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For years, the unpartnered paradigm ruled in health care, says Marla Salmon, dean of the Nell Hodgson Woodruff School of Nursing. Working well together meant honoring well-defined roles. Research questions were framed according to the questioner's discipline. Any effort to blur territorial lines set off burglar alarms.
     With so little value placed on collaboration, each rising generation of clinicians, scientists, and policymakers was seldom taught how to negotiate, navigate, nurture, or evaluate partnerships. After all, there was plenty to do within each discipline. Who needed the hassles of those different professional languages, cultures, and politics across campus, town, or globe?
     Today, Salmon can't think of a single major health challenge that could be solved without people moving beyond their own boundaries and working together in ways that don't have the structure, predictability, and comfortable familiarity of self-contained disciplines, institutions, or traditions. That kind of interdisciplinary, interinstitutional thinking—a new
"partnered paradigm" in Salmon's words—is central to the School of Nursing's own strategic plan, the Woodruff Health Sciences Center's strategic plan to transform health and healing, and the cross-cutting themes of the University's road map for the future.
For Salmon herself, the concept of partnership was instilled in her as she grew up watching her physician father and nurse mother working together in their rural general medical practice at a time when the relationship between both professions was under-rated, misunderstood, and definitely underoptimized.
Today, the School of Nursing is viewed within and beyond Emory as a leader in collaboration. More and more faculty members hold secondary appointments in other schools. Nursing and medical students train side by side in real-time patient simulations, enhancing future clinical practice. Academic partnerships include a course on designing the ideal patient care environment, the first step in what Salmon hopes will eventually be a joint degree program with the Georgia Institute of Technology. Also planned are collaborative programs with Emory's Candler School of Theology that will broaden students' perspectives on quality of life for terminally ill patients. These are in addition to the interdisciplinary offerings already in place. Still other opportunities abound.
Crossing the health care divide
As emergency rooms careen toward the breaking point, with jammed waiting rooms and frequent diversion of ambulances, a handful of nursing schools are training emergency nurse practitioners (ENPs) to help meet this growing challenge. By the end of 2006, 21 ENPs graduated from a new degree program at Emory; another two dozen are enrolled in the tough four-semester program.
     One of many collaborations between Emory's nursing and medical schools, the ENP program is directed by nursing instructor Michelle Mott and Dr. Katherine Heilpern, associate professor of emergency medicine. In addition to many classes (all students complete the family nurse practitioner program as a base), students spend almost 800 hours paired with emergency medicine physicians and nurse practitioners in emergency rooms at Grady Memorial Hospital, Emory Crawford Long Hospital (ECLH), Gwinnett Health System, DeKalb Medical Center, and other participating institutions.
     The adrenalin rush of emergency care is not new to most ENP students, with many already experienced in emergency room, intensive care, and acute care situations. They study triage— evaluating and sorting patients into nonurgent, semiurgent, and urgent cases. They learn to
stabilize and manage emergency patients, whether medical (heart attack, diabetic ketoacidosis, pulmonary embolism) or trauma (car accident, gunshot wound, injury), and to manage the ever-higher number of patients who use the emergency room for primary care needs.
     Having ENPs in the emergency rooms helps streamline patient flow—with fewer waiting for hours in crowded hallways—and improve hospital efficiency. Seeing what these ENP students are learning has given physicians and hospitals increased appreciation for what nurses can offer, says Mott. In fact, preceptors hire many of their students almost immediately. Other students have moved to rural areas in Georgia, with one on the way to Alaska, where their training allows them to stabilize patients far away from quick emergency room care.

     Only three years old, the ENP program is already evolving, with collaborations involving the Georgia Poison Center, more emphasis on pediatrics and geriatrics, and increased preparedness for avian flu, bioterrorism, and other wide-scale threats. Every new component means more partnerships across the health care continuum and better care for those who need it most quickly.
     At the other end of the health care spectrum—keeping chronic diseases on an even keel—Emory nursing instructor Kathy Matthews collaborated with Dr. Richard Gitomer, clinical chief of general internal medicine for The Emory Clinic, to create a new model of care. Funded by the Robert Wood Johnson Foundation, the pilot project focuses on diabetes, which now affects 7% of the U.S. population and continues to rise.
     Currently, says Matthews, patients with diabetes often navigate a maze of physicians, perhaps one to manage blood glucose, another to deal with the hypertension and hyperlipidemia that often accompany diabetes, and still others to work with risks of complications in the heart, kidneys, nervous system, eyes, and feet. What sometimes gets lost in the journey is a focus on patients' roles and responsibilities and what they need to manage their own disease.
