Johns Hopkins Magazine - April 1994 Issue

Nurse at the Helm

By Joseph Anthony

Regardless of how the country's health care reform plays out, "There are going to be many more opportunities for nurses,' predicts Marla Salmon (PhD '77), who directs the nation's Division of Nursing. In a system undergoing change, patients need a trusted communicator--"and this is something nurses do exceptionally well."

Think of Marla Salmon as the nation's Head Nurse.

Salmon, director of the Division of Nursing for the U.S. Department of Health and Human Services (HSS) and a member of Hillary Rodham Clinton's health care task force, has said of the U.S. health care system, "The patient's priorities have been lost in providing health care. Our system is crisis-oriented--a man has a coronary before he gets help, when he should have been put on a diet and given proper attention 10 years earlier."

There's just one problem with calling this trenchant analysis timely: Salmon said it before becoming head of the $60 million HHS department; before chairing the University of North Carolina's public health nursing program; even before getting her doctorate from Hopkins's School of Hygiene and Public Health. In fact, Salmon made this observation 21 years ago, when she was preparing to travel to Germany to study that country's health care system as a Fulbright Scholar. In a sense, that early emphasis has defined her career: putting the patient first.

But don't forget her second-degree black belt in Taekwondo. She earned that two years ago.

Today, the division Salmon runs focuses on federal policy in the areas of nursing education and practice. Are there enough nurses in enough places to meet the country's health care needs? Are nurses getting the right training and education to serve a changing nation? What part can nurses play in providing more medical care at a reduced cost?

To find out, the Division of Nursing funds experimental health care efforts such as a "block nurse" program in St. Paul, Minnesota, in which the local health department sends out nurses to care for elderly people, allowing them to receive medical care without leaving home. "We don't pour money into the system to change what the system does," says Salmon. "Instead, we use money to fund programs that may show us better ways of doing things."

Her HHS office in Rockville, Maryland is down-to-earth practical, dominated by 16 horizontal filing cabinets, a round conference table, and a white chalkboard. On her desk are photos of her children, Jessica, 17, and Matthew, 14. Husband Jerry Anderson works a few floors below as an attorney with the National Practitioner Data Bank, an arm of HHS that tracks reports of possible medical malpractice nationwide.

Sitting in her office, wearing a practical, mid-calf skirt, a black blazer with a silver lapel pin, and tortoise-shell glasses, she looks like Linda Ellerbee, especially when pursing her lips while considering a question.

When you test for a second-degree black belt, you have to (among other things) break three boards in succession with three different kicks. Salmon, testing mostly with men half her age, was the only adult to break the boards without a false kick. "I've never really gotten a permanent thrill out of anything in my career, but finishing that test--oh, that was something! It was an entirely different sense of accomplishment," she says. "But I'm out of practice right now."

Marla Salmon and her sister and two brothers were raised in Sebastopol, a rural town about 60 miles north of San Francisco. Her father, Everett, born in South Dakota, joined the Civilian Conservation Corps as a teenager and eventually became a family physician, the kind of old-time doctor who would accept payment in fish, or in fruit, or simply in grateful thanks. Nobody left his office without being cared for. Salmon's mother, Marceline, a Missouri native, was a nurse and partner in his country practice.

"Both my parents came from very poor backgrounds and have a close connection to hard-working people--they didn't judge people by how much they made or what they wore, and they have a strong sense of social justice," Salmon says. "My mother was instrumental in getting us out in the fields and working with the migrant workers. That was wonderful. I learned you will never meet harder-working people than migrant workers."

Though Everett Salmon, 73, is officially retired, he still spends several months a year working in rural Montana, helping to keep small hospitals open. Marceline Salmon, 69, works with a local nature conservancy group.

After high school, Salmon was somewhat at loose ends. "I pretty much screwed off in high school; I was not someone who many schools were going to consider," she says. "But the University of Portland gave me a chance."

Salmon was an undergrad in the days when women at the Catholic university simply did not wear jeans or slacks to a university dinner or, for that matter, to any other function. She carried signs stating that if priests could wear dresses, then women should be able to wear pants. "I hung out with the basketball team, with a group of Middle Easterners. People probably thought it was intellectual rebellion, but it was more just hanging out with interesting people. I was the leftist, feminist, radical, non-Catholic, war-protesting hippie."


"It was great."

Old friends remember it, and her, as being pretty great also. One day, two decades ago, nursing school classmate Judy Nuccio got in Marla's car--the little yellow convertible with the "Free Palestine" bumper sticker--and the two drove from Oregon to San Francisco to see Hair.

