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THE OFFICIAL PUBLICATION OF THE NORTH DAKOTA NURSES ASSOCIATIONSent to all North Dakota Nurses courtesy of the North Dakota Nurses Association (NDNA). Receiving this newsletter
does not mean that you are a member of NDNA. To join please go to www.ndna.org and click on “Join.” Quarterly publication direct mailed to approximately 16,000 RNs and LPNs in North Dakota
Vol. 85 • Number 3 August, September, October 2016
The North Dakota Nurse
Roberta Young MSN, RN, President NDNA
It is interesting to think about how many times a day a person thinks of safety. My daughter was raiding my pantry the other day and took a jar of my ‘Fall 2015 Salsa.’ She texted me wondering if it was still safe to eat. Apparently she had second thoughts! My son and husband got home from our farm quite late last week and my son was complaining of a headache. He was standing in front of our medicine cabinet trying to decide if it was safe for him to take ibuprofen since he hadn’t eaten all that much yet. I made him toast and soup just to be sure (be safe that is).
Questions and pondering about safety enter our daily lives all the time, in an unintentional manner. We are generally curious and do not want to cause harm. In professional nursing practice we are called to not only be intentional in our safety practices, but curious and passionate enough to continually improve a safe practice environment. I love visiting with nurses who stay curious in their practice. They are creative and have chosen to test their assumptions. They are interested enough to want to know “why” and “how come” and “what if!” I do believe it is a choice that contributes to a culture of safety.
One of Florence Nightingale’s quotes is a basic curiosity question:
“Let whoever is in charge keep this simple question in her head (not, how can I always do this right thing myself, but) how can I provide for this right thing to be always done?” Notes on Nursing: What It Is, and What It Is Not (first published in 1859).
The question, “How can I provide for the right thing to be always done,” leads us to the concept of highly reliable organizations (HRO) that many of us are reading about, working on, and assessing. Below are four trademarks of a system of high reliability:
•Errors and near-misses provide valuablelessons. For example, the organization usesnear-misses to reflect on the fact that thereareeffectivesafeguardsinplace.
What does culture of safety mean to you?
• Thesystemhasajustresponse to humanerroranddifferentiatesthe unintentionalactions from theintentionalones.
• The system providesforeasy,de-identifiedreportingofunexpectedevents or errors so that individuals are notdiscouraged from reporting them. In turn,theycanreceivefeedbackandlearnfromtheexperience.
• Leadersuselearningstoredesigntheoperationsand challenge the assumptions underlying thesystem,withthegoalofcreatingasafersystem.Frequently asked Questions about High Reliable Organizations (Ann Scott Blouin RN PhD, FHCHE. Advisory Board, April 15, 2015)
In other words, these systems are curious and relentless in studying errors and near misses in an effort to find ways to help prevent them. There is a culture of justness in the response to error with the structure to look differently on unintentional actions versus intentional disregard of a safety behavior. These systems provide for an easy way for all employees and patients to report events and near events so all can learn. This encourages active participation in making care safe. Lastly lessons are not wasted but used by leaders to design and resource novel safe workflows to deliver care. Leaders in these organizations do not let their underlying assumptions get in the way of implementing and testing new and innovative care that is safer.
Curiosity is honored, encouraged and expected in these safe practice environments. Today as you read this consider all the times you are curious about safety in your practice environment. Write the questions down, share with your colleagues and see what improvement plans come out of that. Congratulations! You are creating a culture of Safety.
Please consider joining the North Dakota Nurses Association. Together we can make care safer for the citizens of ND. Visit www.ndna.org.
McDougall Retires After 51 Years in the Medical Field
Nursing Student Association of North Dakota
Page 2 The North Dakota Nurse August, September, October 2016
The North Dakota Nurse Official Publication of:
North Dakota Nurses Association
General Contact Information:701-335-6376 (NDRN)
[email protected] Bryhn, MSN, RN
NDNA Director of State [email protected]
Vice President– Vice President–Communications Government Relations Jacki Bleess Toppen, Kristin RoersMSN, PMHNP-BC [email protected]@uhsinc.com
Vice President– Vice President–Finance Practice, Education,Donelle Richmond Administration, [email protected] Jamie Hammer, MSN, RNgmail.com [email protected] trinityhealth.orgDirector at Large-New GraduateKayla Kaizer [email protected]
Published quarterly: February, May, August and November for the North Dakota Nurses Association, a constituent member of the American Nurses Association, 1515 Burnt Boat Dr. Suite C #325, Bismarck, ND 58503. Copy due four weeks prior to month of publication. For advertising rates and information, please contact Arthur L. Davis Publishing Agency, Inc., 517 Washington Street, PO Box 216, Cedar Falls, Iowa 50613, (800) 626-4081, [email protected] NDNA and the Arthur L. Davis Publishing Agency, Inc. reserve the right to reject any advertisement. Responsibility for errors in advertising is limited to corrections in the next issue or refund of price of advertisement.
Acceptance of advertising does not imply endorsement orapprovalbytheNorthDakotaNursesAssociationofproductsadvertised, the advertisers, or the claimsmade. Rejectionof an advertisement does not imply a product offered foradvertisingiswithoutmerit,orthatthemanufacturerlacksintegrity,orthatthisassociationdisapprovesoftheproductor its use. NDNA and the Arthur L. Davis PublishingAgency, Inc. shallnot beheld liable for any consequencesresulting frompurchase oruse of anadvertiser’s product.Articlesappearinginthispublicationexpresstheopinionsoftheauthors;theydonotnecessarilyreflectviewsofthestaff,board,ormembershipofNDNAorthoseofthenationalorlocalassociations.
Writing for Publication in The North Dakota Nurse
The North Dakota Nurse accepts manuscripts for publication on a variety of topics related to nursing. Manuscripts should be double spaced and submitted electronically in MS Word to [email protected] Please write North Dakota Nurse article in the address line. Articles are peer reviewed and edited by the RN volunteers at NDNA. Deadlines for submission of material for 2016 North Dakota Nurse are 3/17/16, 6/16/16, 9/15/16 and 12/15/16.
Nurses are strongly encouraged to contribute to the profession by publishing evidence based articles. If you have an idea, but don’t know how or where to start, contact one of the NDNA Board Members.
The North Dakota Nurse is one communication vehicle for nurses in North Dakota.
Raise your voice.
The Vision and Mission of the North Dakota Nurses Association
Vision: North Dakota Nurses Association, a professional organization for Nurses, is the voice of Nursing in North Dakota.
Mission: The Mission of the North Dakota Nurses Association is to promote the professional development of nurses and enhance health care for all through practice, education, research and development of public policy.