     The model that Matthews and Gitomer use places patients at the center of a wheel; the spokes are the health care providers needed in the individual patient's care, from dietician to subspecialist. Electronic medical records enhance team members' ability to monitor and participate in the patient's care, stepping in as their expertise is needed. For patients to fully benefit from this expertise, however, they must understand the underlying disease process and how behaviors affect health. Patients must know, for example, how to check and care for their feet and when they need a neurologic exam. Nurses' expertise fits especially well with this new model—not just providing essential health-related information but also helping patients figure out how to use information, develop strong coping skills, and become more involved in setting, monitoring, and working to control disease-related goals.
     This nonhierarchical model capitalizes on the strengths of all team members, allowing them to do what they do best and enhancing their partnership, says Matthews. Patients quickly recognize they gain an important perspective from the nurses who help them remain at the center of their own health management.
Across the sciences and beyond
Interdisciplinary" is definitely part of Dr. Sue Donaldson's new title at Emory and the mantra for her lifelong mission in nursing. Donaldson is the first Distinguished Professor of Nursing and Interdisciplinary Science, a position created last year within the School of Nursing and the Woodruff Health Sciences Center to advance interdisciplinary training and research opportunities in the basic sciences.
     Many such partnerships between the medical and nursing schools already exist in clinical areas. Donaldson's charge is to transform nursing's engagement in science.
     The time is right, and Donaldson is the right person, says Salmon. Donaldson is a member of the prestigious Institute of Medicine, a fellow of the American Academy of Nursing, and former dean of the Johns Hopkins School of Nursing, where she created the research infrastructure in their school. "Sue's commitment to head our new program to transform nursing's engagement in science has added greatly to the national ‘buzz' about what is happening here at Emory," says Salmon.
     Bringing nursing and basic science together comes naturally to Donaldson. A master's-prepared nurse with a PhD in physiology and biophysics, she has held joint appointments in physiology and nursing throughout her career, while working within nursing education to set up doctoral programs in nursing. Her new laboratory in the Whitehead Biomedical Research Building focuses on the cellular and molecular mechanisms of muscle contraction, work that includes studies of muscle atrophy after stroke, with aging, and in children with muscular dystrophy, and other studies of muscle restoration with exercise.
     Donaldson already feels at home. Her new office even looks like her last one, pictured in a framed photograph over her desk. Emory's School of Nursing building is modeled after the one Donaldson argued for and oversaw being built while dean of nursing at Hopkins. After a site visit to Baltimore by Salmon and other administrators, Emory hired the same architect. "I feel I've drawn another line between these two great institutions," says Donaldson.
     Another part of her right-at-home feeling may be working once more with Emory Vice President for Health Affairs Michael Johns, former dean of medicine at Hopkins, and with longstanding research colleagues among Emory's senior physiologists and Georgia Tech's bioengineers and other scientists. But the main reason she is certain she came to the right place, says Donaldson, is how the School of Nursing supports what she most values: the exciting possibilities of interdisciplinary work.
     The first step for Donaldson is to consult with Dr. Kenneth Hepburn, associate dean for research, and Dr. Marsha Lewis, associate dean for education, to create new options in the nursing school's PhD and postdoctoral programs, both already structured to be interdisciplinary. Because nursing's perspective of health is broad, focusing on quality of life and experience even when a person is very ill or dying, research opportunities are equally broad, and Donaldson plans to use the resources of the entire Emory campus and those of research partners like Georgia Tech. The new and highly interdisciplinary Predictive Health Initiative with Emory and Georgia Tech was a particular draw. It is the perfect framework, she says, for expanding nursing research in conjunction with medicine, public health, and other disciplines.
     "Nursing research has made major advances in recent years, with many findings now used as a basis for research in other disciplines," she says. "The next frontier for nursing—what we are going to do here at Emory—is to immerse ourselves in work with basic scientists. The research that results may not look like nursing per se, but it will be imbued with the nursing perspective of improving health and quality of life across the entire human experience."
A seat at the table
Partnership undoubtedly begins at home. Michael Johns, CEO of the Woodruff Health Sciences Center, regularly holds court at a long conference table, surrounded by academic deans and directors, chief officers of Emory Healthcare components, and other health sciences administrators. The purpose of these regular leadership meetings, in his words, "is to share responsibility for the whole with those who have responsibility for parts of the whole."
     It is critical, he says, that the School of Nursing have an equal seat at that table. "Marla Salmon represents nursing's unique perspective extraordinarily well; she's a force and sometimes also our conscience."
