Enhanced Role for Nursing in Milwaukee County's Redesigned Mental Health System

Few would dispute the idea that effective mental health care relies on the quality and accessibility of health care professionals, especially nurses. As stakeholders in Milwaukee County work to redesign the county’s mental health system, one of the crucial issues they face is how to build an effective and efficient mental health nursing workforce in light of anticipated changes under the new system.

The Nursing’s Voice project is a collaborative effort of local and national foundations, higher education institutions, and other interested parties to enhance the supply of mental health nurses in Milwaukee.  As part of the project, the Forum surveyed 120 mental health nurses and 34 employers to illuminate the state of the county’s current mental health workforce and to gather insights to inform the redesign planning process and the work of Nursing's Voice.  

Survey responses identified three broad categories of need that an effective redesign effort must address – the need for training and professional development of nurses, specifically in mental health care; the need for a larger mental health nursing workforce today and in the future; and the need for nurses and employers to clarify their respective expectations about what constitutes effective mental health nursing skills and practices. In the research brief that summarizes the survey findings, the Forum describes key policy implications:

• Because of a perceived need for nurses with an interest in mental health both now and in the future, incentives for increasing the mental health workforce might be necessary. The redesign process should also anticipate the need for more nurses. 
• Although employers are satisfied with the mental health nurse applicant pool, very few nurses are nationally certified or advanced practice nurses. This suggests that while schools of nursing provide a basic foundation of mental health training, planners should explore possible reasons for the apparent lack of deeper knowledge and discern how this deficit will affect future service provision.
• Employers envision a larger role for mental health nurses in outpatient/community settings. However, today most nurses work in inpatient settings. Planners should explicitly consider the optimal roles of nurses in community health settings.
• Turnover among mental health nurses is relatively low (less than 10%) with the greatest source of job satisfaction deriving from patient care. Sources of job dissatisfaction are related to pay and advancement. If nurses’ responsibilities become more administrative or policy-oriented under a redesigned system, the reduction in patient contact may cause nurse job satisfaction to suffer (and attrition to rise), particularly if wages do not change.
• Employers and nurses lack consensus about which skills are most important for patients’ recovery. This suggests either a lack of clear communication or differing expectations as to the job objectives. Employers and nurses should work toward greater clarity about these differences if the role of nurses is to change under a redesigned system.
• Employers and nurses find more common ground regarding their views of the specific skills that need strengthening. Planners should therefore focus future professional development resources in these areas.
• Both nurses and employers placed specific importance on the ability of nurses to understand the treatment needs of patients diagnosed with dual/co-occurring disorders in which mental illness coincides with substance abuse. As the county shifts its focus to dual/co-occurring disorder treatment, the need for improved training for nurses will be imperative. 

These findings could serve as guideposts to planners, employers, and nurses themselves as they navigate the uncharted territory of a redesigned mental health care system in Milwaukee County. In addition, Nursing’s Voice will play an active role over the next two years to bring the perspective of mental health nurses to both the redesign and implementation of the new system. To do this, the collaborative partnership will undertake three key activities: 1) conduct research and data collection, such as this survey, to document the current and future need for mental health nurses in the new system; 2) develop strategies to encourage nursing students to pursue a career in mental health service and to provide them with the essential skills to be successful; and 3) provide a platform for the voice of nurses so that the new mental health delivery system can make optimal use of their skills and ideas.

People Speak: Citizens concerned about health care costs and reform

The latest edition of the People Speak poll finds Milwaukee area citizens are concerned about health care costs in general, as well as the costs of the new health care reform law.

Of the 436 residents polled in early November, a majority (62%) agree with Wisconsin joining 25 other states in challenging the constitutionality of the federal health care reform law. Residents do not seem to base their support on uneasiness with the mandate that individuals be required to have at least minimum insurance coverage, however. In fact, 64% say they favor a requirement of this type. Support for the individual mandate drops to 42% when the question is rephrased to include a hypothetical tax increase to cover the costs for those who cannot afford insurance on their own, indicating concerns about the cost of the law may factor into support for the legal challenge.

