One Profession. Many Roles.

Th e Off icial P ublica tion of the Ariz ona F ound ation for t he Fu ture of Nu rsing Arizon Q a N ua rterly Publica u tion dis r tribu s ted to e over 58,000 Registered N urses in Arizo Vol. 74 • Number 3 na JULY 2021

We’re Working for You! JOIN US TODAY Brought to you by the Members of AzNA. For more information on the benefits of membership, please visit www.aznurse.org.

PRESIDENT’S MESSAGE What is it you do?

Much of the public individuals, families, groups, communities, now include caring, compassionate presence, misunderstands what and populations. advocacy, and the recognition of the connection it is a nurse does. How • Where: Wherever there is a patient in need of to all humanity. often have you gotten the care. The updates in the 4th edition also include question “What is it you • When: Whenever there is a need for the influence of technology on nursing as well as do?” While this is a big knowledge, compassion, and expertise. adding to our professional advocacy standards topic for a small article, • Why: The profession exists to achieve the the influence nurses have in their practice. Other I would like to address most positive patient outcomes in keeping updates include the importance for nurses to have some important aspects with nursing’s social contract and obligation full practice authority at all levels and to quantify and sources that explain to society. what competent levels of nursing practice and what we do as nurses. professional performance look like. The American Nurses Selina Bliss, RN These updates to our scope and standards of The Nursing Scope and Standards, along with Association (ANA) provides practice don’t come around too often. The first the Code of Ethics for Nurses with Interpretive us with a guide that describes our scope of practice Standards of Nursing Practice were published Statements, are foundational documents that and the services that qualified health professionals by the ANA in 1973 as the profession sought guide our profession and help explain what it is are deemed competent to perform, and permitted to achieve the most positive patient outcomes we do. It is our resource and guide in our vital to undertake, under licensure. This guide was in keeping with nursing’s social contract and work providing safe, quality, and competent recently released during Nurses Month last May obligations to society. This updated version is a care. If we had more space here, I would love and is the 4th Edition of the Nursing: Scope and guide for Registered Nurses (RN) and Advanced to expand on how the Code of Ethics affects Standards of Practice. This essential document Practice Registered Nurses (APRN) meant to our practice as well, but I will have to leave it answers the who, what, when, where, how, and inform and guide nurses in their vital work to another day. In the meantime, it is exciting why questions of nursing: providing safe, quality, and competent care. to see through the updates in our scope and • Who: Registered Nurses (RN) and Advanced You may or may not remember in 2019 the standards that we are redefining nursing and Practice Registered Nurses (APRN) comprise ANA Nursing Scope and Standards Revision reaffirming our practice. the “who” constituency and have been Workgroup sought member input to this It is an honor to lead our professional organization educated, titled, and maintain active licensure document. Your input and mine were considered that is considered the voice of nursing in Arizona, to practice nursing. at that time. I was fortunate in that in December • What: Nursing is the protection, promotion, of 2019 when I was at the ANA headquarters Selina Bliss, RN, PhD, CNE, RN-BC, ANEF and optimization of health and abilities; in Silver Spring, Maryland, while representing President – AzNA prevention of illness and injury; facilitation the Western States (WEX) on the ANA Nursing of healing; alleviation of suffering through Practice Council, I was able to personally provide Source – American Nurses Association. the diagnosis and treatment of human input into the revised definition of nursing. (2021). Nursing scope and standards of practice response; and advocacy in the care of It is good to see the updates to the definition (4th ed.). Silver Spring, MD: Nursebooks.org.