Says Nuccio, "She would do things that I never had the guts to do, I can tell you that. The woman had energy and drive and smarts like no one I've ever seen. Women have slowly become aware they don't have to sit back and put up with garbage, but she knew that 20 years ago. She would tell people off and tell them why, but she wasn't obnoxious; she was very seductive, very imposing, very strong."

Salmon will talk at length about things she's done outside her profession--college student adventures, personal hobbies and concerns, and so on--but seldom about her professional accomplishments. Likewise, she downplays her early academic record (with degrees in nursing and political science), even though it led to the Fulbright. "I was just lucky to have some professors who kicked me in the butt, who could discern that I'd written a paper while sitting up all night drinking beer with friends."

The work Salmon did on her Fulbright before coming to Johns Hopkins still resonates when she talks about health care issues today. Twenty years ago, she was looking at how the German national health care system might be applied to developing or Third World nations. (Today, of course, the German system is one of several pointed to as a possible model for the United States.)

She was struck by the way the Germans focused on the patient. "Here was a society where the concept that everyone was entitled to health care was taken for granted," she says. "The responsibility of a society for health care; how, or if, you make it accessible to everyone--here, those are issues we are still wrestling with."

"Marla tends to approach things from a humanist point of view, as well as from the perspective of a seasoned professional," says Fitzhugh Mullan, director for the Bureau of Health Professions and assistant surgeon general for the U.S. Public Health Services. "She's had rigorous emergency room training, served as an educator and researcher, but she also always remembers that we're trying to help other people. She doesn't get lost in her professional identity the way many of us tend to."

As a graduate student at Hopkins, Salmon started a patient advocacy program at the hospital's emergency room. Her study of the program became her dissertation. "You know how people don't change their way of communicating with people who are deaf, they just speak louder?" Well, she says, that's how institutions tend to react: if there's a problem, they tend to do even more of the same. Through patient advocacy, Salmon hoped to produce actual changes "in how the staff and the institution behaved toward patients."

The changes could be small from the perspective of the institution, but large from the patients' viewpoint. For example, under Salmon's program the hospital developed a system to let staffers know how long people had been waiting in the emergency room--an important detail when the patient is an inconsolable infant with parents at their wits' end. In another improvement, a room directly next to the emergency room was created for relatives of patients, making it easier for a staffer to relay information on a regular basis. "And for those families who lost someone, it gave them a better place to grieve with some privacy and dignity," notes Salmon. Not all changes, though, were enthusiastically embraced by the hospital.

"It turns out that a good patient advocacy program makes the institution uncomfortable," she says. "There is an inherent though delicate conflict between the interests of the institution and those of the patient, and a successful patient advocacy program frequently does operate at odds with the interests of the institution."

For that reason, Salmon says, she found that any successful patient advocacy program requires the commitment of administrators as well as staff; otherwise, the program will fall short. "Programs that fall short manipulate the patient into accepting services as they are currently provided by the institution. Instead of having the institution meet the needs of the patient, the patient is pushed into meeting the needs of the institution."

The need for advocacy, Salmon then decided, could also extend to people preparing for careers in the health field. "My sense was that a lot of students early on were made to feel that they didn't know anything or have anything to offer. They were sort of being 'unmade,' or torn down so they could be remade into something else."

Unmaking didn't make much sense to a woman who keeps trying to find ways to put people ahead of organizations. "I mean, why not start from the needs or commitments or interests of the students you're serving rather than try to have them meet the needs of the educational system?" she says. "Most adult learning theory talks about finding hooks on which you can hang lessons to make them relevant; my own experience has been that an indivi- dual's ideas and commitments are the single best hooks on which one can hang learning."

In practice, she says, that means nursing school instructors need to find out "what haunts a student," then let the student learn by attacking that particular problem. "If I had a first-year student who really wanted to have an impact on infant mortality, I wouldn't wait until that student's third year," Salmon says. "I would try immediately to get him or her nearer to resources, whether that means involvement with the Children's Defense Fund or understanding infant poverty statistics or tracing a legislative bill."

This kind of emphasis--a medical version of Never Forget Who Your Customer Is--permeates Salmon's work even now, as a federal bureaucrat. "The first thing she did when she came [to HHS in 1991] was to initiate a customer-oriented self-assessment of the division in terms of where it was and where it needed to go," says Robert Politzer, associate bureau director for primary care policy at HHS. "She wanted to know what the schools of nursing, the American Nurses Association, and everyone else thought about what the division was doing and what the division should be doing."