Welcome New Members
Shawna StowmanLori Hodek
Kimberly StrankowskiShari LawrenceMargot Miller
Christina NicolasRobin Hayes
Brandi KastnerKristen Offerdahl
Julie TraynorElle Hoselton
Monica SorgenKristin KjelshusKarleen Cooper
Jacqueline SchwanMelissa Wagner
Jan LynchBiye Tambang
Connie KadrmasBernesia Radcliffe
This is the official call for nominations for the North Dakota Nurses Association Board of Directors. The 4 open positions on the board for the 2017-2018 term are President; Vice President of Finance; Vice President of Practice, Education, Administration & Research and Director at Large: New Graduate.
According to the current NDNA bylaws, the description of open positions are as follows:
The President shall:1. Serve as the official representative of the
association and its spokesperson on matters of association policy and position.
2. Chair the annual meeting and the NDNA Board of Directors.
3. Serve as an ex-officio member of all task forces and ad hoc committees except the nominating committee.
4. Serve as representative to the ANA membership assembly, provided that the ballot reflects that the president will also serve in that capacity.
5. Shall serve as a representative of NDNA at ANA meetings as appropriate.
6. Serve on the Board of the North Dakota Center for Nursing.
The Vice President of Finance shall: 1. Monitor NDNA fiscal affairs. 2. Provide reports and interpretations of
NDNA’s financial condition, as required to the Annual Meeting of the membership and the NDNA Board of Directors, coordinate an annual audit or financial review.
Official Call for Nominations for the NDNA Board of Directors 2017-2018 Term
The Vice President of Practice, Education, Administration, & Research shall:
1. Coordinate practice, education, administration and research activities and initiatives.
The Director at Large: Recent Graduate shall:
1. Coordinate with the Vice President of Membership to develop recruitment strategies for NDNA.
2. With the President, serve as a joint liaison with the Nursing Student Association of North Dakota Board of Directors.
3. The Director at Large: Recent Graduate shall be defined as one who has graduated from their first Registered Nurse educational program within five years of being elected into office.
Your current nominating committee members are:Jami Falk RN, CNML, MSSL & Karla Haug
Please contact [email protected] if you are interested in serving in any of the above positions or have names of nurses you would like to suggest for these leadership roles. All of the positions are 2 year terms. Each nominee will need to complete a “Consent to Serve” form.
The slate of Candidates needs to be solidified by August 15th, 2016. Elections will occur electronically in September. Installation of new board members will take place at the NDNA Annual Meeting & Conference on October 7 & 8th in Bismarck.
Thank you for your consideration to serve!
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August, September, October 2016 The North Dakota Nurse Page 3
Jacki Bleess Toppen MSN, RN, PMHNP-BC
The opioid epidemic is being called the worst public health crisis in this nation’s history. One American dies every 20 minutes from an opioid overdose (Volkow, 2016). Legislators, law enforcement officers, clinicians, educators, families, and those who struggle with addictions, as well as many others struggle to find ways to manage this crisis that has already cost us so many lives. Few have a real understanding of what it means to struggle with addiction.
According to the American Society of Addiction Medicine,
“Addiction is a primary, chronic disease ofbrain reward, motivation, memory and relatedcircuitry. Dysfunction in these circuits leads tocharacteristic biological, psychological, socialand spiritual manifestations. This is reflectedin an individual pathologically pursuingrewardand/orreliefbysubstanceuseandotherbehaviors.Addictionischaracterizedbyinabilitytoconsistentlyabstain,impairmentinbehavioralcontrol, craving, diminished recognition ofsignificant problems with one’s behaviors andinterpersonal relationships, and a dysfunctionalemotional response. Like other chronic diseases,addiction often involves cycles of relapse andremission. Without treatment or engagementin recovery activities, addiction is progressiveandcanresult indisabilityorprematuredeath” (American Society of Addiction Medicine, 1980).
Despite our knowledge of the disease concept of addiction, in many cases, we continue to treat addiction as a crime. Treating addiction as a crime is ineffective and inhumane. President Barack Obama spoke at the National Prescription Drug Abuse and Heroin Summit in March 2016 at which time he took a stance that more resources should be devoted to prevention and treatment
The Opioid Epidemic: Advocating for Increased Access to Life Saving Medications and Evidence Supported Treatments
rather than the “War on Drugs” of the past several decades. The White House committed $116 million to combat the opioid epidemic and support increased access to services (Kounang, 2016). This commitment from our nation’s capital is a powerful step toward decriminalizing and reducing the stigma for what we know to be a largely biologic disorder.
North Dakota is certainly not sheltered from the effects of this epidemic. From 2013 to 2014, North Dakota saw the greatest increase in deaths by prescription drug overdose than any state in the nation at 125%. A distant second was New Hampshire at 73.5% (Center for Disease Control and Prevention, 2016). Unintentional overdose is the leading cause of preventable death in this country and is a public health emergency. We need to focus on saving lives. Naloxone is a lifesaving medication that a person can administer at the time of an opioid overdose.
Many states have passed laws to expand access to Naloxone. In North Dakota, a prescription is required to obtain Naloxone. North Dakota Century Code § 23-01-42 states:A health care professional acting in good faith
directly or by standing order prescribe, distribute,ordispenseanopioidantagonist, ifthehealthcareprofessionalprovidestrainingto:a. An individual at risk of experiencing an
Anindividualwhoactsingoodfaithmayreceiveorpossessanopioidantagonistifthatindividualis:a. An individual at risk of experiencing an
inaposition toassistan individualatriskofexperiencinganopioid-relatedoverdose.
An individual who acts in good faithmay self-administer an opioid antagonist or administeran opioid antagonist to another individualwho issuspected to be at risk of experiencing an opioidoverdose.An individual may receive, possess, or
administer an opioid antagonist under subsection3 or 4, regardless ofwhether the individual is theindividual for or towhom the opioidantagonist isprescribed,distributed,ordispensed.An individual who prescribes, distributes,
dispenses, receives, possesses, or administers anopioid antagonist as authorized under this sectionisimmunefromcivilandcriminalliabilityforsuchaction(NorthDakotaCenturyCode,2016).
Even with increased access, many individuals are not trained to administer an injection of Naloxone properly and may be at risk of administering the medication incorrectly in a time of an acute crisis. Increased training for the correct use of Naloxone is needed. In November of 2015, the FDA approved an intranasal formulation of Naloxone, which is now available at a reasonable cost (about $38). Clinicians should give thought to providing education to all patients on the use of Naloxone if they are prescribing an opioid medication for any reason. Often, we only think of high-risk patients with known addictions. We forget that other people in the home may have access to medications; i.e., a child accidentally stepping on a discarded fentanyl patch lying on the floor, a patient taking the wrong dose or wrong medication inadvertently. The point is that accidents happen, and we need to prepare for them.