President's Message...... 1 NeoECHO: Lessons Learned During a Success Pays ...... 2 Virtual Learning Community Intervention. . 12 Non-Profit Org. CEO’s Message ...... 3 Courage in Everyday Nursing Practice. . . . 13 U.S. Postage Paid Managing Moral Distress...... 4-5 An Educator’s Three Act Journey: Princeton, MN Save the Date! 2021 AzNA Convention. . . . 6 Navigating the Pandemic...... 15 Permit No. 14 BOD and AzFFN Updates...... 6 Scholarship Recipient ...... 15 current resident or Midwifery Led Care ...... 6 Fallen Nurses...... 16 Mortality and Severe Nomination for Nurse of the Year 2021 . . . 16 Maternal Morbidity...... 7 We Know We Are Home...... 16 Promoting Natural Immunity...... 7 The Cures Act...... 17 INSIDE AzNA/AzNF Calendar of Events. . . . . 7 Fun Facts About PACs...... 19 Epidemiology of Work-Related Caring During COVID-19...... 20 Musculoskeletal Disorders ...... 8-9 Two Year Anniversary Members. . . . . 22 Ask Nurse Melissa ...... 10 AzNA’s Superstars ...... 22 The COVID-19–Cancer Connection. . . . .11 Welcome New & Returning Members. . . . 23 Page 2 • Arizona Nurse July, August, September 2021

Call for Article Submission Arizona Nurse Editorial Board Submit your article or research for publication in AzNA’s quarterly print publication. Carol Peyton Bryant, DNP, RN, ACNP, CCRN Kim Callahan, RN The Arizona Nurse is distributed to over 58,000+ RNs in the state. Rebekah Christopher, RN Anna Hustin, MSN, RN, NE-BC AzNA welcomes submission of nursing and health related news items and original articles. Sherry Ray, EdD, MSN, RN, CHSE We encourage short summaries and brief abstracts for research or scholarly contributions Melisa Salmon, MSN, RN, CCRN, MBA with an emphasis on application. Alicia Shields, MSN, RN, CENP, DNP-student Melissa Zuber, BSN, RN To promote inclusion of submitted articles, please review the article guidelines available The editorial board of the Arizona nurses is comprised of on the AzNA website at www.aznurse.org/Guidelines. members of the Arizona Nurses Association, who review all submissions, provide expert advice on content, attract new authors, An “article for reprint” may be considered if accompanied by written permission from the and encourage submissions. author and/or publisher as needed. Authors do not need to be AzNA members. If you are interested in serving on the editorial board, please contact [email protected] for more information. Submission of articles constitutes agreement to allow changes made by editorial staff and publishers. See article guidelines for more information. Submit your article to [email protected].

Chair: Rhonda Anderson, DNSc, RN, FAAN, FACHE Vice Chair: Pat Mews, MHA, RN, CNOR Secretary: Chloe Littzen, BSN, RN Scholarship Chair: Sharon Rayman, MS, RN, CCTC, CPTC Elected Trustee: Carol Stevens, PhD, RN Elected Trustee: Congratulations to the following nurses who have taken advantage Kimberly Behrens-Grieser of the Success Pays offering by ANCC to AzNA Members! Elected Trustee: Phillip Guarrera • Theresa Chmidling, RN-BC; certified Medical Surgical Nurse Executive Director: Dawna Cato, PhD, RN, NPD-BC aznurse.org/SuccessPays