These concerns about the cost of reform may reflect respondents' personal situations. A majority (64%) say they are very or somewhat worried that they will not be able to pay their medical bills in the event of a serious illness in the future, although just 23% say that cost has prevented them from seeing a doctor for a medical problem in the past 12 months. Of these 101 respondents who have skipped a doctor visit in the past year due to cost, almost half (47%) report having employer-provided insurance.

Other findings:

• The 64% of respondents in favor of requiring all Americans to have at least minimum health insurance includes 80% of Democrats and 55% of Republicans.


• While 67% of respondents overall agree that states should be allowed to opt out of the federal health care reform law and devise their own health care coverage systems, 92% of Republicans and 42% of Democrats agree.


• Almost half (48%) of respondents favor guaranteeing health care for every American, even if it doesn't do much to control health care costs.


• On the whole, however, health care is not at the top of people's minds when asked to name the most important issue facing the Milwaukee region. Just 2% said "health" or "health care" is the top issue, while 47% said "jobs" or "unemployment" is most important.

The People Speak poll is a tracking poll conducted three times per year in partnership with the Center for Urban Initiatives and Research at the University of Milwaukee and The Business Journal Serving Greater Milwaukee. Full results of the November 2011 poll and all previous polls can be found at the People Speak website.

People Speak Poll: Budget Debate Trumps Jobs

The latest People Speak Poll, conducted by the Public Policy Forum and the Center for Urban Initiatives and Research at UWM in partnership with The Business Journal Serving Greater Milwaukee, finds that the state budget ranks as the most important issue in the minds of southeast Wisconsin residents. The poll of 400 residents of Milwaukee, Waukesha, Ozaukee, and Washington Counties was conducted in late February and early March, at the peak of the debate over the budget repair bill. Four previous polls over the past two years had found jobs were the issue of most concern.

Analysis and full results of the latest poll, along with those of previous polls, are available at http://www.peoplespeakpoll.org/.

Other findings:

• The region's citizens are less optimistic about the nation's economic future and Milwaukee's eocnomic future than they were in September 2009.


• No major change in opinion has occurred since September 2009 with regard to state government--40% of residents feel the state is on the right track.


• Crime in the City of Milwaukee is not perceived by most to have declined over the past year, despite the actual drop in crime.


• Half of respondents consider the north side of Milwaukee to be an unsafe place to be in the middle of the afternoon.


• One in five respondents feel unsafe in the middle of the afternoon at Mayfair and Grand Avenue Malls.

The People Speak: Citizens' Views on Energy Policy

Most area residents are at least somewhat concerned about increases in energy costs and, accordingly, most say they have taken steps to conserve energy. That’s according to the latest People Speak poll of 395 residents of Southeast Wisconsin, which also shows that most citizens in the region are willing to pay more for fuel efficient cars, appliances, and homes, and that most support certain tax incentives to conserve energy or lessen reliance on non-renewable energy sources.

The latest People Speak is the fourth edition of this regional tracking poll, which is a partnership between the Public Policy Forum, UWM's Center for Urban Initiatives and Research, and The Business Journal Serving Greater Milwaukee. Over the past six months there has been a sharp increase in the percentage of respondents who feel jobs and economic development are the most important issues facing the region. The environment ranks low as a concern for most citizens, as it has in each of the previous People Speak polls.

Despite the low priority placed on environmental issues, citizens are concerned about energy costs and climate change. These concerns are echoed in the actions most citizens report taking to conserve energy, including purchasing energy-efficient light bulbs, turning down the air or heat at home, and buying energy-efficient appliances. Fewer respondents report reducing their driving by walking or bicycling more often, and a very small percentage of respondents say they carpool or take public transit.

Overall, citizens' concerns about cost and climate change are also reflected in their support for energy conservation policies such as tax incentives or benefits to individuals and businesses for conservation, requirements that cars be more fuel efficient, and requiring utility companies and business to use more alternative, renewable energy sources. There is less support building a new nuclear energy plant in Wisconsin. Reducing the speed limit and establishing a utility surcharge for exceeding monthly household energy-use limits are not supported.

For the complete People Speak poll results, as well as analysis of the results, visit the poll's homepage.