So how did we get into this position in the first place? There has been a lot of finger pointing to prescribers due to the huge increase in the
The Opioid Epidemic continued on page 4
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Page 4 The North Dakota Nurse August, September, October 2016
number of prescription opioids given to patients. There is no question that there has been an issue of overprescribing. Of all opioids prescribed worldwide, 85% are here in the United States. Seventy five percent of heroin abusers start with prescription opioids (Volkow, 2016). I have to state that I truly don’t believe that anyone goes into medicine with a careless attitude about getting their patients addicted to prescription drugs. People go into medicine because they want to cure diseases, not create them. For years, there was a misconception that there was lower potential for addiction when the patient has a real pain condition that is treated with an opioid. We now know that this is not the case. This misconception, strong government pressure to adequately manage pain with measurable outcomes, poor understanding of the concept of addiction, few nonpharmacologic options for management of chronic pain, all together have created a recipe for disaster. Did I mention that CMS links reimbursement largely to patient satisfaction (i.e. adequate pain management)? That’s a whole separate topic, but also food for thought. The more we waste time trying to assess blame, the longer it will take for all stakeholders to come together to come up with reasonable solutions.
We need to advocate for increased access to medications that are proven to treat opioid addictions. Medication-assisted treatments such as methadone and buprenorphine are proven to be effective for maintenance of opioid addiction, yet access to these medications is very limited. There are currently no methadone clinics in North Dakota. Due to the Drug Addiction Treatment Act 2000, only physicians can prescribe narcotic medications for maintenance of opioid addiction; the law excludes Advanced Practice Registered Nurses and Physician Assistants. Physicians who prescribe buprenorphine must obtain a special DEA license and are limited to 100 patients that they can treat at any given time. These barriers restrict access to proven medications to patients who are in need of treatment and as previously mentioned are currently dying from their addictions at a rate of one American every 20 minutes. Substance use disorders are a treatable disease. Discoveries in the science of addiction have led to advances in the treatment of substance use disorders that help people stop abusing drugs and prescription medications and resume their productive lives. Combating the opioid crisis is going to take a multi-faceted approach including education about responsible prescribing, expanding delivery of proven treatments, increased access to life-saving medications such as Naloxone, and new advances in the management of pain.
[ASAM Public Policy Statement on Treatment for Alcohol and other Drug Addiction]. (1980, March 01).
2. Kounang, N. (2016, June 2). Obama announces new moves to fight drug abuse. Retrieved June 11, 2016, from http://www.cnn.com/2016/03/29/health/obama-war-on-drug-abuse
3. Center for Disease Control and Prevention. Data Overview. (2016). Retrieved June 11, 2016, from http://www.cdc.gov/drugoverdose
4. North Dakota Legislative Branch. (n.d.) Retrieved June 11, 2016, from http://www.legis.nd.gov/general-information/north-dakota-century-code
5. Volkow, N. (2016, April 15). Opening ScientificPlenary and Distinguished Scientist Lecture.Lecture.
The Opioid Epidemic continued from page 3
Since the state convention this past winter, the Nursing Student Association of North Dakota board has been busy transitioning into their new roles and getting to know one another! Two meetings have been held and lots of changes have been made already. The first meeting took place on a beautiful February Saturday in Bismarck, where the old board members were able to attend and assist the new board in taking over the necessary duties. In March, NSAND had a few members attend the national conference in Orlando. This experience was an awesome opportunity to learn more about the profession
Nursing Student Association of North Dakota
of nursing while also getting a break from the cold North Dakota weather. Another meeting was held in April via Google Hangouts, as it was a very busy time for many of the nursing students and meeting in person was not feasible. The board spent time revising the bylaws and already preparing for the upcoming state convention. We hope to organize a time during the busy summer months where we can get together and continue updating the association and preparing for the state convention. We have a very enthusiastic and passionate group that makes up the 2016 NSAND Board and are excited to make an impact on the Nurses of North Dakota!
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August, September, October 2016 The North Dakota Nurse Page 5
Appraised by: Naomi Rudolph SN, Libby Olson SN,
Samantha Van Cleve SN, Hasan Abshir SN, Nadia Dudyreu SN
(NDSU Nursing at Sanford Health Bismarck, ND)
Clinical Question: In patients with Acute Respiratory Distress
Syndrome (ARDS), does placing them in the prone position decrease mortality rates?
Articles: Gattinoni, L., Tognoni, G., Pesenti, A., Taccone,
P., Mascheroni, D., Labarta, V., . . . Latini, R. (2001).Effect of prone positioning on the survival of patients with acute respiratory failure. TheNewEnglandJournal ofMedicine, 345(8), 568-572.
Guerin, C., Reignier, J., Richard, J., Beuret, P., Gacouin, A., Boulan, T., . . . Mancebo, J. (2013). Prone positioning in severe acute respiratory distress syndrome. The New England Journalof Medicine, 368(23) 2159-2168. doi: 10.1056/NEJMoa1214103
Fernandez, R., Trenchs, X., Klamburg, J., Castedo, J., Serrano, J.M, . . . and Lopez, M. J. (2008.) Prone positioning in acute respiratory distress syndrome: a multicenter randomized clinical trial. Intensive Care Medicine 34(8), 1487-1491. doi: 10.1007/s00134-008-1119-3
Park, S. Y., Kim, H. J., Yoo, K. H., Park, Y. B., Kim, S. W., Lee, S. J., . . . Sim, Y. S. (2015). The efficacy and safety of prone positioning in adult patients with acute respiratory distress syndrome: a meta-analysis of randomized controlled trials. Journal of Thoracic Disease,7(3), 356-367. doi:10.3978
Taccone, P., Pesenti, A., Latini, R., Polli, F., Vagginelli, F., Miatto, C . . . Gattinoni, L. (2009) Prone positioning in patients with moderate and severe acute respiratory distress syndrome: a randomized controlled trial. JAMA; 302:1977-84.