     For example, while the leadership team was planning the new hospital to be built on campus in the next decade, Salmon kept asking how to incorporate the community into the facility. As a result, the hospital is being designed as a place where people can come to learn more about their health, become more involved in care for themselves and their families, or simply enjoy healthy foods in a pleasant restaurant.
     Whether the subject is improving safety and quality of care, focusing on research to change treatment and delivery of care or, better yet, prevent disease and disability from ever occurring, nursing keeps the perspective on the total patient in a way that enhances what we all do, says Johns. "Our partnerships with each other make us better partners with our patients, colleagues, and the communities we serve."

Connections across the water
Most visitors to the Caribbean see white beaches and friendly people. Faculty and students in the School of Nursing also see a worsening nursing shortage, as epidemics and faltering economics challenge fragile health care systems worldwide.
     The British Virgin Islands (BVI) to the east of Puerto Rico illustrate both the nursing shortage and how School of Nursing partnerships with the region's nursing leaders are helping turn that problem around. With a population of only 25,800 people, the BVI has no nursing school. Most islanders who decide to be nurses or broaden their nursing education travel to the United States. For every 10 who arrive, however, only two or three can resist the siren call of higher pay, easier working conditions, and more advanced technology here. The Caribbean nursing shortage now averages 35%.
One nurse who proudly returned home is Bernet Scatliffe, 04MSN, a graduate of the health care leadership program and the chief nursing officer for the BVI. Scatliffe says the power of the partnership between the School of Nursing and Caribbean nations lies in its vision, practicality, and networking strengths.

     Networking takes place at the highest level. Senior government health leaders from across the world gathered in Atlanta this fall for the third global forum hosted by the Lillian Carter Center for International Nursing. The inaugural forum, held in 2001, marked the first time many chief nursing officers had come together to look for common ground to address problems back home. The 2004 forum achieved another milestone by bringing chief nursing officers and chief medical officers together for the first time. The 2006 forum, hosted by Salmon and Dr. Jeffrey Koplan, Emory's vice president for academic health affairs and former director of the CDC, provided top-level government nursing and medical leaders with new knowledge and insight to address the shortage of nurses and other health workers.
     Networking also takes place nurse-to-nurse, says Scatliffe. Community health nurse Noelene Clarke returned from the nursing school's summer teaching institute "with eyes opened to what nurses can do, given training and opportunity. She's ready to help change what we do here, and she knows she has partners in the School of Nursing who will help her." Scatliffe herself calls for advice and encouragement from nurses she met during her Emory experience.
     Of course networking works both ways. While studying at Emory, Scatliffe helped organize the visit of a dozen School of Nursing students, and their faculty supervisors, to conduct a comprehensive screening of BVI children in secondary school. Considering nursing resources in the country, the health ministry had expected the project to take months. With help from Emory nursing faculty and students, the project took a week. Nursing students gained a firsthand appreciation of the impact of the nursing shortage on smaller islands and the creative ways nursing can be practiced with limited resources. Scatliffe foresees other projects, such as pap smear clinics, that could be completed in a short period of time.
For love of community
The average life expectancy in Atlanta is 78. If you are homeless, it is 42. That disparity, the disproportionate amount of poorly managed chronic disease, and a sense of abandonment and despair among the homeless makes them a natural focus for the School of Nursing's mission of social responsibility. For years, nursing faculty and students have worked in shelters and through social agencies such as Café 458. The new Gateway Center in downtown Atlanta makes possible longer-term involvement and service learning for students.
     The school is one of 50 formal partners in the Gateway Center, the centerpiece of the Regional Commission on Homelessness' effort to reduce chronic homelessness, designed as a "gateway" to connect the homeless with community services to help them move toward self-sufficiency.
     Under the direction of nursing instructor Monica Donohue, community health nursing students complete a five-week clinical rotation at Gateway, providing much-needed services, such as foot care or blood pressure screenings, for the hundreds of homeless clients who pass through the center. Students also care for patients recently discharged from acute hospital settings who arrive at Gateway's 23-bed respite facility. But the keystone of the students' rotation is a requirement to develop and deliver a project to benefit clients. This past year, a team of students designed a health education program around the complex, ever-shifting situation of homelessness.
     "This really challenged our students," says Donohue. "They were able to create a street-workable program only after they turned to the clients themselves and got a clear picture of what their lives were like and how they thought they could fit hygiene, nutrition, even appropriate exercise, into their lives on the streets and in shelters. That partnership with clients was an invaluable lesson."

Sylvia Wrobel is former associate vice president for health sciences communications and a frequent contributor to Emory's health sciences publications.
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