Overview. In her early career, Linda Norlander, BSN, MS, RN, swayed from bedside nursing and home care in Minneapolis to public health nursing in rural Minnesota. Later, she immersed herself in improving the end-of-life experience, and then moved on to the mental health field. In rural areas of Minnesota in the early 2000s, patients in a mental health crisis could only turn to their family doctors for help. Mental illness, Norlander discovered, was “hidden under a rock”—hidden, that is, until Norlander began to scrutinize it.
Drawn to hospice. As a student at the University of Minnesota, Norlander ruled out becoming a doctor because she had no interest in calculus or organic chemistry, two grueling prerequisites on the long road to a medical degree. Instead, she found herself torn between majoring in English or social work, but worried that an English degree might not translate into a job after graduation.
Ultimately, she said, her interests in social work, medicine, and health care “pushed me into nursing.” Norlander earned her undergraduate degree in nursing and later a master’s degree in nursing and public health from the University of Minnesota.
Her early career focused on hospital bedside nursing in Minneapolis. But when Medicare started a certified home care program in the 1980s, that was the field she chose. “I really found my calling there. I loved seeing patients in their own environment. I loved the challenge of ‘how do we work with the patients when we are guests in their homes?’”
This home care nurse then moved with her family to rural Minnesota, where she began a 10-year career as a public health nurse, “doing everything from wound care to working with teen moms and their new babies,” said Norlander. The move also gave her a different career focus. “I found that the patients that particularly drew me to them were the patients who were dying. We didn’t have a good way to take care of them, and the hospice movement, in the 80s, was in its infancy.”
To be a part of the fledgling movement, Norlander became patient care coordinator for North Hospice in Robbinsdale, Minn., treating patients both at home and at an inpatient hospice unit. There, she said, “I started developing my passion for doing better care for people who didn’t have long to live.”
“I think we really do make a difference for patients and families. We are meeting them at such a critical point in their journey and helping them through difficult times.”—Linda Norlander.
Making the connection with RWJF. Norlander next moved to St. Paul as hospice manager for the Health Partners Hospice of the Lakes, where she “kept getting bumped into more management positions.”
She soon participated in an Institute for Healthcare Improvement project to improve end-of-life care, which in 1999 prompted three Minneapolis-based health care organizations to form the Minnesota Partnership to Improve End-of-Life Care. The partnership included the Allina Health System, Fairview Health Services/BlueCross Blue Shield of Minnesota, and HealthPartners.
In October 1999, the partnership received a grant (ID# 37635, $445,140, October 1, 1999 to February 28, 2002) from RWJF’s Community-State Partnerships to Improve End-of-Life Care program to strengthen policies and practices for people at the end of life. For more information, read the Program Results Report. Norlander became director of the project.
Soon afterwards, a brochure about Robert Wood Johnson Foundation Executive Nurse Fellows landed on her desk. She recalls thinking, “I’m not an executive nurse” and put the brochure at the bottom of the pile. But “this brochure just wouldn’t go away.”
Mental health service shortages in rural areas. Finally, Norlander decided to apply, and was accepted into the 2001 cohort. RWJF Executive Nurse Fellows is a three-year, advanced leadership program to address the needs, opportunities, and challenges of registered nurses in senior leadership roles. Through coaching, education, group training, and individual initiatives, the fellowship builds capacity among nurses to help transform health care at the local and national levels. It enrolled its first cohort of nurses in 1998; its final cohort starts in 2014. For more information, read the Program Results Report.
As part of the program, Norlander received funding to design a leadership project in her home community. By then, she had taken what she described as a “needed departure from doing end-of-life care” and was program supervisor for the Minnesota Department of Health in St. Paul. Her new passion became the lack of mental health services in rural areas.
“In Executive Nurse Fellows, they push you to push yourself beyond your comfort level,” she said. “At that point, I had gotten comfortable and knowledgeable with end-of-life care. Rural mental health services was an area I knew nothing about.”
In Minnesota’s rural areas, Norlander noted, “if a patient comes in with a mental health crisis, it’s the primary doctor or the family doctor who deals with it. We don’t have psychiatrists and psychologists in rural areas. The problem we wanted to address was the scarcity of mental health services in rural areas.”
RWJF Executive Nurse Fellows allowed Norlander to hire a facilitator and assemble a 28-member Rural Health Advisory Committee, including a rural primary care physician, a rural hospital director of nursing, and representatives from the consumer, government, academic, and insurer sectors. After meeting for six months in 2004, the committee developed The Rural Health Advisory Committee’s Report on Mental Health and Primary Care, which the Minnesota Department of Public Health published in January 2005.
Key findings. The advisory committee’s 114-page report indicated that some 950,000 people in Minnesota had mental health problems of some kind, including almost 180,000 with serious mental illness. The report also noted that rural Minnesota was experiencing its greatest growth in mental health distress.
Among other findings:
- Rural primary care providers had seen an increase in mental and behavioral health issues in their clinics.
- The shortage of rural mental health providers resulted in long waits for appointments and long travel to obtain specialty care.
- The cost of mental health care, the complexity of the payment system, and stigma were barriers for patients seeking care.
- Rural primary care practitioners needed and wanted more education on managing mental and behavioral health issues.
The committee concluded that community collaboration and integrating mental health services into rural primary care settings were essential to ensuring the best quality services. Recommendations included additional training for health care providers, adequate funding, and state and federal policies that more effectively supported mental health care.
The committee presented their recommendations to public and private policy-makers in Minnesota. Norlander also presented the report at the 2005 National Rural Health Association conference in New Orleans.
“I know that one of the recommendations was actually picked up by one of our senators and brought to Washington,” says Norlander.
Coming full circle. Norlander readily acknowledges that she could not have hired a facilitator and coordinated a committee to address rural mental health issues without funding from the RWJF Executive Nurse Fellows program. She also noted that she enjoyed working with her mentor during her time in the program, and is still in contact with her nearly 10 years later.
By 2014, Norlander’s career path had come full circle. After returning to the hospice field in 2007, Norlander was named director of clinical services for Franciscan Hospice in Seattle in 2014. She had also returned to one of her first loves: writing. Norlander is now the author of three books: To Comfort Always: A Nurse's Guide to End of Life Care (named the American Journal of Nursing’s 2009 Book of the Year in Medical-Surgical Nursing); Being Present: A Nurse's Resource for End of Life Communications (co-authored with Marjorie Schaffer) and Choices at the End of Life: Finding Out What Your Parents Want Before It's Too Late, (co-authored with Kerstin McSteen).
Norlander’s short story, “Aurie’s Last Dance,” won the 2009 Minnesota Magazine short fiction contest. It was inspired by a 2002 trip to Cuba that Norlander took with her RWJF Executive Nurse Fellows cohort to study the country’s public health system.
Cuba puts its limited resources “into public health, primary care, neighborhood clinics all over the place with disease prevention and training doctors and nurses. It is a different way to look at health care,” says Norlander.
“It was amazing,” Norlander recalled of the trip. “I would have to put that down as one of the great experiences of my life.”
RWJF perspective. The RWJF Executive Nurse Fellows program was created in 1997 to capitalize on the profession's strengths and build the leadership capacity of nurses. The leadership development program was designed to prepare a select cadre of registered nurses in leadership positions for influential roles in shaping the U.S. health care system of the future.
“Because of their front-line experience with patients and families, nurses bring a unique and valuable perspective to local and national efforts to transform our health care system," says Maryjoan D. Ladden, PhD, RN, FAAN, RWJF senior program officer and program alum. "The Executive Nurse Fellows program is part of the Foundation's building human capital strategy to develop a diverse and well-prepared workforce and leadership.”