Prone Position in Patients with ARDSSynthesis of Evidence:
A total of five research articles were evaluated to answer the PICO question. Four article studies were randomized control trials, and one article was a meta-analysis. One of these studies included a 10 day randomized control trial done by Gattinoni et. al. (2001) involving 28 intensive care units in Italy and 2 intensive care units in Switzerland. The study focused on 304 patients; 152 patients were randomly assigned to the prone group and the other 152 patients were assigned to the supine (control) group. The patients that were assigned to the prone group were in the prone position for an average of 7 hours per day. Patients in the supine group were not repositioned to their stomachs at all during their stay. Every morning each patient was assessed for respiratory and biochemical variables used to monitor patients for system failure; which was criteria determined by Acute Respiratory Distress Syndrome Network Trail of the National Heart, Lung, and Blood Institute. Data was collected by having hospital staff members assess patients every morning and fill out the set criteria. The findings of this study indicated there is no significant decrease in mortality rates. However, they did determine that placing the patient in the prone position improved oxygenation status by 70% after the first hour and may be beneficial to patients who are unable to maintain oxygenation saturation. There are not specific limitations to this study, however, they do recommend another study be conducted in order to provide more accurate data.
Park et al. (2015) conducted a meta-analysis of 8 randomized control trials that took place in an adult intensive care unit. A total of 2,168 patients were included in this study. The intervention group of 1,099 was placed in prone positioning in conjunction with protective lung ventilation to decrease mortality in patients who suffer from severe acute respiratory distress syndrome or ARDS. The control-group of 1,042 was placed in the supine position. The results showed the patients placed in the prone position
had a decrease in lung strain and stress. This is especially helpful for the patients who are severely hypoxemic. The included trials were somewhat diverse with variable in the severity of ARDS, the duration of the prone position, ventilation strategies, and associated treatment. Secondly, all relevant evidence may not have been included considering all the articles searched were limited to English. Lastly, the small number of trials available may have led to underestimation of the heterogeneity and less precise estimates of the pool-effect. Prone positioning is a relatively safe procedure if equipment and position change is handled with great care. Prone positioning demonstrated a reduction in mortality rates in patients with ARDS in conjunction with lung-protective strategies and longer duration of the position (>12hrs). This procedure should be prioritized, although additional large RCT’s are required to continue researching this intervention.
Fernandez et al. (2008) conducted a randomized control trial in 17 Spanish medical surgical ICUs for period of 60 days to identify if prone position with patients with ARDS decreases the mortality rate. Participants in the study were forty mechanically ventilated adult patients with ARDS with the average age 54-55. The intervention group included twenty one patients positioned in prone position while control group included nineteen patients positioned in supine position. Patients turned prone demonstrated an apparent increase oxygenation within six hours, and this increase reached statistical significance on day 3. Also, discovered was a 15% reduction in mortality in the prone group compared with supine (38% vs. 53%). Although this difference fits the projected survival advantage, it did not reach statistical significance due to the small sample.
In addition, Taccone et al. (2009) conducted a randomized control trial at 25 different Intensive Care Unit facilities in Paris and Spain over a period of 28 days. A total of 342 patients diagnosed
Prone Position in Patients with ARDS continued on page 6
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Page 6 The North Dakota Nurse August, September, October 2016
with ARDS were included in this study. The intervention group was 168 patients placed in prone position for twenty hours of each day. The control group was a group of 174 patients that remained in the supine position for the 28 day period. They were only able to be placed in prone position in emergencies. Sequential Organ Failure Assessment scores were calculated each day to assess how each patients’ organs were functioning in prone or supine position. The primary outcome that was measured was death from any cause. Investigators did not get to see outcome data until the end of the study. At the end of study it was concluded that mortality rates between the two groups had no significant difference because in a population of 342 people any mortality rate below 15% cannot be identified. The 72 hours allowed for enrollment may not have been favorable because sooner interventions would have been more effective.
Prone Position in Patients with ARDS continued from page 5 Lastly, a prospective multicenter randomized controlled trial conducted by Guerin (2013) over a 5 year period. Patients were recruited from 26 ICU in France and 1 in Spain. The purpose of this research was to identify if prone positioning would decrease the mortality rate in patients with ARDS versus supine positioning. The study included two groups. First group consisted of 229 patients assigned to supine positioning who remained in a semi-recumbent position during mechanical ventilation for 4 hours. The study included 237 patients assigned to the prone position who were turned to the prone position within the first hour after randomization. They were placed in a completely prone position for at least 16 consecutive hours with mechanical ventilation. In supine group, measurements were performed every 6 hours. In the prone group, measurements were taken just before the patient was turned back to the supine position, after 1 hour of prone positioning, just before the patient was turned
back to the supine position, and 4 hours after the patient was returned to the supine position. A total of 31 cardiac arrest occurred in the supine group versus 16 in the prone group (P=0.02). Mortality rate at day 28 was significantly lower in the prone group than in the supine group and persisted at day 90. In conclusion, this trial showed that patients with ARDS and severe hypoxia could benefit from prone treatment when it is used early and relatively in long sessions.
Bottom Line: Three out of the five studies concluded that
there was no significant difference in regards to prone position and decreased mortality rates. The two other studies indicated a decreased mortality rate if patients with ARDS were placed in the prone position. Considering that half of the studies indicate no significant difference and the other half of the studies indicate that placing patients in the prone position does decrease the chances of mortality rates more studies need to be conducted. In conclusion, placing ARDS patients in the prone position is not going to harm them so we would recommend this intervention if our patient is not maintaining their oxygen saturation.
Implications for Nursing Practice: Evidence suggests that we should place
patients in the prone position if they are unable to maintain their oxygenation status. This may not decrease likelihood of mortality but evidence states that it will improve their oxygenation saturation. This occurs because the prone position allows the patients lungs to be at maximum expansion. This therapy should be assessed and reassessed often, as airway and breathing are included as our top nursing priorities.
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Printable application and position information at www.hrrv.org or call Human Resources at (701) 356-1601.
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www.tiogahealth.orgP: 701-664-3313 • F: 701-664-2240
810 Welo Street • PO Box 159 Tioga, North Dakota 58852
August, September, October 2016 The North Dakota Nurse Page 7
Appraised by: Mollie Anderson SN, Kristen Bortke SN,
Molly Horner SN, Bridget Mehrer SN(NDSU Nursing at Sanford Health Bismarck, ND)
Clinical Question:In adults, is bacteriostatic normal saline as
effective as buffered lidocaine in decreasing pain during peripheral IV catheterization?
Articles:Burke, S. D., Vercler, S. J., Bye, R.O., Desmond,
P. C., & Rees, Y. W. (2011). Local anesthesia before IV catheterization. American Journal ofNursing,111(2), 40-47.
Ganter-Ritz, V., Speroni, K. G., & Atherton, M. (2012). A randomized double-blind study comparing intradermal anesthetic tolerability, efficacy, and cost-effectiveness of lidocaine, buffered lidocaine, and bacteriostatic normal saline for peripheral intravenous insertion. JournalofInfusionNursing, 35(2), 93-99.