AzNA partners with the American Nurses Credentialing Center (ANCC) using the Success Pays Program to support professional development of nurses, increase the number of certified nurses in the workforce, decrease test-taking anxiety and reduce financial burden for our members. Board of Directors Take the exam up to two times and pay the reduced rate of $260 only if they pass the exam. President: Selina Bliss, PhD, RN, CNE, RN-BC Save time, money and anxiety. Vice President: Heidi Sanborn, DNP, RN, CNE Certifications with ANCC can also be renewed through AzNA at a reduced price of $250. The Secretary: Arizona Foundation for the Future of Nursing is offering scholarships through the Sasmor Scholarship Amanda Foster, BSN, RN Fund. The first ten AzNA members per year who successfully pass their certification exams will have Treasurer: their ANCC fees paid in full. Beth Hale, PhD, RN Government Affairs Officer: Success Pays is offered to all AzNA Members. Not a member? Join today – aznurse.org/JoinToday Denice Gibson, DNP, RN, CRNI, BMTCN, AOCNS Director-At-Large: Janice Bovee, MSN, CNM Director-At-Large: Robert “Bill” Adams, MSN, RN, CDCES, NHDP-BC Past President: Carol J. Stevens, PhD, RN Staff Dawna Cato, Phd, RN, NPD-BC, Chief Executive Officer Wendy Knefelkamp, Director of Operations Debby Wood, Senior Project Coordinator Madi Moyer, Communications Specialist The Arizona Nurse (ISSN 0004-1599) is the official publication of the Arizona Foundation for the Future of Nursing (AzFFN), peer reviewed and indexed in Cumulative Index for Nursing and Allied Health Literature. Arizona Nurse Author Guidelines are available at www.aznurse.org. Call 480.831.0404 or [email protected] for more information. No material in the newsletter may be reproduced without written permission from the Executive Director. Subscription price: included in AzNA membership or $30 per year. The purpose of the Arizona Nurse is to communicate with AzNA members and non-members in We are seeking highly motivated nurses order to 1) advance and promote professional nursing in Arizona, 2) disseminate information and encourage input Exciting nursing opportunities and breathtaking allure of Navajoland await and feedback on relevant nursing issues, 3) stimulate committed and highly motivated nurses. interest and participation in AzNA and 4) share information about AzNA activities. Come join us in Winslow! We are located just seven miles from the southern edge of the Navajo For advertising rates and information, please contact Nation, 45 minutes east of Flagstaff and a few hours north of Phoenix. You can go from Standing on Arthur L. Davis Publishing Agency, Inc., PO Box 216, Cedar the Corner of Winslow, Arizona to hiking scenic and majestic landscapes. Falls, Iowa 50613, (800) 626-4081, [email protected]. Responsibility for errors in advertising is limited to corrections in the next issue or refund of price of advertisement. • Clinical Nurse • Employee Health Clinical Nurse Advertisements do not imply endorsement nor approval by the Arizona Foundation for the Future of Nursing (AzFFN) • PRN • Infusion Clinical Nurse of the product advertised, the advertisers or the claims • Clinical Care Coordinator • Cardiology Clinical Nurse made. AzFFN shall not be held liable for any consequences • Public Health Nurse • Nurse Recruiter resulting from the purchase or use of advertised projects. • RN Case Manager AzFFN, AzNA and Arthur L. Davis Publishing Agency, Inc. • Urgent/Emergency Care Nurse Manager reserve the right to reject advertisements. Rejection of an advertisement does not imply that the offering or product for advertisement is without merit, lacks integrity, or that this association disapproves of the offering or product. The Arizona Nurses Association is a constituent member of the American Nurses Association. July, August, September 2021 Arizona Nurse • Page 3 CEO’S MESSAGE The Importance of Professional Association Membership

