Do Nurses Eat Their Young? What’s Wrong With Communication in Health Care?

The Workplace Bullying Institute defines Workplace Bullying as repeated, health-harming mistreatment of one or more persons (the targets) by one or more perpetrators that takes one or more of the following forms:

  • Verbal abuse
  • Offensive conduct/behaviors (including nonverbal) which are threatening, humiliating, or intimidating
  • Work interference — sabotage — which prevents work from getting done

040811_020 retouchedRenee Thompson, MSN, RN, CMSRN, nurse, author, educator and advocate for workplace change, is making it her mission to bring nurse bullying  to light.  In her question “Do nurses eat their young?” she shocks us into awareness of nurse bullying.  “I’ll do whatever it takes,” she asserts. “Enough of us who believe in kindness, support and nurturing each other can do it!  New nurses (and the rest of us) deserve to work in nurturing supportive environments…Bullying has no place in a profession dedicated to caring and compassion.”

So what is wrong with interpersonal and organizational communication in the health care setting? Bullying.  Why is bullying happening?  One theory suggests that since nurses are not valued in the workplace they feel powerlessness.  This results in bullying behavior.  Another points to nursing as a predominantly female profession with a forced hierarchy.  In this model, the cause of bullying lies in female competition for prized males.

Despite these notions, or perhaps because of them, Ms. Thompson speculates that medical and nursing school education may start the process. “Doctors and nurses learn separately, then are forced to work together without training. We wouldn’t do that with an All-Star basketball team,” Thompson says.  “Respectful communication is a skill that can be learned and it is just as important as clinical knowledge.”

Yet it is missing from the beginning.  “Nurse sand doctors don’t learn how to communicate respectfully with each other. Student nurses are not even allowed to speak to doctors when they are learning.”  It makes sense.  “When members of a team learn together, they learn to respect roles and work together.. all working towards the same goal…patient care.”

Research literature describes  nurses “as an occupational group, at considerable risk of violence-related workplace trauma” and recounts experiences of “harassment, bullying, intimidation and assault.”(1)

In her own research for her book, which Ms. Thompson conducted while developing student and new nurse residency programs, she heard horrific stories. In her research she encountered recurring themes. “Students and new nurses are the most vulnerable, but any time you change positions, you are at risk. We are still trying to sabotage, especially when the female is younger, thinner, more beautiful and smarter. While nurses are caring to patients, they can be horrific to each other.”

NursingA study of bullying published in Journal of Professional Nursing in 2009 reveals which departments  in hospitals were most likely to have bullying incidents and who were the perpetrators.  The medical-surgical and critical care units had the highest frequency of incidents at 23 and 18 % respectively.  Bullying incidents occurred within nurses’ first 5 years of employment.  Senior nurses were the highest percentage of perpetrators at 24% followed by charge nurses, nurse managers and physicians (8%).   This research confirms Ms. Thompson’s observations.  “Nurses know we eat our young.  Some nurses think it’s good to “toughen up” the new nurses. In reality it’s not. It decreases confidence and competence. “

In fact it seems to be a vicious cycle.  Those who are bullied lose their confidence and are more likely to be targeted.  Ms. Thompson identifies passive communication styles, like “frequent apologizing, avoiding conflict by keeping quiet, giving others priority” as characteristics of victims.  Other characteristics included being of a different gender, race, or from a different location.

Ms. Thompson has witnessed workplace bullying in the nursing profession.  The behaviors range from“overt-screaming, yelling and openly criticizing in front of others to covert-sabotage, backstabbing and undermining.” Bullying can be as simple as “being nice to your face, but then complaining about you to other nurses all night” or as complicated as “gathering a “posse” against you.”


A 2006 article in Nurse Inquiry suggests that there may be hidden processes at work causing nurse-to-nurse bullying.  The authors propose that health care organizations may actually be maintaining the status quo, recruiting nurses who support a top-down hierarchical structure.  Ms. Thompson uses an Italian saying “the fish rots from the head,” to describe her understanding of what is happening. She believes that many organizations rely too heavily on policy to solve bullying.  Without a robust program, zero tolerance policies don’t work. “Policies don’t solve problems – people do,” she notes.

Bullying can impact patient care.  “Organizations with a high rate of bullying have worse patient outcomes.** Many studies demonstrate bullying prevents nurses from asking for help and calling docs at nursing_02.sized3am,”  Thompson observes.   “I  know some nurses who feel they can’t rely on co-workers if they need help for patient.” Nurses who are bullied suffer physical, emotional and mental distress which is disabling, impacting their ability to effectively care for patients.  “Bullying is pervasive, destructive and nurses are suffering all over the world. I know because they call me!”

Patients are becoming aware of nurse bullying. They are asking questions about it. “They’re on to us! “ she says.  And Ms. Thompson is glad. “Awareness is vital to change. The first step for organizations is awareness. You have to know how bad it is first before you can take action.  We get numb to bad behavior, accepting it as normal. Too often we believe what the bully tells us.”

The most powerful intervention to stop bullying, she notes, is for witnesses of bullying to speak up. “We need to teach people how to establish peer-to-peer accountability.  A simple way is to just starting naming behavior. ‘You are screaming and yelling at me in front of others.’” Thompson proposes “skill development for managers and strong human resources partnerships.”.