Kabre, C., Fortune, V., Hurley, J., & Winsett, R. (2011). Randomized controlled trial to compare effects of pain relief during IV insertion using bacteriostatic normal saline and 1% buffered lidocaine. Journal of PeriAnesthesia Nursing, 5(26), 310-313. Doi:10.101016/j.jopan.2011.05.009
Winfield, C., Knicely, C., Jensen, C., Taylor, S., Thomas, K., Conaway, M., Burns, S., & Quatrara, B. (2013). What is the least painful method of anesthetizing a peripheral IV site? Journal of Perianesthesia Nursing, 28(4), 217-222. http://dx.doi.org/10.1016/j.jopan.2012.09.00
Synthesis of Evidence:Four experimental studies were analyzed as
evidence regarding the PICO question, each study was examined for its credibility and validity. The studies included fit within the inclusion and exclusion criteria set by the appraisers.
The first study was a randomized, double-blind, parallel-design quasi-experiment conducted by Burke, Vercler, Bye, Desmond, and Rees (2011). It compared the patients pain rating during the
IV Catheterization Pain AnalgesiaIV peripheral catheterization and the type of pain analgesic used. The population studied was adults (18-80 years old) who went through the same-day surgery unit from February to May in 2008; 150 patients were enrolled in the study. The patients were split up into two groups, one group received a bacteriostatic normal saline injection prior to intravenous catheterization as a means of an analgesic; the other group received buffered lidocaine before intravenous catheterization as the other means of analgesic. Findings of the study showed that the patients who received the buffered lidocaine as the analgesic reported a lower perceived pain level.
The second study appraised was a randomized control trial performed by Winfield et al (2013) in a 23-bed surgical unit. Data was collected from 94 individuals who were given either lidocaine, bacteriostatic normal saline, or topical spray analgesic prior to peripheral IV insertion. After being given one of the pain relief measures and upon IV insertion, the patients rated their pain on the Pain Analog Scale. There was no statistical difference in pain when anesthetizing the site using the above three methods. However, there was a difference in pain when the IV was inserted. The use of 1% lidocaine resulted in the least pain IV insertion when compared to topical spray. Research shows, the use of bacteriostatic normal saline (BNS) and/or lidocaine provides more effective options in controlling pain felt when starting IVs.
The third study analyzed was by Ganter-Ritz, Speroni, and Atherton (2012) and a double blind randomized control. They tested which intradermal anesthetic was the most effective for pain relief during IV insertion using a technique. Two hundred fifty six surgical patients met the inclusion criteria and were randomly put into one of the three groups (1% lidocaine, 1% buffered lidocaine, and bacteriostatic normal saline with a benzyl alcohol preservative). The subjects completed evaluation at three points during the study and were asked to rate their pain on a 0-10 scale. The conclusions drawn from this study
were that the lidocaine products were superior to the bacteriostatic normal saline when it came to lowering pain during IV cannulation.
Lastly, a double-blind randomized controlled trial by Kabre, Fortune, Hurley, and Winsett (2011) was reviewed. This study randomly selected 56 healthy Registered Nurses, aged 21 years or older, in a Midwestern nonteaching hospital. The study was conducted to determine if there was a decrease in the level of pain felt when inserting I.V.’s using bacteriostatic normal saline compared to 1% buffered lidocaine. Group participants received bacteriostatic normal saline in one hand and 1% buffered lidocaine in the opposite hand. Once the IV was put into place the participants were asked to rate the pain level they felt using a modified verbal descriptor scale and they were asked to select the preferred arm for future IV insertions. Kabre et al (2011) reported when inserting IV’s 1% buffered lidocaine was more effective in reducing pain compared to bacteriostatic normal saline; but bacteriostatic normal saline was effective in reducing pain and should not be ruled out.
Bottom Line:After reviewing all of the studies, the findings
were consistent. All studies looked at the pain control of buffered lidocaine and bacteriostatic normal saline in adults receiving peripheral IV’s. All four studies concluded that lidocaine was more effective in pain control compared to bacteriostatic normal saline. It also showed that bacteriostatic normal saline was effective in reducing pain as well.
Implications for Nursing Practice:A common deterrent to providing pre-insertion
analgesia is difficulty obtaining resources on the floor, the cost of lidocaine, and having to subject the patient to at least two injections. The need for the project is to improve patient I.V. satisfaction by decreasing pain ratings while using the most effective analgesic in lidocaine or bacteriostatic normal saline (BNS) while maintaining effectiveness and efficiency for nursing staff.
S a v e t h e D a t e
N D N A ANNuAl MeetiNg OctOber 7th & 8th
Presentation Medical Center in Rolla, ND, is seeking a Family Nurse Practitioner to staff our clinic. A provider can expect compensation for this position to be approximately $105,000 annually. There is also the opportunity to provide occasional coverage in our ER for additional
compensation. Benefits include medical, dental and vision insurance, along with malpractice insurance and reimbursement for CME. Excellent
student loan repayment options are available as PMC is a NHSC facility and with a HPSA score of 20. Relocation assistance is available. Providers who apply should be ATLS, ACLS and PALS certified.
For more information about this position, contact Chris Albertson, Human Resources, at 701-477-1949, ([email protected]).
Page 8 The North Dakota Nurse August, September, October 2016
Appraised by: Jesse Gall SN, Cayla Nelson SN,
Amanda Erickson SN, Ashlee Kalvoda SN (NDSU Nursing at Sanford Health Bismarck, ND)
Clinical Question:In postoperative patients, does listening to music
help reduce pain?
Articles:Cutshall, S., Anderson, P., Prinsen, S., Wentworth,
L., Olney, T., Messner, P., . . . Bauer, B. (2011). Effect of the combination of music and nature sounds on pain and anxiety in cardiac surgical patients: A randomized study. AlternativeTherapies inHealth andMedicine. 17(4), 16-23. Retrieved September 17, 2015, from Ebscohost.
Jose, J., Verma, M., & Arora, S. (2012). An experimental study to assess the effectiveness of music therapy on the post operative pain perception of patients following cardiac surgery in a selected hospital of New Delhi. InternationalJournal of Nursing Education, 4(2), 199-201. Retrieved September 17, 2015, from EBSCOhost.