Dear Professional Colleagues, In addition to advocacy through our Public Community Partnerships The Arizona Nurses Policy Committee, AzNA members are hard at AzFFN is the philanthropic arm of AzNA. Our Association is committed to work developing content for the RNconnect highly engaged, volunteer Board of Trustees is supporting our members Initiative (Text RNconnect to 609289) to support hard at work creating and establishing meaningful and the nursing community the psychological well-being of our nurses. relationships with individuals and organizations at large through Advocacy, This opt-in platform continues to support that support our mission and focus areas. In Leadership, and Innovation. approximately 3700 nurses in Arizona and has partnership with the Cactus Pine Girl Scouts, we Our mission is to: Support the garnered national recognition. In April 2021, the delivered over 10,000 cases (120,000) boxes of girl advancement of the nursing program was launched in 17 additional states scout cookies! In partnership with Better Place profession to promote a healthy across the country. Forests, our fallen heroes will have a memorial Arizona. We strive toward To provide a small gesture of meaningful garden in Flagstaff Arizona! In partnership with this mission with four focus Dawna Cato, recognition, our very own Teri Wicker launched the March of Dimes, AzFFN is sponsoring the areas: Safe and Healthy Work AzNA CEO our “Hearts” campaign, Teri and her group of Distinguished Nurse of the Year Award! Finally, Environment, Professional volunteers have sewn and delivered over 10,000 oops! I can’t reveal another exciting partnership! and Leadership Development, Community hand-made hearts to nurses across the valley and This will be revealed at the AzNA convention, can’t Partnerships, and Membership Development and beyond! wait to see you there! Please visit aznurse.org/ Resources. As we begin to emerge from the Covid AzFFN to view our new website. Pandemic and reflect on what we have been through, Professional and Leadership Development I would like to take this opportunity to update you on AzNA provides many opportunities for Membership Development and Resources the work you have done as participatory members professional growth and leadership development. AzNA realizes that we have the opportunity even amidst a pandemic! Our Bylaws Committee, AzNA Convention to engage with our members in a meaningful Committee, Fallen Heroes Taskforce, Nursing way with effective use of technology. We have Safe and Healthy Work Environment Situation Monitoring and Response Team invested in the Reviewer platform to improve the We would like to recognize the hard work of the (SMART), and Nominations Committee are experience of nurse planners submitting for Nursing members of the AzNA Public Policy Committee who working hard to deliver on their respective duties Continuing Professional Development, invested in volunteered many hours reading, interpreting, and and tasks. We are pleasantly surprised by the an online learning platform to provide education commenting on the 83 bills we followed this session. increased engagement we have seen as we put and activities in a virtual format, and enhanced our Bills that were signed into law this session, and have a out a call for volunteers! We are also working hard website and social media platform. In addition, we direct impact on our profession, include: to support our emerging chapter leaders with are pleased to introduce Madison Moyer, our new • SB1220 modifies the definition of a licensed orientation, retreats, and AzNA board liaisons. AzNA Communications Specialist. Madison recently mental health professional as it relates to Our work does not end there, we have affiliate graduated with her Bachelor’s in Communication traumatic event counseling to include Mental nursing associations that align with AzNA to share from Messiah University in Pennsylvania and is Health Nurse Practitioners and Psychiatric resources, best practices, and collaboration for working remotely from Missouri. Welcome Madi! Clinical Nurse Specialists. the profession. As you can see the AzNA Board of Directors, • SB1278 promotes Advanced Practice Registered Recently, AzNA obtained re-accreditation AzNA Chapter Boards, Volunteers, Affiliates, AzNA Nurse preceptorships. by the American Nurses Credentialing Center Staff, and community partners have been hard at • BH26433 allows Nurse Practitioners and Clinical (ANCC) for our Approver Unit and Provider work recognizing, supporting, and elevating the Nurse Specialists to order home for Unit to award Nursing Continuing Professional critical role nurses play in Arizona’s Healthcare Medicaid patients. Development Contact Hours. We are excited to System. Through your hard work, commitment, and • HB2454 allows health care providers to use continue to provide this service to our practice engagement in the profession, Arizona is ranked #1 telehealth as a vehicle for a patient visit and get partners and have volunteers ready and willing to for the “best places to work!” (Best & Worst States for reimbursed by commercial insurers at the same review Individual Activities! Nurses (wallethub.com). rate as an in-person visit. As this bill journeyed Finally, our Success Pays Program and the Thank you, Arizona Nurses and AzNA members! through the legislative process, multiple Sasmor Scholarship Funds provided by the Your devotion to the profession has not gone amendments garnered the support of more Arizona Foundation for the Future of Nursing unnoticed. and more legislators. The final vote in the House (AzFFN) provides funding to obtain certification was unanimous (60-0). AzNA worked hard on through ANCC. Please check out this opportunity Dawna L. Cato PhD, RN, NPD-BC this bill from start to finish. It is a landmark win on our website at www.aznurse.org! AzNA CEO for Arizonans and Health Care Providers.