StopBullying It sounds a lot like personal courage is key.  “What you ignore – you condone. It doesn’t matter if the aggression is aimed at you or someone else… Set behavioral expectations. You can’t assume everyone knows what respectful behavior looks like. So spell it out….[It’s true] confronting might not work. But not confronting NEVER works. We have to try.”  In speaking up, Renee Thompson has decided to do just that!

For a detailed discussion of this topic, see the transcript of the #hchlitss twitter chat that this summary is based on.

Several chat participants requested seminar information from Renee.  Please visit Renee’s seminar information page at http://rtconnections.com/events-2/bullyproofing-communication/ to learn more about her upcoming seminars in:

  • Irvine, CA: February 7th and 8th
  • Orlando, Fl: March 14th and 15th
  • Raleigh, NC: April 24th and 25th
  • Atlantic City, NJ: May 22nd and 23rd

If you are interested in reading Renee’s book, Do No Harm both the hard copy and the Amazon kindle version can be accessed at http://rtconnections.com/products/book/

1) Vessey, J., DeMarco, R., Gaffney, D., Budin, W. (2009) Bullying of Staff Registered Nurses in the Workplace: A Preliminary Study for Developing Personal and Organizational Strategies for the Transformation of Hostile to Healthy Workplace Environments Journal of Professional Nursing, 25, (5) , 299-306.

2)Hutchinson, M. Vickers, M. Jackson, D. Wilkes, L. (2006).Workplace bullying in nursing: towards a more critical organisational perspective.  Nursing Inquiry 13,( 2),  118–126.

**Aleccia, J. (2008).  Hospital bullies take a toll on patient safety.  http://www.msnbc.msn.com/id/25594124/ns/health-health_care/t/hospital-bullies-take-toll-patient-safety/#

http://www.workplacebullying.org/individuals/problem/definition/

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Giving Back One Telemedicine Backpack at a Time

During a disaster, infrastructure, like electricity, water, roads and communication, may be damaged or destroyed.   Large crowds of people are in critical need. “Help can’t get to them and they can’t get to help,” Randy Roberson found. The social infrastructure is surely overwhelmed and chaotic without any command and control.  Medical care, which is desperately needed, may not be able to get to those in need.  Imagine yourself  in such a  bleak situation, overwhelmed,  with desperate or injured mothers, children, elderly, and you have nothing to offer them.

Over the past 15 years, Roberson has entered turmoil and tried to find solutions.  Using technology, Roberson has created two innovations that are making a difference.  The “Doc-in-a-Box” and the “Bring-Em-Back-Pack” uses telemedicine and solar or wind power to bring the expertise of physicians living outside the disaster zone to relief workers treating the injured.   Since 2004, telemedicine has been rendering medical aid to disaster victims in India, Thailand, Africa and the US.

Roberson was motivated by need.  There has been “a repeatedly documented need for a medical clinic that was clean, well equipped and brought in via land, sea or air,” he remembers.  Creating the clinic included assuring that it was securable and tough enough to withstand aftershocks and rough terrain.

Roberson didn’t start out doing relief work.   He was a broadcast journalist who had a life changing interview with Dr. Larry Ward, founder of Food for the Hungry, an international relief and development organization.  “The interview really rocked my understanding of many things and made me want to know more,” says Roberson.  Subsequently Roberson quit his job and began an eight year mentorship with Dr. Ward, learning how to perform needs assessments and how to move in chaotic environments.

Yet even with this mentorship, Roberson felt he needed more.  “The first hours and days after major events are when large crowds are in critical need…People would be crying out to me for help but I wasn’t a medical professional,” Roberson explains.  “But I did know satellite communications and have always been a tech nerd.”  By the 2004 tsumani that hit Indonesia, Roberson and Dr. Alan Michels had created a telemedicine clinic.  “He (Dr. Michels) would look over my shoulder from 8000 miles… He guided me with ‘Do this-try that-put pressure here’ sort of fashion.  I placed a digital stethoscope on a patient in anIndia relief camp in and on other side of world he could hear the beat.”

Roberson is clear that in the future deployments of the mobile medical clinic, they will be staffed with former special forces corpsman. “These corpsman also know what it is like to work in chaos when you run out of bandages and use t-shirts instead,” Roberson assures.  With that kind of experience they are ready for anything.

 The clinic idea has grown to include a “complete containerized field hospital with all medical, housing, food, water and sanitation needs,”says Roberson.  The backpack was created for versatility.  They provide first response before the clinics are delivered. With it, relief workers can preform needs assessments and  “mass triage and transport operations and even day -to -day operations of humanitarian relief,” Roberson explains.  Patient assessments and electronic medical records can be started in the field and the patient information gets to the field or ship hospital prior to the patient’s arrival there.

Using solar power and wind is truly forward thinking, “In almost every major disaster event power is out and communications are down.  In many instances it takes weeks to restore those (in some countries months). To sustain operations we focus on solar, wind and fuel cell technologies to remain functional when completely off power and telecommunications.  We can then quickly switch back to cellular and standard power when it’s reliable again,” Roberson explains.