Lin, P., Lin, M., Huang, L., Hsu, H., & Lin, C. (2011). Music therapy for patients receiving spine surgery. Journal of Clinical Nursing, 20, 960-968. doi:10.1111/j.1365-2702.2010.03456.x
Vaajoki, A., Pietilä, A., Kankkunen, P., & Vehviläinen-Julkunen, K. (2011). Effects of listening to music on pain intensity and pain distress after surgery: An intervention.Journalof Clinical Nursing, 21, 708-717. doi:10.1111/j.1365-2702.2011.03829.x
Synthesis of Evidence:A prospective clinical study with two parallel
groups was conducted by Vaajoki, Peitila, Kankkunen, and Vehvilainen-Julkunen (2011). One hundred and sixty-eight men and women were chosen for this study between March 2007- April 2009 to identify if listening to music after abdominal surgery helped alleviate pain intensity and pain distress for three days postoperatively. Forty-two men and forty-one women were in the music group. Forty-eight men and thirty-seven women were in the control group. Pain intensity and pain distressed were measured using the VAS pain assessment tool eight times before and after intervention. Patients who were a part of
Music Therapy Postoperatively for Pain Controlthe control group were treated the same as music group, their only difference being the music intervention. Pain while deep breathing, resting and shifting positions were all assessed each time. At the end of the study results showed that in the music group, the patient’s pain intensity and distress in bed rest, deep breathing, and shifting positions were significantly lower on the second postop day compared to control group. Some limitations to this study include that music interventions were occasionally interrupted by other nursing tasks that needed patients full attention.
A stratified randomized controlled trial was conducted by Cutshall et al (2011) to decide whether or not music/nature sounds decreases pain and anxiety on cardiac surgical patients. There were 100 participants, forty-nine were the music group and fifty-one were the control group. The VAS scale was used to evaluate pain, anxiety, relaxation, and overall satisfaction before and after the treatment. The music group received 20 minutes of standard postoperative care and music two times a day on postoperative days 2 through 4, while the control group received the standard postoperative care and 20 minutes of quiet resting period on days 2 through 4. Cutshall et al (2011) reported a significant decrease in pain scores in the music group. There was also a decrease in the need for opioids postoperative day 3 for the music group. The relaxation scores also improved. There were no major barriers in this study.
A quasi-experimental study design was conducted by Lin, Lin, Huang, Hsu, and Lin (2010) to determine if music therapy had effects on anxiety, postoperative pain, and physiological reactions in patients undergoing spinal surgery. Sixty patients were recruited from a veteran’s hospital. The study group listened to music the evening before the surgery to the second day after surgery, while the control group did not listen to any music. Patients’ level of anxiety and pain were measured with the VAS scale. Heart rate, blood pressure, and a 24-hour urinalysis were measured for physiological reactions. Lin et al (2010) showed that the differences between the two groups in VAS scores for both anxiety and pain were statistically significant. One hour after surgery, the mean blood pressure was also significantly lower in the study group than the control group,
but there were no significant differences found in the urinalysis for levels of norepinephrine or epinephrine. Some limitations of this study included that the research was conducted at a veteran’s hospital, so there were low numbers of females and the advanced age of the Chinese patients.
A randomized control study was conducted by Jose, Verma, and Arora (2012) to determine the level of pain perception among patients admitted in the cardiothoracic and vascular surgery department. Sixty-four subjects were selected but only sixty participated in the study. The one group was exposed to music after surgery for 30 minutes, while the other group rested for 30 minutes. Pain perception was measured using a numerical pain rating scale, structured opinionaire, blood pressure, and pulse rate. Jose, Verma, and Arora (2012) found there was a significant reduction in anxiety and pain in the group that received music compared to the control group. A limitation to the study is that patients were unable to choose the music they listened to after surgery. By having patients choose their favorite type of music, scores could be altered.
Each study had moderate sample sizes that detected statistically significant results. All four studies had an intervention of music therapy and a control group without music therapy. All four studies used the VAS numeric pain scale. All four studies provided a good description of the measurements. All of the studies reviewed suggest that music is an appropriate and effective intervention used to alleviate pain in postoperative patients.
Bottom Line:All four articles concluded that music therapy
is an effective measure in reducing patient’s pain perception postoperative. In three of the articles music therapy had a positive effect on blood pressure and heart rate.
Implications for Nursing Practice:Evidence suggests that offering music therapy
to postoperative patients will in fact help reduce pain. We recommend patients have access to music, whether it is via TV music channels or personal music players.
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August, September, October 2016 The North Dakota Nurse Page 9
Appraised by: Kari Bartholome, RN, Brittni Lenius, RN, and Trisha Steiner, RN,
Mayville State University, RN-to-BSN students
Clinical question: In adults with coronary artery disease (CAD), without a history of
myocardial infarction (MI), does the risk of having an MI decrease more with the use of cholesterol lowering medications compared to lifestyle changes, alone, such as diet and exercise?
Articles:1. Lytsy, P., Burell, G., & Westerling, R. (2011). How do prescribing
doctors anticipate the effect of statins? Journal of Evaluation inClinicalPractice, 17(3), 420-428. doi: 10.1111/j.1365-2753.2010.01442.x
2. Mills, E. J., Rachlis, B., Wu, P., Devereaux, P. J., Arora, P. & Perri, D. (2008). Primary prevention of cardiovascular mortality and events with statin treatments. JournaloftheAmericanCollegeofCardiology, 52(22), 1769-1781. doi: 10.1016/j.jacc.2008.08.039
3. Karalis, D.G., Victor, B., Ahedor, L., & Liu, L. (2012). Use of lipid-lowering medications and the likelihood of achieving optimal LDL-cholesterol goals in coronary artery disease patients. Cholesterol, 2012. doi: 10.1155/2012/861924
Synthesis of evidence: Prevention of cardiac events for adults with CAD can be facilitated by
encouraging exercise and a healthy diet but sometimes lifestyle modifications aren’t enough. Cholesterol-lowering medications are commonly used to decrease the amount of LDL (low-density lipoproteins, or bad cholesterol) from remaining in the blood which can help prevent MI for those with CAD. According to a survey from the Journal of Evaluation in Clinical Practice from 2011, 89.5% of physicians prescribe a statin medication to a patient without a history of CAD, but with risk factors.1 Additionally, 93% would prescribe a statin to those patients with a current cardiac history.1
These statistics speak loudly about the importance of cholesterol-lowering medications and their utilization in primary and secondary prevention of cardiac events. In addition to lowering LDL levels, our group found further
Cholesterol Lowing Medication, Lifestyle Changes and their Effects on Coronary Artery Disease
information, through extensive research surrounding this clinical question, showing that statin medications can also help prevent clot formation and reduce inflammation in the patient’s vascular system, adding to their potential cardiac benefits.2 Also, there is potential that the addition of a statin medication could add an additional three, or more, years to the life expectancy of those on statin therapy.1
Bottom line:Often diet and exercise alone are not an effective strategy to reduce the
risk of MI in patients with CAD. The gold standard is the addition of statin medications to reduce cholesterol and lipid levels in the blood. “While medication should not be viewed as a substitution for a healthy diet and exercise, statins continue to be the cornerstone of LDL-cholesterol-lowering in CAD patients.” (Karalis, Victor, Ahedor, & Lin, 2012, p. 6)
Implications for nursing practice: It is important for nurses to recognize the risk factors and symptoms for
CAD and MI, as well as the potential benefits of adding statin therapy (or other lipid-lowering medications) to the plan of care for adults with CAD. Nurses should also reiterate and further educate their patients on the importance of making effective lifestyle changes, as these measures have overall health benefits that cannot be achieved by medication therapy alone.