The People Speak: Citizens' views on transportation issues

The June 2010 People Speak poll, conducted in conjunction with the UWM Center for Urban Initiatives and Research and The Business Journal Serving Greater Milwaukee, covers several transportation issues, including congestion, transit options, revenue diversification, and regional governance.

The People Speak is a tracking poll, conducted at regular intervals throughout the year. Its purpose is to gather information from the region's citizens about their interests in, concerns about, and preferences for public policy. By gathering and reporting these citizens' perspectives, the partners hope to expand the public voice in policy matters affecting greater Milwaukee.

Highlights from the June 2010 poll of 386 residents of Milwaukee, Ozaukee, Washington, and Waukesha Counties include:

• Average grades for the region's transportation infrastructure. Local roads garner a C- and freeways a C+. Local bus service and main thoroughfares each earn a C-, as well.


• Overall, respondents see traffic congestion as a moderate to severe problem, but do not feel it has been increasing over the past decade. Still, there is majority support for increasing the capacity of the I-94 East-West freeway.


• Declining support since September 2009 for commuter rail and for high speed rail to Madison.


• Support for a downtown Milwaukee streetcar system is strongest among Milwaukee County residents, although about a third of respondents overall say they would regularly use a streetcar to get around downtown Milwaukee.


• Over half of respondents say they would support a $0.01 per-gallon increase in the gas tax to fund transportation improvements. This funding option is more popular than toll roads or increases in the vehicle registration fee. With respect to funding the Milwaukee County Transit System in particular, most agree that a half-cent sales tax is the "best option."

For the Research Brief and full results, please go to the poll's website.

The People Speak: Citizens' views on water issues

The winter 2010 People Speak Poll, conducted in conjunction with the Center for Urban Initiatives and Research at UWM and The Business Journal Serving Greater Milwaukee, focuses on water issues including quality, quantity, governance, and economic development.

The People Speak is a tracking poll conducted at regular intervals throughout the year. Its purpose is to gather information from local citizens about their interests in, preferences for, and concerns about public policy. By gathering and reporting these citizens' perspectives, the partners hope to expand the public voice in policy matters affecting greater Milwaukee.

Highlights from the February 2010 poll of 429 residents in Milwaukee, Waukesha, Washington and Ozaukee counties include:

• Solid support for efforts to use the region's fresh water resources as an economic development tool.


• Concern for water quality in Lake Michigan, but confidence in the quality of local drinking water.


• Consensus on the need for and importance of water conservation in general, but not a tendency to conserve water on a household level.


• Moderate to strong support for allowing the City of Waukesha to access water from Lake Michigan, as long as the water is returned to the Great Lakes basin.


• Preference for regional water governance, rather than leaving it up to municipalities or the state.

In addition, the February findings on a more general set of public policy issues mirrored the September poll results in these ways:

• Evenly split opinions on whether to pursue high speed rail and commuter rail and whether to implement toll roads.


• Weak support for increased user fees or sales taxes to provide property tax relief.


• Weak support for a mayoral takeover of Milwaukee Public Schools.

The February poll also revealed growing sentiment that jobs are the most important issue facing the region, growing pessimism regarding the direction of the United States government, and virtually no support for using sales tax dollars to pay for a new arena for the Milwaukee Bucks.

For full results, go to the poll website.

The People Speak: Citizens' views on transportation, education reform, taxation

The second installment of the results of the autumn People Speak poll, conducted in partnership with the University of Wisconsin--Milwaukee's Center for Urban Initiatives and Research and The Business Journal Serving Greater Milwaukee, focuses on public policy issues such as mass transit and mayoral takover of MPS.

The People Speak is a tracking poll that will be conducted at regular intervals throughout the year. Its purpose it to gather information from local citizens about their interests in, preferences for, and concerns about public policy. By gathering and reporting out these citizen perspectives, the partners hope to expand the public voice in policy matters affecting Greater Milwaukee.

Highlights from the most current Research Brief include:

• A majority of residents of southeastern Wisconsin favor high speed rail connecting Chicago, Milwaukee and Madison, as well as commuter rail connecting Racine, Kenosha, and Milwaukee. A downtown streetcar line in the City of Milwaukee is less favorable, but still garners support from half of Milwaukee County residents.