When relief workers come into a disaster area, they are always forced to make critical decisions based on a lack of real time information.  The “Bring-Em-Back-Pack” provides information through its rapidly deployable live audio, video and other data streams.  Saving lives and reducing suffering are the two greatest initial needs of a disaster situation and they are the focus of

this mobile telemedicine project. With it,  the same tool is used to move the situation through the 4 stages of incident response: rescue, recovery relief and redevelopment.

One of the most important features of this technology is its ability to keep people engaged after the media stops reporting about a disaster. “We also use to reach back to the world through social media and board rooms of corporate sponsors and foundations.  [It] keeps people engaged after the media stops reporting (all too quick) and it provides amazing accountability and transparency which is greatly lacking in humanitarian relief worldwide,” Roberson believes.

Creating these aids has been an act of love for Roberson.  [I’ve] “mostly paid out of pocket, [and am] working on now attracting partners.  Some support [has come] from friends. It drains pockets quickly, Roberson states.  Roberson and his colleague have created a for-profit arm  of his organization to bring these technologies to market and thus fund the not-for-profit Disaster Logistics Relief  that has been established.  To learn more please contact Randy Roberson at rroberson@disasterlogistics.org .

Are Patient Communities an Effective Way to Deliver Care?

Are Patient Communities an Effective Way to Deliver Care?

Dr. Andrew Watson
Dr. Jeffrey Benabio

That was the question debated at the 2012 Connected Health Symposium on October 25.  Two physicians, Dr. Andrew Watson, Surgeon and Medical Director for the Center for Connected Health and Dr. Jeffrey Benabio, Physician Director of Innovation with Kaiser Permanente faced off on this topic.  Alexandra Drane, Founder of Eliza Corporation, moderated the event.

Dr Watson presented the argument in favor of patient communities.  Noting the Institute of Medicine’s figures that $750 to $900 billion are wasted by traditional healthcare in the US, Watson feels that the face-to-face system of care needs to evolve.  With so many US patients already online, online communities are a vehicle to reach people over distance and time and the medical community has an obligation to help organize this, he said.

Dr. Benabio began with a quote from another physician “Patients running online communities are like animals running the zoo.”  Although he felt this comment both shocking and insulting, he felt that it expressed the depth of his worry.   He also voiced concern about who sponsors online communities, especially pharmaceutical companies.

After these preliminary comments each debater worked to refute the other’s points.  Dr. Watson asked Dr. Benabio for the research proving that  patient communities cause harm.  He also refuted Benabio’s assertion that all communities are sponsored.  Dr. Watson believes that patients are waiting for physicians to engage.

Dr. Benabio continued providing examples he found on the Internet  to disprove the appropriateness of patient sharing.  For example, he stated that on one site a patient stated that he had a flu vaccine, followed by a seizure.  The patient said he never gets a flu vaccine because of this experience.  Several people “liked” the comment.  Dr. Benabio believed this statement would stop people from getting the flu vaccine.

The debate continued along the same vein.

Perhaps there was a flaw in the question that was asked.  Are patient online communities really about providing care?  Or are they doing something else.  The debate  illustrates the division  among physicians and other healthcare providers concerning patient communities.  However, in the end, patients are moving forward, reaching out to each other to exchange information, support and experience.  Ignoring online communities, standing back and watching, claiming that time spent online is wasted: these are unproductive attitudes. Getting involved with online communities will not only inform patients, it will also inform healthcare providers.  Communications is key and online patient communities are not going away.

What do you think?

After taking the survey please share your thoughts in the comments.  Thank you.

Alone Together: Sherry Turkle

On “Wait, Wait Don’t Tell Me” Paula Poundstone describes her view of the neighborhood playground.

Wait, Wait, Don’t Tell Me Radio Show October 6, 2012

Transcript

Right now, panel, time for you to answer some questions about this week’s news. Maz, according to a study by the Wall Street Journal, a rise in the number of minor injuries to children might be caused by what?

MAZ JOBRANI: It’s not computer related.

SAGAL: It is, actually.

JOBRANI: Oh, the parents are not paying attention.

SAGAL: Because they are?

JOBRANI: They’re driving while being on the phone. Texting while…

SAGAL: They’re texting while parenting.

JOBRANI: Yeah.

(SOUNDBITE OF BELL)

SAGAL: This is a problem now.

PAULA POUNDSTONE: Does no one see it? Do you not see it right in front of your eyes? I don’t understand this stupid thing with the phones and the iPad and all that stuff. I don’t get it.

(APPLAUSE)

POUNDSTONE: It’s right in front of us and we don’t see it. You know what I mean? I mean, we live right near a park, and I watch people all day long, go by the park, doing this here, or talking on their phone. You know, while the kid is like hanging out of the carriage.

(LAUGHTER)

AMY DICKINSON: My mother, anyway, never paid any attention to me and she didn’t even have an excuse.

(LAUGHTER)

SAGAL: Yeah.

DICKINSON: It was like…

JOBRANI: Well if you get the kids an iPhone, you could text each other at least.

SAGAL: That’s true.

(LAUGHTER)

SAGAL: It’s like, “Mommy, I fell down a well.” Be right with you.