october 7thNDNA 2016:
culture of sAfetyRamada Inn – Bismarck
(1400 Interchange Ave.)Registration 9:00 am
Conference 9:30 am – 4:30 pmContinuing education hours applied for – Lunch provided
october 8thNDNA ANNuAl meetiNg
Annual Member Meeting 8am – 12pm – Breakfast providedNSAND & NDNA Board Meeting 12:15-1:30pm
Page 10 The North Dakota Nurse August, September, October 2016
Appraised by: Sabina Laughlin RN, Mayville State University
RN-to-BSN, Lanette Swendseid RN, Mayville State University RN-to-BSN, Megan
Sylling RN, Mayville State University RN-to-BSN
Clinical Question:How does rounding with intent of utilizing the 5
P’s (pain, potty, possessions, pathway and position) change patient experience in the acute hospital setting?
Articles:Dewing, J., & O’Meara, B. L. (2013). Introducing
intentional rounding: A pilot project. NursingStandard, 28(6), 37-44.
Fabry, D. (2015). Hourly rounding: Perspectives and perceptions of the frontline nursing staff.JournalOfNursingManagement, 23(2), 200-210. doi:10.1111/jonm.12114.
Harrington, A., Bradley, S., Jeffers, L., Linedale, E., Kelman, S., & Killington, G. (2013). The implementation of intentional rounding using participatory action research. InternationalJournal Of Nursing Practice, 19(5), 523-529.doi:10.1111/ijn.12101.
Hutchings, M., Ward, P., & Bloodworth, K. (2013). ‘Caring around the clock’: A new approach to intentional rounding. Nursing Management –UK, 20(5), 24-30.
Studer, Q. (2010). Thenurseleaderhandbook:Theartandscienceofnurseleadership. Gulf Breeze, FL: Fire Starter Publishing.
Synthesis of Evidence: Health care systems are being affected by the
implementation of the Affordable Care Act and the reimbursement changes associated with it. Patient
Purposeful Roundingexperience as reported by the Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) scores are driving reimbursement rates (Fabry, 2015). These changes are influencing health care systems to find ways to increase patient satisfaction. One method, intentional rounding, also known as hourly rounding or rounding with intent, has been implemented in many hospitals throughout the United States and other countries. The primary goal of intentional rounding is to engage patients on a consistent basis while making sure primary needs are addressed.
Three research articles focus on the implementation of intentional rounding. Harrington et al. (2013), used participatory action research (PAR) to implement rounding. The benefit to this type of implementation is the encouragement of staff participation as well as adaptation to the plan as it is implemented and reviewed. Both Dewing (2013) and Hutchings, Ward, and Bloodworth (2013), described education of staff prior to implementation. These articles both discuss the importance of staff training prior to implementing rounding.
A study completed by Dewing and O’Meara (2013) implemented a proactive approach to the education of nurse leaders prior to implementation of rounding with intent. These leaders then ensured front line staff had the tools needed, including guides, posters, and literature, prior to implementing patient rounding. Another study which documented the implementation process also had leadership working with the front line staff giving and receiving feedback in real time while directly engaging the staff. (Hutchings, Ward, Bloodworth, 2013). Both of these studies
resulted in positive feedback from both patients and direct care staff.
The articles reviewed are all very similar in the approach and intent to hourly rounding. The main topic is underlying within the different articles. Hourly rounding is patient focused and research is driven to study the effects of this nursing intervention. In a study that was performed by the Studer Group’s research subsidiary, the Alliance for Health Care Research, nurses who did hourly rounding with intent decreased multiple patient requests which resulted in decreased use of call lights (Studer, 2010).
Bottom Line: Hourly rounding with intent is implemented
to help nursing increase patient satisfaction. Studies support that the patient experience has benefited as there is decreased call light use, decreased patient falls, decreased pressure ulcers, increased staff satisfaction and increased patient satisfaction.
Implications for nursing practice: Hourly rounding is patient focused and
research is driven to study the effects of this nursing intervention. Before hourly rounding was implemented, “staff reacted to patient problems and requests rather than developing a focus to preventing them” (Harrington et al., 2013, p.524). Action items, such as the utilization of hourly logs, show the patients’ needs at a specific time which keeps staff accountable for rounding on their patients and are ways that facilities can implement changes to maintain hourly rounds. Nurses also need to educate their patients on the reasoning behind hourly rounding with intent to help the patient benefit even more from it.
Submitted by Chris Albertson
In less than a week, Peggy McDougall will leave the only profession she’s ever known. After 47 years at Rolla’s hospital and 51 years in the medical field, McDougall still wasn’t sure if she would make it to the exit of April 30th, her last official day.
“It might not be easy to walk out of here,” said McDougall from her office on the second floor of Presentation Medical Center, where she currently serves as the Vice President of Patient Care. McDougall’s career in health care began in 1965 as a Certified Nursing Assistant at St. Andrew’s Hospital in Bottineau, where she grew up. She attended a training program at the facility and received a nursing diploma and later attended Minot State University, earning a Bachelor of Science in Nursing.