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Cynthia Saver, RN Effects of moral distress The COVID-19 pandemic has added to nurses’ Moral distress affects both individuals and Moral resilience daily work in many areas, including forcing them organizations. In individuals, it can produce Developing resilience can help nurses cope into situations where they feel moral distress. symptoms that are emotional (frustration, anger, Failure to manage this distress appropriately can anxiety, guilt, sadness, powerlessness, withdrawal), with moral distress more effectively. Strategies affect nurses’ wellbeing and cause them to leave physical (muscle aches, headaches, heart include: the profession. But applying strategies to help palpitations, neck pain, diarrhea, vomiting), and • Developing self-awareness (for prevent moral distress or resolving moral distress psychological (depression, emotional exhaustion, example, examine positive and negative in a positive way can benefit both nurses and loss of self-worth, nightmares, reduced job assumptions that may be guiding your organizations by promoting optimal patient care satisfaction, depersonalization of patients) in behavior to see if they are accurate). and reducing staff turnover and the risk of litigation nature. Repeated episodes of moral distress that • Learning to self-regulate to disrupt from clinical errors. aren’t resolved can accumulate as “moral residue,” negative patterns of thinking and with nurses ultimately experiencing burnout and behaving. Methods to help with this What is moral distress? leaving their jobs—or even their careers. include mindfulness-based stress According to the American Association of Job attrition causes organizations to incur reduction, meditation, and movement Critical-Care Nurses (AACN) tool “Recognize & turnover costs. More importantly, unresolved practices such as yoga and tai chi. Address Moral Distress”, moral distress occurs moral distress can negatively impact the quality of • Wisely discerning ethical challenges and when someone “knows the right thing to do, but patient care, potentially leading to adverse patient principled actions. This requires you events. This not only affects an organization’s to understand your values and analyze reputation in the community, but it could result in ethical dilemmas. greater liability exposure from errors. • Nurturing the willingness to take Moral distress strategy: courageous action. Keep in mind that The 4 Rs Taking action: What should you do if you are when speaking up, state your concerns experiencing moral distress? clearly and calmly. Cynda Hylton Rushton and Kathleen Turner • Discovering meaning amid adversity. Identify the source. The source may be a patient created a tool nurses can use to sort through It may help to keep a journal and to situations that can cause moral distress—the 4Rs. care issue, a policy problem (such as how family member meetings related to end-of-life issues are reaffirm your values. • Recognize. The first step is to recognize • Preserving one’s integrity, as well as the situation for what it is. To do so, be held), a lack of collaboration among team members, or something else. the integrity of the team, and others. aware of the complexities related to the Remember that you can seek support patient, the patient’s family, and the care Conduct a self-assessment. Self-assessment begins with determining the severity of the distress. from others, for instance, by talking with team, including what each party wants trusted colleagues or leaders. to happen and emotions that may affect The Moral Distress Thermometer, developed by their perspectives. Wocial and Weaver (2013), is used for research, but also can be helpful for clinicians. The thermometer Source: Rushton CH. Moral resilience: a capacity for • Release. Consider what you can change asks you to rate your distress on a scale from 1 to navigating moral distress in critical care. AACN Adv Crit and what you can’t. Let go of past 10 and includes descriptions (mild, uncomfortable, Care 2016;27(1):111-119; Rushton CH. Building moral experiences that aren’t helpful in the distressing, intense, and worst possible) to help resilience to neutralize moral distress. Am Nurse Today. current situation. with the process. The results will give you a sense 2016;11(10). • Reconsider. You may need to reframe an of how urgently you need to act, and you can use issue or view it in a new way. Be open to the tool to track changes in your distress over time. fresh approaches and ensure everyone The second component of self-assessment is Make the case. Share your concerns with the understands each other’s perspectives. determining your readiness to act. The “4A’s to Rise appropriate person(s). Present the facts in a calm, • Restart. At this point, you may find you Above Moral Distress,” published by AACN (2004), respectful way. Consider timing and location— are asking new questions or have new suggests asking yourself these questions: unless the situation is urgent, you’ll want to bring up ideas about how the situation can be • How important