(LAUGHTER)

SAGAL: I mean parents who are too busy with their phones you’re not missing much. It’s like, “Yeah, I saw my baby’s third step. You know, it looked pretty much like the first.”

(LAUGHTER)

POUNDSTONE: And then the other thing is they have to take pictures of it and put it up. I don’t like that either. I’m sick of seeing the happy people’s children on the Facebook. I’m just sick of it.

(LAUGHTER)

(APPLAUSE)

SAGAL: It shouldn’t be surprising though, a lot of the parents who were texting while parenting were texting while conceiving as well, so…

(LAUGHTER)

(SOUNDBITE OF MUSIC)


Even though everyone is laughing, there is something important going on.  According to Sherry Turkle, Poundstone’s observations aren’t unusual.  Turkle, Professor of Social Studies of Science and Technology in MIT’s Program in Science, Technology, and Society and founder and director of the MIT Initiative on Technology and Self,  has been studying how technology changes minds and hearts for many years.

Dr. Turkle was one of the keynote speakers at the 2012 Connected Health Symposium October 25 and 26 in Boston.

Turkle started her presentation with a quote by Winston Churchill, “We make buildings and then our buildings make and shape us.”  She thinks it may be the same with mobile phones, mobile technologies and computers.

Based on 15 years of research and hundreds of interviews with children, teens and adults, Turkle has concluded that we need to take a closer look at ourselves, especially when teens tell her “we’d rather text than talk.” Her new book, Alone Together: Why We Expect More From Technology and Less From Each Other documents her quest to understand the relationship we have with new technologies, especially with mobile devices.

In her talk, Turkle pondered changes in relationships among parents, children, sweethearts and friends.  Perhaps, Turkle asks, we have too close a connection with our machines, perhaps behind our incessant “connecting” lies loneliness.

Basically, her thesis is that we are so busy with our connections that we are neglecting each other.  When people text at meals, at funerals, at religious functions, what is really happening? she wonders.

She is most concerned about those who should be developing conversation skills.  Her findings suggest that  people are fearful of the give and take of conversation and may be substituting “mere connection” for conversation.  As one 18 year old told her that, “I can get everything I need from g-chat.” Another teen states, “When you text, you have more time.  On the telephone, too much might show.”  Her fear is that with text messaging, the collaboration, creativity and concentration of face-to-face communication is lost.

Adolescents are sharing between 3,500 and 10,000 texts per month.  From her many interviews, she surmises that many teens use texting to confirm their feelings.  Turkle is concerned about what is being lost during all the face time with a phone.  As one teenager stated, “Someday soon I want to learn to have a conversation” while another described her efforts to learn to “try to have eye contact while texting.”

If we don’t’ teach our children how to be alone, they only know how to be lonely, Turkle believes.

Turkle’s voice, at a conference about mobile technology and connection, was illuminating and powerful.  Her words were about “health” the central message of the symposium.  The Center for Connected-Health‘s welcome to Turkle’s research was tremendous. Those who work in connected-health and telemedicine truly desire improvement in the well-being of all.  With that in mind, her work sheds light on the human condition, the need not only for connection but also for intimacy.  It sheds light on the need for balance.

What are your thoughts?  

 

Dr. Turkle’s presentation made me wonder if there is a way for health communicators and believers in all the good that connected-health can bring to help us achieve balance.   Perhaps we could tweet messages like this…

“Stop texting and start talking!”

“Set aside “no technology times” with your loved ones, you’ll love the connection!”

“Turn off the phone, (or the computer), and give your child a hug!”

In the comments section provide some feedback.  If you voted yes, can you think of other messages?  If you voted no, what are your views on Dr. Turkle’s observations?

To your health: Music!

I’ve been singing something a lot lately.  It’s silly really but it makes me feel better, keeps me going, even gives me courage…

why does this little ditty work?

Or why do I feel peaceful when listening to this piece of music?

I went looking for a journal article. Just to prove to myself that there was something in this sense of well-being.  Here it is.  In 2008 a group of physician researchers convinced 60 patients who had just had a middle cerebral artery stroke (they were “in the acute recovery phase”) to take part in a little experiment.  At random, the patients were placed in three groups, a music listening group, a “language” group and a control group.

Everyone took neuropsychological assessments, cognitive tests and quality of life at the begining, at 3 months and at 6 months after their stroke.  With all the testing its a wonder that only 6 patients dropped out of the project!

Everyone received the same standard of medical care and rehabilitation that they needed.  The differences were the listening assignments.  The music group listened to music daily, the language group listend to audio books daily, the control group were given no listening material.

Here’s the cool part.  The music group had significant improvement in verbal memory and in focused attention as compared with the other two groups…AND they were less depressed and confused than the control group.

So with this one journal article, I say: sing, turn on those mp3’s, radios, cds, even if you are still in the dark ages,  tapes, 8-tracks or records.  Have a blast with a tin penny whistle, a guitar, a piano, a cello, a french horn….It’s great for your health!

Sarkarmo, T. et.al. (2008)Music listening enhances cognitive recovery and mood after middle cerebral artery stroke.  Brain: The Journal of Neurology, 131(3). 866-876

Awareness Months

In Action:  Beyond Awareness I broached the subject of Awareness Months.  Because there is some confusion, I am going to discuss the Transtheoretical Model to clarify.

