all nurses sharing the same passion for our communities and patients. It was good.

On the road, literally

Wow, the past month has whizzed past from spending hours on the freeway and days making Powerpoint presentations. For the KRISP Project (see the blog list for a link), I've been creating and then delivering weekly 2-3hour "trainings" for employees at two of the local health departments that are participating in the project. The amount of effort needed equals that for teaching a graduate course, but more intense in terms of the effort needed to meet the health department "where they are".

Our customer-focus and accommodating approach has resulted in weekly trips to deliver the trainings. The trip is 6 hours, round-trip, through two of the five Cook County collar counties, and then the cornfields of Illinois. There is no bus or train that goes were we need to be. So, I'm becoming familiar with where the highway patrol like to wait for the speeders.

We briefly covered doing community assessment via MAPP. Most of the effort has been on teaching the staff how to do quality improvement. When I wrote the grant, I had not imagined the amount of effort it would take to gain access to the public health nurses, nor did I imagine the need for so much face-to-face teaching time. I naively thought I'd just step and and things would get done. Not so. These are slow moving, if not well intending, organizations with lots of competition for their attention.

Over the past couple of weeks, overseeing and managing this project has again brought up the awareness of the timing as both a curse and a blessing.  On the cursed side, I wrote the grant before the economy went bad, before the H1N1 outbreak, before the states failed to make payments to the local health departments, and before the health departments had to lay off half of the staff. How, under those conditions, can I possibly make any difference in the empowerment and valuing of public health nurses? How can I possibly meet my grant objectives? Will all these trainings really translate into improvement in health?

On the bright side, the project has been a blessing. We are able to be a compassionate sounding board  and  give moral support to the nursing directors. We are able to validate that the nurses are important enough to receive this special attention. We have given hope to public health nurses throughout Washington state and rekindled their enthusiasm for who they are and what they do.  We have acknowledged the nurses as lifelong learners facing a strange new work landscape.  

In writing the non-competing grant renewal, I did realize that we have done a lot in the past year. Naturally, I tend to see the work ahead and the gas bills staying high. But, to be honest, there's a part of me too that's renewed and rekindled.

Living the C-Change

This week was a record for me: 5 flights in 50 hours, with two presentations, consultation, lunches and a little shopping at the Portland airport. The flights took me to Spokane and Vancouver, WA for the KRISP grant.

I flew to Seattle, met up with Betty. From there we flew to Spokane for the night. In the morning, we would do a 3 hour presentation-workshop with the public health nurses at the Spokane Regional Health Department. Betty and I got to the auditorium early. While we awaited our turn, the nursing director was giving staff an update on the state budget and possible scenarios for budget and program cuts. Then some of the nurses added changes (read decreases) to the TANF support for mothers.

Betty and I looked at each other, shook our heads, and sighed. These nurses will be the front line workers who see the consequences of our national economy doldrums.  This reality gives our work urgency, but also an irrelevance. We were there to help the public health nurses learn about using data to improve their programs and to think about populations, not just individual clients. Asking nurses to not get personal satisfaction from interactions with their clients is asking them to change their identity. A huge ask. But, that is all the more necessary given the changes occurring all through the public health system and the national economy.

In the afternoon, we spent a couple of hours with a small group talking about how to evaluate a creative, community-based and community-directed initiative. It was the type of discussion with no single correct answer and certainly no easy answer. In the end, I had flipped their outcome of "decrease child abuse" to the positive of "infants meet developmental milestones."  Why do we (evaluators, practitioners) seem so determined to focus on what we don't want? The group liked the change. It still requires head scratching to figure out how to get "good" data, but it has greater potential to generate enthusiasm and participation from the neighborhood.

The next day we did a 2 hour version of that presentation-workshop for the public health nurses of the Clark and Cowlitz health departments. Not nearly enough time, but far better than none.

During the lunches Betty and I had with the nursing directors, we talked openly and honestly. We talked about the future of health programs for various high risk groups, about the realities of union seniority systems and what that could mean for how programs would be implemented, about the need for more academe-practice collaboration for a wide variety of activities that would be good learning opportunities for nursing students, about the nature of the support from their health administrators, about how local politics of an interpersonal nature affects major health department decisions, and about the way things used to be but never will be again.

As Betty and I said good-bye at SeaTac, we agreed that it had been a good two days. Not perfect, but on balance, good. We both felt committed to doing our parts in moving this segment of the public health system forward, going boldly into a future that has only been outlined. It remains our collective responsibility to give that outline life, texture, success, doing so collaboratively and with a hint of utopian longing.

Roller Skate Week

Looking forward to a week is always different than looking back on it. Nonetheless, the week from December 9 through December 17 was what I call a "roller skates" week. Skating, which is slightly faster than running and takes less effort, from task to task, from location to location, from meeting to meeting.

The highlight of December 10 was the little holiday party we had for the KRISP project. We managed to have about an hour of sweets, small present exchange, and photo ops. (see the KRISP blog for the group photo)  It was also a day of problem solving with a couple of my MPH advisees. A mix of paperwork, encouragement and a little hand holding. All in all, a busy, productive, fun, smiling day.