is it to you to try to change the the issue privately. Following the chain of command moved forward in a positive way. situation? is important, particularly if your concerns aren’t • How important would it be to your colleagues/ being acknowledged. For example, if a physician Sources: Hilton L. 4Rs strategy offers a fresh perspective unit to have the situation changed? isn’t listening to your concerns about lack of to confront ethical challenges. Nurse.com. 2020. www. • How important would a change be to the sufficient pain medication, you’ll want to involve nurse.com/blog/2020/09/15/4-rs-strategy-offers-a-fresh- patients/families on your unit? your immediate supervisor. If your supervisor does perspective-to-confront-ethical-challenges; Rushton CH, • How strongly do you feel about trying to not take action, move up to the next level. In the Turner K. Suspending our agenda: considering what will change the situation? case of non-clinical issues related to an individual serve when confronting ethical challenges. AACN Adv Crit • How confident are you in your ability to make team member, you may need to speak to a human Care. 2020;31(1):98-105. changes occur? resources representative. • How determined are you to work toward Document. Document your conversations, making this change? including whom you spoke with, the information constraints, conflicts, dilemmas, or uncertainty conveyed, and the response. If related to a patient make it nearly impossible to pursue the right course The AACN publication contains a rating scale, situation, record the information in the patient’s of action.” Moral distress differs from burnout, but you also can simply reflect on whether you feel health record. If you are dealing with a problem which refers to physical, mental, and emotional you are ready to act. Listing the risks and benefits with a team member or organizational policy, you exhaustion caused by workplace stress, and it of taking action may be helpful in making your should keep a personal record, so you can retrace differs from compassion fatigue, which is physical, decision. the steps you took. mental, and emotional weariness related to caring Keep in mind that in some cases the law will for those in significant pain or emotional distress. compel you to take action. For example, your state Prevention likely has laws requiring you to report child or elder Nurses, units, and organizations play a role Causes of moral distress abuse. Failure to do so leaves you open to legal in preventing moral distress and addressing it Various situations, usually related to values liability. You’ll also need to consider if the standard effectively should it occur. Nurses can enhance their conflicts, trigger moral distress. Examples of these of care is being violated. In these cases, failure to moral resilience (see Moral distress strategy: The situations include continuing what the nurse feels speak up can make you the target of a state licensing 4 Rs) and participate in professional development is unnecessary treatment for a patient or witnessing board complaint, or a target in any lawsuit related to activities such as continuing education programs inadequate pain relief because a provider fails to patient harm that occurs as a result. on ethics. order adequate medication. Develop a plan. Once you decide to take The AACN tool identifies strategies for units and Many external factors can constrain or stop action, consider when you will act, who will be organizations. Units can identify ethics champions nurses from acting in the way they wish, thus involved, and what resources are available to for peer support, create a committee to address contributing to moral distress. According to the you. For example, you may want to gather facts common areas that cause distress, and establish a AACN tool, unit-level factors include inadequate and share your concerns with a trusted colleague mentoring program for new staff. staffing, ineffective communication, working with to ensure you have a sound plan. Your plan Organizations can provide resources to support incompetent colleague(s), bullying, and lack of a should include self-care, as this will be a stressful staff (for example, an ethics consulting service), healthy work environment. Organization factors time. Resources to help you in assessing the provide education on topics such as debriefing, include inadequate staffing, lack of resources, situation and developing a plan include the ANA adopt zero-tolerance policies for all forms of pressures to decrease costs, hospital policies, Code of Ethics with Interpretive Statements, your violence, and offer programs that improve staff hierarchy of power, ineffective communication, state (when a practice issue is well-being. Ultimately, the goal should be to create and financial limitations. If not addressed, these involved), the ethics consulting service in your a healthy work environment. factors can lead to the disturbing effects of moral hospital, and your organization’s employee distress. assistance program. July, August, September 2021 Arizona Nurse • Page 5