Prochaska, Norcross, and DiClemente developed the Transtheoretical Model.  It is used extensively in developing behavioral change programs for individuals.  The model describes the series of stages that an individual goes through in the process of change.

Precontemplation:  This is the first stage.  It is when the individual is unaware or underaware of their problems.     There is no intention of changing behavior.

Contemplation:  The second stage is contemplation; the person is aware that a problem exists and is thinking about it.  They have not made any commitment to take action.

Preparation:  Some behaviorists parcel out this stage into 2 parts.  First, the individual  intends to take action in the next month.  Second, they have made a commitment to do so.

Action:  This is the stage where the individual makes overt behavioral changes.  Modifications in behavior, environment or experiences occur.

Maintenance:  During this stage, the person works to prevent a relapse.  The gains achieved during the action period are integrated into their life.

Relapse:  Unfortunately, there is the opportunity for relapse.  Those who have relapsed may move into the preparation stage again or remain relapsed.

One of the most important features of this model is that it is all about the individual–moving the individual along a path toward change.

What does this change model have to do with Awareness Months?

Awareness Months assume that everyone who is receiving information is in the precontemplation stage.  They assume that all individuals being targeted by the campaign are unaware or underaware of the disorder/disease.   This is not the case.

When measuring the impact of an awareness campaign, pre-test/post-test surveys are done. The people who didn’t know anything about the disease/disorder or the material in the campaign (found in pre-test) are asked if they learned anything during the campaign.  If there is a change in knowledge among those people, the campaign can be termed “successful.”  There can also be questions about intent to do certain actions that the campaign promotes or even checks to see if actions actually occurred.  {An example of an effective campaign among those with low health literacy can be found here.}

What happens if an Awareness Month is only about letting people know how to determine if they or their loved one has a disorder?  Or what if an Awareness Month is only about preventing an individual from getting a disorder?

If the focus is on preventing the disorder, isn’t there an unintentional stigma “out there” for those who have the disorder?   It is as if  having the disorder is something that you could have controlled/prevented.  In most cases, this is not true.  Genetics plays a significant role in our lives.  The environment that we are surrounded by, pollutions or toxins we do not know about, impact us from babyhood.  The interaction between our genes and our environment can result in diseases and disorders.  Is that the fault of the individual?

People with the disease or disorder and/or their caregivers are fully aware.

Awareness Months that focus only on prevention or only on determining if an individual has a disorder leaves out people who have the disorder.  It doesn’t make anyone aware of what it is like living with the disorder nor does it help those dealing with that reality.  It doesn’t make anyone aware of the financial burden of the disorder; or the incredible efforts made by caregivers on behalf of those who have the disorder.  

So, where do you think change is needed?

Let’s get the message right!

Life in the Deep South is definitely different from life in say, Boston.  For one thing, most towns in the South don’t have sidewalks.  Mass transit just does not exist…it’s the car or nothing.

In the summer, it is HOT.   You have to stay indoors and you need air conditioning because it is HOT.  …and did

I mention that it is HOT!  I don’t mean 80 degrees, I’m talking about 95 degrees plus and that’s in the shade.  And it’s humid, often between 80 and 100 percent.  It doesn’t cool down at night either…you’re lucky if it’s in the 80’s at 11pm.

To cool off, it’s sweet ice tea.  If there is a public swimming pool, the water is warm as a bath and the pool is really crowded.  Most poor kids raise themselves during the day, because there is no school, no camps, no one to watch them…mom and dad are working.

Alright…the stage is set, the reader is wondering where this post is headed.  It is headed for a rant:   A rant about bullying, victimization and childhood obesity.

When I read about Disney’s recent boondoggled attempt at “addressing” childhood obesity, I wasn’t really all that surprised.  After all, I’ve come to expect insensitivity from movie producers that start their children’s movies with the child hero losing a parent.

Ads created by a pediatric hospital in Georgia are the same thing.  Just another grim reminder that medical professionals lack significant training in social determinants of health or for that matter, nutrition.  As one recent survey reveals, physicians felt the “greatest barrier to managing obese patients [is] lack of patient motivation.”  Oh really, doctors?  Then tell me, how do you explain all the money that is spent on dieting?

So another $50 million is wasted on an ad campaign telling people that the individual is the problem.  Only Disney knows the amount of money and time wasted on their Epcot debacle.

So let’s go back to the earlier description of summer in the South or a description of much of the United States.  There is little environmental support for children dealing with weight.  School physical education programs have been cut back or eliminated to reduce costs.  Snack machines and drink machines are part of today’s school setting.  Sidewalks and safe neighborhoods are the exception, not the norm, especially in low income areas.  Restaurants supersize portions and membership in the clean plate club is mandatory.  Parents in the workforce come home exhausted and rely on easy to prepare meals to make it.  Children are targeted by fast food, fatty food and sugary drink commercials.  Instead of decent grocery stores, fast food restaurants and quick stops are within walking distance of neighborhoods.  Fruits and vegetables are expensive to buy and can be time consuming to prepare.  Medications that children are required to take to be in school ‘cause kids aren’t allowed to be kids nowadays can reduce metabolic rates so it make it very, very difficult to lose weight or to keep it off.