• When it comes to funding transportation improvements, toll roads have the most support, with about half of all residents in favor. Increasing the gasoline tax is not favored by most residents, nor is the creation of a regional transit authority funded by an increased sales tax.


• A mayoral takeover of the Milwaukee Public Schools is favored by 43% of poll participants in the region. The level of support among City of Milwaukee residents is the same--43%. The greatest support comes from Democrats, 50% of whom are in favor of the idea.


• Establishing a regional authority to oversee parks and cultural facilities for all of southeast Wisconsin garners the support of a majority of poll participants across the region. The only county in which a majority of respondents is not in favor is Ozaukee.


• Residents of the region are split on whether they would favor increased user fees in order to lower property taxes. Increased sales taxes for this purpose are slightly less favored.

For full results of the poll, go to the poll website.

The People Speak: Greater Milwaukee citizens' views on the economy

The Public Policy Forum is pleased to launch a new research product today in partnership with UWM's Center for Urban Initiatives and Research (CUIR) and The Business Journal Serving Greater Milwaukee: results from our new The People Speak poll.

The People Speak is a tracking poll that will be conducted at regular intervals throughout the year. Its purpose it to gather information from local citizens about their interests in, preferences for, and concerns about public policy. By gathering and reporting out these citizen perspectives, the partners hope to expand the public voice in policy matters affecting Greater Milwaukee.

Each poll will have a set of standard questions on topical public policy issues, the responses to which we can track over the long term. Because some of those questions are identical to those used by the Forum in previous public opinion surveys of southeastern Wisconsin residents, we'll also be able to compare the results to those we obtained several years ago.

In addition, each poll will have a set of questions that centers on a specific public policy theme. The poll results released today (from polling conducted during the last week of September) center on the economy: both how the economic downturn is impacting Greater Milwaukee residents, and how residents view governmental efforts to get the economy back on track.

Accompanying each set of poll results will be a Research Brief that analyzes key results. The Research Brief released today can be accessed here at the new The People Speak web site. The following are some highlights:

• About a third of respondents say they have experienced problems saving or paying for retirement, paying bills, and paying for health care during the past six months. Nevertheless, 64% are optimistic about their financial futures.


• Milwaukee area residents are more supportive of state and local tactics to revive the economy than federal efforts. For example, solid majorities believe that state and local governments should be doing and spending more to promote development and attract new businesses, yet only 45% believe the federal stimulus legislation was a wise use of public funds and 35% believe another stimulus package is warranted.


• While "jobs" ranked only as high as fourth or fifth in citizens' rankings of most important issues facing the four-county Milwaukee region in polls conducted from 1999-2002, it ranked first in the 2009 poll. The issues of crime/violence, schools/education and transportation ranked lower than ever before.

Stay tuned for release next month of results and analysis of the general public policy questions from our September survey.

Back to the 80's?

The Pew Charitable Trusts released results from a new poll this week and have characterized the findings as an indicator that "support for government assistance to the disadvantaged [is] up to where it stood in the late 1980s..."

The new survey asked some questions that had previously been asked in 1987 and 1994:

Three core questions regularly asked in Pew surveys since 1987 were analyzed to track attitudes toward government assistance to the disadvantaged. In addition to asking about their views on government help to the needy even if it means going deeper into debt, respondents were read these statements: "The government should guarantee every citizen enough to eat and a place to sleep"; and "It is the responsibility of the government to take care of people who can't take care of themselves." Respondents were asked if they completely agreed, mostly agreed, mostly disagreed or completely disagreed with each of the three statements after it was read.

Over half of this year's respondents (54%) agreed that the government should do more to help the needy, up from 41% in 1994 and about the same as in 1984 (53%). In addition, 69% agreed that the government should guarantee food and shelter to all Americans, up from 59% in 1994 and higher than in 1987 when 62% agreed. Over two-thirds (69%) agreed that it is the responsibility of the federal government to take care of people who can't take care of themselves, a 12 percentage point increase since 1994, though still less than in 1987. Overall, the percent of respondents who agreed with all three statements increased from 29% in 1994 to 41% in 2007. While the percent who disagreed with all three statements fell by nearly half, from 24% to 13%.