AACN has identified six standards for a healthy American Nurses Association. (2015). Code of Ethics Cynthia Saver, MS, RN, is president of CLS work environment: skilled communication, true with Interpretive Statements. www.nursingworld. Development, Inc., in Columbia, Md. collaboration, effective decision-making, meaningful org/practice-policy/nursing-excellence/ethics/ recognition, appropriate staffing, and authentic code-of-ethics-for-nurses/coe-view-only. Disclaimer: The information offered within this leadership. A healthy work environment improves Hilton, L. (2020). 4Rs strategy offers a fresh perspective article reflects general principles only and does to confront ethical challenges. Nurse.com. www. nurses’ psychological health, job satisfaction, and job nurse.com/blog/2020/09/15/4-rs-strategy-offers-a- not constitute legal advice by Nurses Service retention; it also results in reduced patient errors and fresh-perspective-to-confront-ethical-challenges. Organization (NSO) or establish appropriate or patient mortality. Rushton, CH. (2017). Cultivating moral resilience. Am J acceptable standards of professional conduct. Nurs, 117(2 Suppl 1), S11-S15. Readers should consult with an attorney if they A partnership Rushton, CH. Moral resilience: a capacity for navigating have specific concerns. Neither Affinity Insurance Ideally, nurses and leaders should work together moral distress in critical care. AACN Adv Crit Care, Services, Inc. nor NSO assumes any liability for to establish a health work environment that 27(1), 111-119. how this information is applied in practice or for supports nurses in many ways, including providing Rushton, CH. Building moral resilience to neutralize the accuracy of this information. adequate staffing and a mechanism for dealing moral distress. Am Nurse Today, 11(10). with ethical dilemmas, so moral distress is reduced. Rushton, CH & Turner, K. (2020). Suspending our This risk management information was provided by Nurses and leaders should also partner to ensure agenda: considering what will serve when Nurses Service Organization (NSO), the nation’s confronting ethical challenges. AACN Adv Crit that those experiencing moral distress have the Care, 31(1), 98-105. largest provider of nurses’ professional liability resources needed to address the situation. Ulrich, B, Barden, C, Cassidy, L & Varn-Davis, N. (2019). insurance coverage for over 550,000 nurses since Critical care nurse work environments 2018: findings 1976. The individual professional liability insurance RESOURCES and implications. Crit Care Nurse, 39(2), 67-84. policy administered through NSO is underwritten American Association of Critical Care Nurses. 2020. University of Kentucky Moral Distress Project. 2020. by American Casualty Company of Reading, Recognize and address moral distress. AACN. http://moraldistressproject.med.uky.edu. Pennsylvania, a CNA company. Reproduction www.aacn.org/clinical-resources/moral-distress. Wocial, LD & Weaver, MT. (2013). Development and without permission of the publisher is prohibited. American Association of Critical-Care Nurses Ethics psychometric testing of a new tool for detecting For questions, send an e-mail to [email protected] Work Group. (2004). The 4 A’s to Rise Above Moral moral distress: the Moral Distress Thermometer. or call 1-800-247-1500. www.nso.com. Distress. Aliso Viejo, CA: American Association of J Adv Nurs, 69(1), 167-74. Critical-Care Nurses. Page 6 • Arizona Nurse July, August, September 2021