Life intervenes.

So let’s stop talking about all these unmotivated individuals!  Bullying and branding people doesn’t help.  Instead put all that cold hard cash to good use…put in some sidewalks, clean up some playgrounds, put in a few public pools for crying out loud.

Public health, let’s get the message right.  Childhood obesity is the symptom.  The environment is the cause.


Begin With the End In Mind: Let Evaluation Lead

Nothing says success better than provable results! So it is easy to see why the folks at Health Literacy Wisconsin are smiling from ear to ear. This past fall they put together a winning health communication campaign by sticking with the fundamentals: they did their research. Erin Aagesen, MS, MSPH, the Health Literacy Coordinator at Health Literacy Wisconsin, a division of Wisconsin Literacy, Inc., joined the Health Communication, Health Literacy and Social Sciences tweetchat to explain their process. Erin manages statewide health literacy interventions in partnership with Wisconsin Literacy’s 63 member literacy agencies, community-based agencies and health care organizations throughout Wisconsin. The plain language health communication campaign, ‘Let’s Talk about Flu’ was conducted this past fall and winter of 2011-2012. During this short timeframe, 53 workshops served 921 adults with low health literacy. Funding and support came from Anthem BCBS and Walgreens and resulted in a lesson book, a 1-hour workshop and flu vaccine vouchers. According to Erin, a key to their success was “making the information relevant to participants’ lives.” Another vital component to success was delivering workshops in “trusted settings where people already live, work, study and socialize.” “Most participants were adults from our 63 member literacy agencies, who are reading below the 5th grade level. We also worked with populations in which there is generally a large overlap with low literacy, including [the] homeless.” Community based organizations often take shortcuts to save time and money. Pre-testing campaign content is often left out. In this case, Health Literacy Wisconsin didn’t skip this important step, they “pre-tested our lesson book with physicians, adult learners and adult literacy program directors. This was an essential step; we learned a great deal and revised our program and materials based on this feedback. We’re all rushed, but I think scheduling time for feedback and revision upfront saved us time in the long run.” “You have to prioritize. We were successful because we made some decisions about what was crucial data and what was not.” All their stakeholders were gathered together prior to developing their evaluation plan. And they followed the crucial advice to “begin with the end in mind!” By taking that advice, the results were worth sharing. With an 85% completion rate of the pre- and post-tests they found that flu knowledge increased from 56% to 83%. The participants intention of getting the flu shot increased from 74% to 83% and 42% obtained the flu shot (tracked through voucher system provided by Walgreens). The University of Wisconsin Extension Cooperative Extension pamphlet provided Erin and her colleagues with the tools and the self-confidence to do it right. As Erin assures other community based organizations, “it’s OK not to be research experts. ‘There is no blueprint or recipe for conducting a good evaluation.’ Make it work for you!” For further information check out Erin’s tweetchat and the University of Wisconsin Extension Cooperative Extension evaluation tools, especially their booklet.

The Power of Play, Part 2

Children will put in over 10,000 hours of video gaming before the age of 21.  How do the video game producers keep people playing?  Can health communicators harness the power of gaming by applying game mechanics to our campaigns?

These two questions have been nagging at me and I have found some answers.   Following up on “The Power of Play” blogpost, this post will explore gamification (applying game psychology to non game environments) further.

Why do we keep coming back to games and spending hours acquiring points?

Games are created from the ground up to engage us.  They are make believe.  Game producers create an experience.  The best video games are created around story that is meaningful to the player.  Saving the world, or at least the environment created by the producer, is the overarching goal of many video games.

Mastery is the experience of being competent , of achieving something.  This experience is at the core of what makes any good game fun and engaging.  The producers of video games also create a rule system to master.  There is a clear overarching long term goal and what is called a structured flow of nested goals.  For example, the long term goal is to save the world, a medium term goal is to kill the monster, to do that you need to obtain coins so a short term goal is to collect 5 coins.  Mastery is fun and it is addictive.  We crave learning: overcoming obstacles and then succeeding.  Joy lies in the tension between a risky challenge and the successful resolution of the challenge.

And this leads to a discussion of flow…Does the game have flow?  Flow means that it is neither under-challenging or over-challenging.  If the game is too easy the player becomes bored.  If it is too hard, the player experiences anxiety and frustration.

One of the tricks is to have frequent easy challenges that allow the player to savor their mastery but also have sudden spikes in difficulty.  The goals that are created need to be structured so that at each level it gets a little bit harder to reach the next level—for example, the player needs to earn more points to reach the next level  Another part of the creation of a game is to provide lots and lots of positive feedback when mastery occurs.

When creating a game, knowledge of your users is critical.  Games are tested and prototyped and retested.  Finally, successful game producers help us feel that we are playing rather than working.  Working is something that we are forced to do; playing is something we choose to do voluntarily.

One of the things that keeps us playing is that they aren’t reality.  They are make-believe.

Yet our vigor, our fitness, our physical condition is our reality.  A person’s body and a person’s ability to function in the world are all reality.  Health is reality:  seeking good health or increasing good health or motivating healthy behaviors are all real world endeavors.    And games mimic reality… as we play our games we are always looking for points to increase our hero’s health so that s/he doesn’t die and we don’t lose.