The gains appeared across all demographic groups except African-Americans, who had much higher support for government assistance in the '94 survey than did other demographic groups. According to Pew:

One of the largest increases occurred among the oldest Americans. Since 1994, the proportion of those 65 and older who agreed with the three propositions increased from 16% to 38%. These shifts narrowed the gap between old and young from 21 percentage points to 12 points. Support also grew disproportionately among whites (+13 points) compared with blacks, (+6 points), though a far greater share of blacks (61%) than whites (38%) consistently agreed. Among whites, the biggest increases occurred in the South, where support for the social safety net grew by 24 percentage points, from 24% to 48%.

What do these findings say about the success of welfare reform nationally, which came out of the Republican-led Congress of the 90's and was signed into law by President Bill Clinton, a Democrat? Among respondents in the bottom quartile of household income, overall support for the three statements had a 21-point increase, from 38% in 1994 to 59% today. If welfare reform is not meeting the needs of families in this lowest income group, greater support for increased government assistance is to be expected. However, support for a federal safety net also increased among the highest earning households. Favorable responses from those in the top quartile of household income for all three statements increased from 16% in 1994 to 29% in 2007. The breadth and depth of the change in attitudes across all demographic groups does seem to indicate a gap between opinion and policy.

Unfortunately, the Pew survey does not report findings by state. It would be interesting to see whether attitudes in Wisconsin, the birthplace of welfare reform, have changed in the past 13 years on this issue. What has changed in our state is the volume of people receiving assistance. In 1994 the average monthly total recipients of welfare (Aid to Families with Dependent Children, or AFDC) numbered 226,197. In December 2006 the total recipients of welfare (Temporary Assistance for Needy Families or TANF) in Wisconsin equaled 36,420. It seems unlikely that a change of that magnitude wouldn't impact public opinion in some way. Is Wisconsin more or less like the rest of the nation? Perhaps an argument could be made either way.

PPF in the morning

The reaction to Don Imus referring to female basketball players as “nappy-headed hos” highlights an important finding from the Forum’s 2006 survey on race relations: Whatever our race, we are typically not exposed to offensive racial terms. In the survey, we asked 400 whites, 400 blacks and 200 Hispanics: “In the past year, …has someone called you an offensive term?” Responding “yes” were 11% of whites, 23% of blacks, and 32% of Hispanics.

Interestingly, the survey found that people of color are more likely to feel ignored than insulted. Half of African Americans and 38% of Hispanics report having been ignored because of their race, presumably by a store clerk, a loan officer or perhaps a teacher. While overt racial jokes and slurs draw attention, saying nothing whatsoever can be offensive too.

April 3: The Ultimate MPS Survey

In a few days, Milwaukeeans will elect members of the Milwaukee School Board. Let's hope we choose board members who pay attention to their constituents.

Over the past 30 years, Milwaukee’s children have been subjected to massive busing and racial desegregation; plans to split the district into pieces; efforts to take the schools out of the hands of an elected board and turn them over to the state or the mayor; decentralization; the return to neighborhood schools; No Child Left Behind and high stakes testing; school to work; school vouchers; and now recentralization.

These reforms add up to one rule of life: Education reform is rarely about education. It tends to be about ideology, politics, power, business and money. And often the powers that be don't listen to what children and their parents want and need.

That’s why the Forum, at the request of MPS administrators, conducted telephone interviews last year with 900 city residents. The findings read like a primer on priorities for the newly-elected Milwaukee School Board.

First, most people envision schools as being more like full-service social service agencies. They want MPS to provide adult mentors for children, before/after school programs, employment counseling, measures to improve attendance, nursing services, social services like mental health counseling, housing assistance for poor families, and measures to reduce poverty.

Also, more than 80% think it is extremely important that MPS provides violence prevention services, as well as other measures to improve safety and discipline – such as scanning everyone who enters school buildings for weapons, assigning police officers to work in middle and high schools, using dogs to search student lockers for controlled substances, and drug and alcohol prevention programs.