Says Salmon, "We found we have to build in as many assurances as possible that people will be treated fairly. For example, we had a two-stage process for reviewing grant proposals. By the time people got initial feedback on a proposal, they'd have missed the deadline to resubmit an improved application. So we dramatically shortened the time between submission and feedback from months to weeks. That way, applicants know in a timely way whether they should be working on a new application."

Like the responsible bureaucrat she now is, Salmon avoids speculating on what a reformed health care system will finally look like. Whatever the new system's shape, however, Salmon thinks nurses will be at the cutting edge. "A system undergoing tremendous change can gain a lot higher level of acceptance by patients if there is someone who is a trusted communicator between patient and system, and this is something nurses do exceptionally well," she says. "I think people believe nurses will represent their interests. Nurses really are often viewed as the patient's only advocate."

She also says that well-trained nurses can do much of what other medical professionals currently do. "Regardless of the specifics of any future health care plans, I think there are going to be many more opportunities for nurses," particularly those with specialties. For instance, clinical nurse specialists are increasingly looked to to coordinate and supervise ongoing patient care in non-primary care areas such as orthopedics or mental health. Nurse anesthetists can (and do) give anesthesia. Nurse midwives can deliver both babies and prenatal care (see "High-Touch Care," p. 26). And nurse practitioners "can do about 60 to 80 percent of what a primary care physician does," says Salmon--and all these nurses work at a much lower cost.

A bigger role for nurses won't happen without some trauma for other professionals in the system, acknowledges Salmon, who notes that nurses frequently don't get the respect they deserve. In one recent case, a nurse- midwife working in a rural area was delivering a baby to a woman who'd received no prenatal care. The baby was breached, and mother and child were both in trouble. But the nurse-midwife had to handle the birth alone--the physician who was supposed to be available decided he would not work with a nurse-midwife.

"Afterward, that nurse said she wanted to quit her job," says Salmon. "Everything turned out fine for the mother and baby, but how do you deal with knowing there's a life or two you could lose because of how someone approaches the professional dynamics?"

She continues, "It's very difficult for people who have a stake in the way things are to see things changed in a direction that they see as affecting their well-being. But people may come to the realization that if 37 million people are without care and the system doesn't provide it, we need more people in the system who can provide care."

To that end, Salmon wants to make sure there are enough nurse practitioners, enough nurse midwives, enough nurses coming out of two-year programs, enough nurses earning graduate degrees- -and enough racial and cultural diversity in the profession so that all people are served by nurses who can at least understand what they say. "The idea that you can deliver services and literally not be able to communicate with the patient is pretty crazy, but it's a prevalent notion," she says. Among the new HHS initiatives she's proudest of is a small $400,000 annual program that provides health services to migrant workers and their families. One of the requirements is that student nurses be able to speak Spanish.

That type of program is part of her drive to "make nursing look like the rest of society." Salmon speaks of the "emerging majority" of African-Americans, Asian/Pacific Islanders, Native Americans, and Hispanics, and says more nurses must come from those groups. "As long as nursing does not have the diversity and richness of our society, it will not be able to fully serve the changing needs of that society," she says. Under her direction, the division has sponsored two conferences that looked at ways to recruit and train more minority nurses.

Salmon says that's all part of trying to build a health care system in which each patient is seen as more than just a collection of symptoms. "You can only advocate for the whole person if you know, and are actually caring for, the person," Salmon says. "And that's what nurses do."

Nowadays, most of Salmon's time is taken up in meetings, working to develop legislative proposals, implement programs, review internal federal policies, carry out the will of the government. She started one recent day at 7:15 a.m. by reading her e-mail messages before moving on to employee performance appraisals, attending three policy meetings, reading a stack of faxes ("I try to look at them before they're old and faded"), another meeting, a conversation with statisticians on projecting population trends and health care needs, a meeting on the department's budget, and scores of telephone conversations. It all seems pretty, well, dry.

When Marla Salmon shows how it looks through her eyes, though, the vision is rich with possibilities. "My patient or client is the United States," she says. "My relationship with that patient has to be one of caring, of being concerned for the future of that patient and with what nurses can do to make sure the future good health of this patient is realized."

Joseph Anthony lives in Portland and writes on social and financial trends. He is a contributing editor of American Health and National Geographic Traveler magazines.

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