I believe that this is where a game creator who is interested in improving health could plug their behavioral messages.  When the player loses health, opportunities that are real world oriented, could be implemented to gain it back.  The most important part is that this needs to be tightly integrated in the “make-believe,” bringing a player back into reality makes educational or health games preachy

Again, incorporating research into the creation of a game is critical, test and retest to determine what your players want in a game will make it a successful and fun experience. Losing play means you lose your players– the strength of games is the power of play.

Unlocking the Individual’s Ability to Care for Themselves*

“The “biggest value [of connected health]* is in unlocking [the] individual’s ability to care for themselves!”  So says Joseph Kvedar, MD, Founder and Director The Center for Connected Health, a Division of Partners Health  in Boston, Massachusetts.

#HCHLITSS, Health Communication, Health Literacy and Social Sciences twitter chat started 2012 with a bang.  With our guest, Dr. Joseph Kvedar, participants entered into a thought-provoking and engaging conversation.

Dr. Kvedar is an innovator in the use of new technologies to connect health care providers-physicians, nurses, pharmacists and others-with patients.  Using remote health monitoring tools, the Center is involved in helping patients manage their chronic disease and engaging people in their own health and wellness.

To get the chat started and get everyone on the same footing, Dr. Kvedar (@jkvedar) answered the question, What is connected-health?

Connected health is “creating a new model of healthcare delivery by leveraging IT to move care from the doctor’s office into the lives of patients.”  The way to achieve this change in healthcare delivery is [to provide]“objective information about you, presented to you in context, surrounded by the factors that motivate you to improve your health.”

Motivation or engagement comes from the “objective info about you.  [It] holds everyone in the conversation to the same objective standard and aids in reality and accountability.”

Feedback seems to be a powerful motivator.

“Feedback loops offer active reflection, sentinel effect and ability to take action.  [With] info[rmation] about health, indiv[iduals] can ch[an]ge behavior.”

One program the Center is known for involves home monitoring of patients with Coronary Heart Failure (CHF).

“Home monitoring for CHF is a terrific example of integrating patient, nurse and physician to achieve health at home and [at a] low cost. …We’re expanding our CHF program to include acute MI (myocardial infarction) and other cardiac conditions. [We] already do HTN (hypertension or condition of chronic high blood pressure)… CHF – p[atien]ts [are] responsible for daily weight, bp[blood pressure]/hr[heart rate]. [This information] goes automatically over phone line. Nurses view dashboards,[and] do exceptional m[ana]g[emen]t.”

Another innovation developed by the Center involves improving medication adherence.

“The RX [Prescription] vitality glow cap first glows, then chimes. [It] r[e]m[in]ds U to take med[ication]s. Improved adherence by 68% in our trial!

Dr. Kvedar notes in previous presentations that there are certain people who are more likely to want to be involved in connected health.  They are truly engaged in knowing their numbers, for example, how many steps they take in one day or how many calories they use in one hour.  He calls them the “Quantified Self” population.  During the chat, he was asked


“How can connected-health get beyond the Quantified Self population to a more generalized population?” 

He believes that this can happen by “1) understand[ing] patients and their motivations; 2) giv[ing] them simple tools to track and understand the data 3) empower[ing them] to take ownership.”


Who will drive connected-health (or m-health) physicians or patients? Or pharmacists or nurses? 

                “All of the above, but mostly patients,”


Will the volume of baby boomers help “force” a move towards telemedicine if hospitals cannot meet demand?

 “I don’t know if boomers will be the sole catalyst, but something outside the system will be the tipping point.”


Another mover in the connected-health arena may be large businesses.

“Several global fortune 500 firms are getting into CH [connected-health] as we speak.”

One participant noted, “one day, soon, connectivity is gonna prove its[e]lf to be cost-effective and improving outcomes. (or: are we there yet?)”

Dr. Kvedar agrees that we are “very close to proving the value of connectivity… Especially in the context of ACO (Accountable Care Organizations).”

Following up on this comment, Dr. Kvedar was asked if our present health care cost crisis will be solved by innovation occurring outside of traditional healthcare delivery system, Dr. Kvedar replied,

“My hypothesis: the cost crisis cannot be solved from within. each dollar saved is a dollar of someone’s income lost… MDs are the last to come on board, but with new payment models, they are coming on board. 80% ready in our IDN (Integrated Delivery Network).”


Dr. Kvedar’s passion or vision for connected-health (which he admitted was tough to do in 130 characters) is

“Empower consumers to be their own doctor. It can be done.” Then he clarified by saying that “of course there will always be a need for providers. We just overuse them now.”


Although there was some enthusiasm about connected-health, participants voiced real concerns.

Concerns about connected-health that were raised by participants included:

                The digital divide:

                “Health literacy and literacy as part of the digital divide”

                “Low tech communities need most help”

“Those who are rural are the ones who may need this kind of distance support the most”

Cost of technology for the poor: “When I see personalized medicine- I think medicine for those with “resources” only”

Use of hands, eyes for text messaging

“The age ceiling to connected health”

“Risk of increased disparities”

                Where is the desire “for telemedicine in #diabetes?”