A related finding is that the worst perceived problems in MPS have nothing to do with the schools themselves – as we think of them with today’s blinders on. The biggest problems - lack of resources, parental involvement, discipline, drugs/alcohol, and student safety - are not internal, in fact, to the actual school system as it is currently constituted. Things more within MPS’s control, such as efficiency, discrimination, quality of principals and teachers’ ability, are not perceived to be major problems.

If MPS is going to listen to its customers, school board candidates – and certainly next week’s winners – need to address these findings.

Specifically, candidates need to contemplate this question: What would schools look like if they were full-service agencies that combined the functions of state, county, municipal and school governance?

The list of “what-ifs” is long and may be helpful for sparking discussion and thoughtful debate:

• What if all three of the largest governments in Wisconsin, not just MPS but also the city and county of Milwaukee, were major players in all MPS schools – and were responsible for MPS outcomes?
• What if current partnerships – such as the new Browning School that shares a building with the Silver Spring Neighborhood Center, or Metcalfe that shares a building with the Boys and Girls Club -were replicated system-wide?
• What if MPS provided more direct services -adult education, health care, job placement, parenting education?
• What if the schools were more of an information clearinghouse and referral service for the families of their students?
• What if every school had social workers doing case management and coordination for all their students and their students’ families?
• What if the informal triage that divides children into future productive citizens and future prisoners were replaced with a coordinated state/county/city/MPS partnership truly aimed at leaving no child behind?

Suppose the school board got creative to address the real concerns of actual children and their families? Then this election could get interesting.

Race relation-omics?

The Forum's public opinion survey on race relations released late last year found race relations in SE Wisconsin are poor and not perceived as getting better. But we also found that in areas of interpersonal relations, such as marriage, adoption, friendship, etc., attitudes toward people of another race have improved across the board since we last surveyed on the issue in 1991. How can one survey find such disparate results? The answer may lie in economics.

A recent column by Tim Harford in Forbes magazine highlights the research economists have done on racism and concludes:
Economists tend to assume that people respond to the incentives they face. If that's true, we have to face up to the fact that young black Americans are facing some lousy choices. There is a lot of work for all of us to do.

Turns out economists are making a distinction between "taste-based" discrimination and "statistical" discrimination. The former is when discrimination occurs because of a dislike of minorities, the latter is when race is used as a marker for a trait to be selected out. Harford explains:
Non-racial statistical discrimination is actually rather common: An insurer will consider your age and your sex when deciding how much to charge for auto insurance. Why? Because the stereotypes, however crude and however unfair to individuals, contain a bit of extra information.

Harford's pessimistic conclusion arises from the realization that statistical racial discrimination by employers could be an economically reasonable position, if race is, in fact, a relatively reliable marker for something such as the quality of school attended. In that case an employer will respond to the positive incentive resulting from discrimination:
A racist who turns down workers even though he knows them to be competent will take a hit to the bottom line, but statistical discrimination could improve profits, which makes it harder to stamp out. As long as an employer can learn something extra from an applicant's race that he can't learn from looking at a résumé...then the worrying possibility for profitable discrimination exists.

So, the longer most minority children are attending the country's worst schools, the more reliable race is as a marker for quality of schooling. Even more troubling, however, is evidence that statistical racial discrimination based on an unreliable marker can cause the marker to become more accurate.
[Roland] Fryer and two colleagues, Jacob Goeree and Charles Holt, showed how statistical discrimination could easily lead to a vicious circle. They used computer-based classroom games that assigned students the role of employers, "purple" workers and "green" workers. Students in the role of employers quickly jumped to the mistaken conclusion that purple workers were uneducated, and that view became self-fulfilling, as purple workers abandoned hope of getting hired and stopped paying for education. Once the downward spiral set in, a color-blind employer would actually lose money.
"I was amazed," recalls Fryer. "The kids were really angry. The purple workers would say, 'I'm not investing [in an education] because you won't hire me', and the employers would respond 'I didn't hire you because you weren't investing.' The initial asymmetries came about because of chance, but people would hang onto them and wouldn't let them go."

Thus, if people feel that the instances in which they make distinctions based on race are not due to dislike of that racial group, but to a racially-relevant factor, we can find individuals reporting that their own attitudes about race have improved while race relations overall continue to be dismal. Because, if you're on the receiving end of the discrimination, does it really matter what label an economist has given it?