Monday and Tuesday (December 13 and 14) were more unique. For the past month, I served as chair for a search committee to hire a new faculty into our department. After vetting a few applications, we invited the two best candidates to visit with us. The daylong process involves interviews, a presentation, and informal lunch in the commons area. Making the process public and inclusive made the faculty feel as though this was a real opportunity to hire a junior faculty. This may seem obvious, but in these economically bad times in Illinois, hiring a faculty feels like an sweet treat. The foresight and planning of our department chairperson made this hire possible. Each day with the candidate went smoothly. My own preference for one of the candidates was aligned with the consensus of the search committee and faculty who met the candidates.

Right after the last of the meetings with the candidate, I hopped in the car and drove 3 hours to Peoria. I needed to do this because on Wednesday morning Kathy and I were doing a training session with the public health nurses at Tazewell County. I arrived at Kathy's house as she was finishing baking the goodies for the morning meeting. The feds prohibit any purchase of food, so the treats of baked good and fresh fruit will come out of our personal pockets. (I understand the the restriction, but really...)  The public health nurses seemed engaged and ready to have us come back next month.  As soon as that meeting was finished, I had to drive back to Chicago and attend to the candidate selection.

I spent Thursday and Friday in the office working on KRISP budget, trainings and meetings. Whew....

PHN Conference

Friday before the conference, we collated handouts, verified that we had the flip chart paper, and double checked the supplies box. Then we loaded those boxes into my car. On Monday morning, we gathered at the hotel and began to sort out what would go where. I felt calm, ready, confident that I had done the best that I could to make the conference a success.

As old friends arrived, I greeted them with warm hugs. As new friends arrived, I extended my hand in a jesture of welcome. Both of my Deans (School of Public Health and College of Nursing) were there to extend their welcomes to the audience. The audience of 50 invitted speakers and participants came mostly from nursing, but also from public health and from economics. Yes, there was a lot of grey hair, but we also had doctoral students participating.

Monday afternoon included an overview by Kris Gebbie of why the conference was important. Pam Mitchell give a nice history of the development of nursing sensitive indicators for acute care. The panel pattern was to address theory, methods and practice issues. We then broke into small groups for discussions. This pattern was repeated on Tuesday morning and early afternoon. On Wednesday, with the guidance of the facilitator, we generated a draft list of reserach themes for public health nursing.

I count the success as having several individuals volunteer to take actions after the conference.The other marker of a success was the several thank you emails that I received afterwards.  Yes, we will present the draft findings at APHA, and yes, we will be writing manuscripts. But, the energy and enthusiasm generated was definitely the most important. 

For those interested in the conference, I have created the PHN page at this blog. We can use it to continue the conversation.

Disaster in Progress

It's mind boggling. The Illinois state budget deficit even warranted an article in the Wall Street Journal. The economics aside, my concern naturally is for the health of the people of the state. In my work with the local health departments, they are saying that county budgets have been hard hit because the state has not paid for services rendered. No one feels confident that the state will pay its bills, for services given in the past fiscal year, not to mention the current fiscal year.

From the point of view of public health, it feels like an economic disaster for which no preparedness training could help. Many county governments are making some really deep cuts into programs and services most of us have taken for granted for decades. The state funds support mostly health promotion programs and screenings for early detection and prevention. In contrast, federal dollars generally support direct clinical services, like primary care. At least in Illinois, most local health departments have gotten out of the business of providing primary care. Instead, they focus on the health promotion, disease prevention for which reimbursement does not exist.

As the programs are cut because there is no money to pay staff to do the programs, questions arise. What will happen to the health statistics for conditions like sexually transmitted diseases (STDs), breast and cervical cancer, and child abuse? How will health departments reconfigure and reconceptualize themselves in this new economic landscape? What new or old skills are needed by the remaining workforce to actualize this new reality?

I don't worry about those few organizations that are trendsetters, enlightened, prospectors (in the language of Miles and Snow) that can turn this crisis into an opportunity. But, not all organizations have that ability. Those that can't survive or adapt or morph, what will happen to the health of the people they once served?

Days Gone By

Tuesday and Wednesday were uneventful, with one exception. I got the last of the speakers for the AHRQ conference. Relief! Now I can turn to doing KRISP work on Friday and maybe manuscript writing on Saturday.

And, that little email I sent to the listseve yesterday did indeed generate lots of discussion and posts. I found it fascinating how differently individuals read the original email and chose differnt foci. The emotions were present in all of the emails. Public health nurses feeling slighted, ignored by the nursing profession, expressing profound uncertainties aobut their collective futures, and more than a hint of anger.

I came to realize some time ago that anger is a peculiar emotion. It often serves to energize in the face of overwhelming odds. And, that's what I saw as thread in the posts. Angry public health nurses, struggling to find validation for who they are professionally and for what they do. Unfortunately, although anger can energize, that energy does not allows get manifesed in ways that are benficial, that are PC or that challenge rationales.

Nonetheless, I'm glad that I stirred the pot and urged the group to take unifed action. We need the leaders to step up and be leaders. We need leaders to be visible, like generals before a war. We, public health nurses need this. The urgency and the timing is now. If we miss this moment in history, we only have ourselves to blame.