Participants also proposed solutions and or disagreed with  these concerns:

“Digital divide can be addressed several ways: provide access in clinics, libraries, community centers, or provide print “

“Use existing communication resources in the community to engage/ distribute info[rmation] this is when the value of partnerships with community health leaders and advocates becomes more vital”

“Projects provided to many people have cell phones-programs such as text4baby.org by the National Healthy Mothers. Healthy Babies Coalition can help”

“Actually at least in much of the #US, even the poor have dumb cell phones, and most have basic texting, least from what I’ve seen”

“In developing countries mobile phone technology developed where there were no landlines everything now moves on new platform.”

 Although this statement was challenged “For many in developing countries-local comm.[unity] leaders (word-of-mouth) [is] still [the] most effective source of med[ical] info

Others suggested more ways to use connected-health:

“Encouraging mentorship in online communities is a very powerful tool to give more power to the patient and their loved ones


Participants also provided useful information on the use of technology for those who have a disability.

The chat provided a forum for information exchange and opportunities for further discussion.  Finally, there was generous sharing of information among the participants. Many thanks to Joseph Kvedar, MD and all the participants in #hchlitss chat.


Wonderful links were provided by participants:

The Center for Connected Health http://t.co/quTwGzdg

Dr. Kvedar’s blog http://t.co/gnni5SC6

UC Davis eHealth Broadband Adoption: http://t.co/62wbn5Fl bridging the divide

California Model E-Health Community Awards http://t.co/Dywo8Q9s

In Canada, the Telemedine Network http://t.co/CauUkO6v has made great inroads connecting /helping esp with mental health

Also need a connected healthcare workforce where needed, when needed & tech to get them there http://t.co/Bjg0dIiX

Recent blog post ?: Can connected work in a fee for service model, or more movement in integrated system?http://t.co/wlGfzSc5

Telcare review from Walt Mossberg. WSJ tech writer with type 2 diabetes. http://t.co/vhQsSSHj

Scottish Centre for Telehealth and Telecare http://t.co/Ncfd0ICv

Project Echo- promoting care for complex diseases in rural and underserved areashttp://t.co/v3OZSDEM

Non traditional entrants into connected-health http://t.co/alxEdh5r

MyVoice is for aphasia and stroke http://t.co/byXDK5W5

Ipad apps for kids with autism @thinkingautism @shannonrosa

*Due to the twitter’s 140 character requirements, comments are shortened by eliminating articles or using shorthand.  [Braces] are used throughout this summary to enhance readability.

*Previously posted at #hchlitss  New youtube videos have been added.

The Power of Play

Why do gamers spend hours amassing points for rewards that don’t really exist?  

Because games are fun.    What does this have to do with health communications?  Health communicators are trying to use game mechanics to hook people into doing things that will improve their health.  That’s right:   instead of being preachy, there is an effort afoot to make losing weight or increasing physical activity enjoyable.  By coupling a system of incentives with any number of efforts to improve health , health communicators hope to make doing a new healthy behavior fun and “addictive.”  Getting people to begin a new health behavior is difficult…that’s where the fun comes in.  Making it ‘addictive’ is critical because one of the major problems for any behavior change initiative is maintenance:, that is,  how can we find a way to keep people from backsliding, losing their momentum and quitting the behavior? Gamification is the new buzz word.  Why is gamification so fashionable?  It makes sense.  Let’s look at human beings.  According to economists, we are loss averse, favor immediate gratification and are overly optimistic about the future.  What this means is that the risk-oriented messages that are part of traditional health interventions really don’t convey.  Investing in your future good health or relating present behaviors to the future just doesn’t have as much impact as the immediate rewards of the behavior.  For example, even though you know smoking that cigarette can cause cancer in the future, you still smoke it because it tastes great with your first cup of coffee. According to health game aficionados, since people are more interested in reward in the present than what will happen in the distant future, communicators need to think out of the box.  This is where the structure and reward system of games comes in. With games you can invent immediate gratifications for behavior change, you can offset the configuration of time of action and payback around desirable health behaviors.   Here are some ideas to keep in mind when making a behavioral intervention, at ,for example, a workplace, into a game. The first is KISS…keep it simple means choosing one task or behavior and focusing on that.  Second, it is important to find out the key motivators for the audience. What can you do to integrate their motivators into the game? Relatedness, or an individual’s need to feel connected socially or to a group is a powerful tool that is used.  This is also related to a person feeling valued by things outside his or her self.
Third, incorporate the opportunity to work together if there is a desire.  The group size is important, apparently 8 is the magic number to get things to happen.Fourth, allow people to advance through levels and acquire points as individuals and as teams.  Fifth, use social and monetary equivalent rewards. Be sure to reward based on information on motivations.Sixth, be creative and use narrative themes to keep interest. Finally, provide rewards/incentives at regular intervals but then add to the game some surprise rewards.  Surprises work and keep people interested.

An innovative use of game mechanics is the Biggest Loser Minnesota Challenge.  The Alliance for a Healthier Minnesota partnered with RedBrick a company located in Minnesota to create the game. More than 22,000 Minnesotans participated in this statewide health program.  Altogether they lost 75,000 pounds. Now that’s a powerplay!