McDougall did her pediatric rotation at the Rolla hospital and later was one of five nurses transferred to Presentation Medical Center. “Rolla was short on nurses in pediatrics because of all the babies being born here,” McDougall recalled, “I
was just 20 years old and wasn’t even old enough to be an official witness for patients to go into surgery. You had to be 21 to do that.” McDougall’s first official day in Rolla was June 16, 1969, and she remembered being a “bit overwhelmed.” She received a long list of patients and the medication for each one. “(The nurse in charge) said if I had any questions to just come find her,” McDougall said. “It was trial by fire but the nursing program I had in Bottineau was hospital-based so I did better that some of today’s nurses who come straight from the classrooms.” The first thoughts that came to McDougall on her first day reflected a different time in the history of medicine as well as the city of Rolla. “I thought, ‘Wow, it’s busier here than I thought it would be,” McDougall said. It was a time when Presentation Medical Center was bustling with new babies, the city was growing and even the simplest technology of the time wasn’t fully encompassed in hospitals. “There were no phones in patient’s rooms. There was just one at the desk, so when someone called for (a patient) we had to go find that person’s room and bring them to the phone,” McDougall said “it was quite interesting.” Babies and new mothers were a big part of another exasperating experience of McDougall’s. In 1974, when the new hospital was finished the staff began transferring newborns and children to the new facility. “That kept us busy,” McDougall said, “it was hectic. That was a time when we kept newborns and moms for three to five days and our average pediatric case count was 15-18 patients of kids age 2 months to teenagers.” Rolla’s hospital was staffed with three doctors in those days and served patients with needs ranging from intensive cardiac care and strokes to cold and flu symptoms. “We would keep all the patients here, there was not transferring out,” McDougall said. “A lot of procedures that are common now weren’t even invented back then.” Along those same lines, McDougall said the burst of technology during her half century in medicine is by far the biggest change she’s seen. As an example, she pointed out the first cardiac monitor the hospital has was “about as big as two big filing cabinets put together, while today’s machine is hand-held.”
Beyond the technology, however, McDougall said another noticeable change at the facility involves a seemingly “constant turnover” of employees in
nearly all medical concentrations from nurses to doctors. “When we were asked to work an extra shift, we just did it, there were no second thoughts,” McDougall said. “It was a job where dedication was expected and I just thought, ‘People need me.’”
In contrast, McDougall said today’s workers don’t always feel the same way, but pointed out that she bears them no ill will for it. “I think it’s just a generational thing,” McDougall said. “Kids today are looking for things that are bigger and better.”
In her current job, McDougall has spent a lot of time trying to fill the health care positions that come open at Presentation Medical Center as well as scheduling clinic and emergency room staff. That’s a far cry from being a nurse and she considers the added responsibilities as her biggest trials. “People kept giving me things to do and none of it is easy,” McDougall said. “It’s all a challenge.” That’s not to say McDougall has faced all of this alone. She said her co-workers, some of whom she’s worked with for four decades, were also a key to her longevity and ability to do the jobs. “There are a lot of people here who I share a distinct connection with and when they’re not around, it’s like I’m missing my left arm,” McDougall said. “We’ve always depended on each other. We know exactly what we need to do, we don’t even need to talk about it. That’s a special bond.” It’s also one McDougall said she will miss dearly after April 30. “It won’t be the same not interacting with them every day,” she said. Retirement will give way to McDougall’s hobbies. She and her husband, Ross are both noted photographers who have had pictures published in outdoor magazines and calendars. The couple is also involved in high-tunnel gardening. Peggy said after April 30th, it won’t feel like she’s married to the hospital and she can slow down a bit as well as visit the couple’s son, Shane, and his family in Texas. As she looks back on her 50-year career, she said the most gratifying moments will forever be in her heart. “Initially, it was the patients who appreciated the care I gave them and as time went on, it was the staff who wanted to work hard for me,” McDougall said. “Today it’s the respect and credibility that I’ve gained with my peers. It’s something that came with years and years of experience.”
McDougall Retires After 51 Years in the Medical Field
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August, September, October 2016 The North Dakota Nurse Page 11
Join NDNA Now! Use form provided or go to www.NDNA.org
American Nurses Association
Re-Elects PresidentSILVER SPRING, MD – The American
Nurses Association (ANA) announced that Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN has been re-elected as President of the professional association that represents the interests of the nation’s 3.6 million registered nurses (RNs).
The voting representatives of ANA’s Membership Assembly also elected five members to the nine-member board of directors. Terms of service begin January 1, 2017.
“For the past two years, it has been with great pride that I have led ANA, a trusted voice that represents nurses in the halls of government, protects and promotes nursing practice, and influences healthcare policy,” said Cipriano, a member of the Virginia Nurses Association.
“Registered nurses are on the frontlines of providing lifesaving health care to millions of people each day and it is an honor to advocate for nurses and to lead an association committed to improving health care for all.”
The following ANA board members were re-elected: Secretary Patricia Travis, PhD, RN, CCRP, Maryland Nurses Association; Faith Marie Jones, MSN, RN, NEA-BC, Wyoming Nurses Association (two year term); and Director-at-Large, Staff Nurse Gayle M. Peterson, RN-BC, ANA Massachusetts. The newly elected board members are: Director-at-Large (one year term) Elizabeth Fildes, EdD, RN, CNE, CARN-AP, APHN-BC, Nevada Nurses Association; and Director-at-Large (two year term) Tonisha J. Melvin, MS, CRRN, NP-C, Georgia Nurses Association.
Those continuing their terms on the ANA Board are: Vice President Ernest James Grant, PhD, MSN, RN, FAAN, of the North Carolina Nurses Association; Treasurer Gingy Harshey-Meade, MSN, RN, CAE, NEA-BC, of the Indiana State Nurses Association; and Director-At-Large, Recent Graduate Jesse M.L. Kennedy, BSN, RN, of the Oregon Nurses Association.
Elected to serve on the Nominations and Elections Committee are: Amanda Jean Foster (Chair), BSN, RN, Arizona Nurses Association; Sabianca Delva, RN, ANA Massachusetts; and Annie Lee Bowen, MSN, RN, CPN, of the Ohio Nurses Association.
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Page 12 The North Dakota Nurse August, September, October 2016
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(800) 966-6278grandforkssubaru.com2400 Gateway Dr | Grand Forks, ND 58203
2016 Subaru 2.5i
*Manufacturer’s suggested retail price does not include destination and delivery charges, tax, title and registration fees. Prices, specifications, options, features and models subject to change without notice. **EPA-estimated fuel economy. Actual mileage will vary. See Grand Forks Subaru for complete details. Model GDB-01.
Grand Forks SubaruBetter People, Better Products, Better Prices
Grand Forks Subaru
Hiring RNs & LPNs$5,000 SIGN ON
BONUS POSSIBleWe hire new graduates and offer tuition reimbursement
For more information,
call 701-845-8222 or visit our website at
Applications can also be picked up at
979 Central Ave N, Valley City ND 58072
and faxed back to 701-845-8249.
Visit our new Facebook page @ www.facebook.com/sheyennecarecenter
North Dakota Nurses Association has teamed up with Mutual of Omaha Insurance Company to offer you a variety of products and services to help you protect your individual needs.
Association [email protected]
Everyone Deserves A Job They Love!!Let Us Help Today, Call 406.228.9541
Prairie Travelers is recruiting Traveling Healthcare Staff in Montana, North & South Dakota
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