2021 AzNA Convention

October 2, 2021 with AzNA Membership Meeting October 1

Wild Horse Pass Hotel & Casino Chandler, AZ

Save the Date! Keynote Speaker Recognize - Reflect - Rise Sara Reynolds, RN 2021 AzNA Convention New York Times featured RN Death, Through a Nurse’s Eyes

Saturday, October 2, 2021 Also Includes: with AzNA Membership Meeting October 1, 2021 • NASH Talks (Nurse’s are Super Heroes, 15-minute presentations) • Poster Presentations In-Person • Awards Luncheon • Exhibit Hall at Wild Horse Pass Hotel & Casino • Friday, Oct 1 - Morning and Afternoon Membership Meetings Chandler, Arizona of Arizona Nurses Association, open to all attendees

BOD and AzFFN Midwifery Led Care Updates Ayannah Nicole Peterson and birth as a physiologic event, not a medical Diana Jolles, CNM condition. The profession of nurse-midwifery The AzNA Board of Directors meets monthly. The is built on shared decision-making and respect following are highlights from the February and April In December of 2019, the Centers for for an individual’s cultural needs, comfort, and 2021 meetings. Medicare and Medicaid Innovation published privacy. The midwifery-led model of care has • Discussed how AzNA can assist with community an impact analysis that reported the results been documented by research studies in the education to the importance of vaccinations of a 40-million-dollar grant demonstrating Lancet, which have acknowledged the vital • Verified planning for that midwifery-led care is the appropriate and cost-effective contribution of midwives Symposium, to be held in July, and the AzNA level of care for most childbearing Medicaid to high-quality care and projected that scaling Convention, to be held in October beneficiaries (Dubay, Hill, Garrett, Blavin, up the model worldwide would improve many • Updates on AzNA’s goals surrounding current Johnston, et. al. 2020). However, many barriers maternal and newborn outcomes, including Arizona legislation and proposed bills to supporting the expansion of midwifery- mortality and morbidity (Institute for Medicaid led care exist and little action has been taken Innovation). Nurses across many disciplines, The Arizona Foundation for the Future of Nursing on the Federal or State level to take these including public health, home visits, family (the philanthropic arm of AzNA) has moved the results to scale. Between 2020 and 2021, planning and prenatal clinics, hospital maternal needs of nurses forward through the following: multiple stakeholder groups from Arizona child health departments, emergency rooms, • Partnered with Girl Scouts Arizona Cactus-Pine have participated in the Institute for Medicaid and urgent care, play an active role in supporting Council to distribute over 120,000 boxes of Girl Innovation’s Leveraging Midwifery-Led Care the expansion of access to midwifery care in Scout Cookies to frontline nurses throughout to Address Disparities and Equity in Medicaid Arizona. Be on the lookout for updates related Arizona Learning Series. The series is a yearlong virtual to the Institute for Medicaid Innovation’s • Partnered with Better Place Forests to build learning collaborative for state Medicaid Learning collaborative and expanded support a “Heroes Memorial” recognizing Arizona’s Agencies and Medicaid Managed Care for access to nurse-midwifery care in Arizona. fallen nurses and healthcare heroes who lost organizations to provide technical assistance their lives as part of their service during the that will help support taking midwifery-led care References: global COVID-19 pandemic and beyond to scale in Arizona. Midwifery is a normative Dubay, L., Hill, I., Garrett, B., Blavin, F., Johnston, • RNconnect 2 Well-being, AzFNN’s text-based model of care for most women in developed E., Howell, E., Cross-Barnet, C. (2020). selfcare and wellbeing program, has been rolled countries, where childbirth outcomes are Improving birth outcomes and lowering costs out nationally via American Nurses Foundation markedly better than they are here in Arizona for women on Medicaid: Impacts of ‘strong start for mothers and newborns’. Health and in the United States (Tikkanen, R., Gunja, Affairs (Project Hope), 39(6), 1042-1050. M., Zephyrin, L., & FitzGerald, M, 2020). For doi:10.1377/hlthaff.2019.01042 Arizona nurse-midwives, lack of adequate NursingALD.com can point you Institute for Medicaid Innovation. (n.d.). Improving reimbursement from Medicaid for professional Maternal Health Access, Coverage, and right to that perfect NURSING JOB! services and birth center facility fees are a Outcomes in Medicaid: A Resource for State significant barrier to practice. Medicaid Agencies and Medicaid Managed Care Organizations. NursingALD.com Approximately 70% of women under Medicaid are in their reproductive years and Tikkanen, R., Gunja, M., Zephyrin, L., & FitzGerald, Free to Nurses 15-49 years of age, yet only 50% of all births M. (2020). Maternal Mortality and Maternity Care in the United States Compared to 10 Privacy Assured are covered under Medicaid which is less than Other Developed Countries Commonwealth the number of individuals insured. The use of | Fund. Common Wealth Fund. Easy to Use a midwifery-led model of care promotes the E-mailed Job Leads understanding and facilitating of pregnancy July, August, September 2021 Arizona Nurse • Page 7 Promoting Natural Immunity Mortality and Laurie Ryba, MSN, MMS, FNP-BC, FAARFM, ABAAHP causes the least gastrointestinal upset is slow release Severe Maternal magnesium malate. The recommended daily dose is Reprinted with permission from between 250mg-500mg, not to exceed 1000mg. Mississippi RN June 2021 issue Vitamin C is another superhero nutrient that Morbidity promotes immuno-function in many ways. It is known In today’s atmosphere of quarantine and Covid- to positively affect genes that control inflammation Ayannah Nicole Peterson fear, reclaim life and promote natural immunity. and inhibit the enzymes that generate a powerful Diana Jolles, CNM We are continually warned of what NOT TO DO free radical. Many years ago, the death rate from to prevent illness. Let us today, focus on what we measles was cut in half with the supplementation of In 2019, Senate Bill 1040 established the CAN DO to keep ourselves and our families healthy. high dose vitamin C, and with the addition of zinc, Arizona Advisory Committee on Maternal There are many components to this concept; we will the death rate fell to 80%. Fatalities and Morbidities. Multiple stakeholder begin with the basics. Vitamin C is water-soluble and found naturally groups are involved in the committee aimed at A healthy lifestyle promotes a healthy immune in many fruits and vegetables. It is an antioxidant reducing preventable maternal morbidity and system, but we are all different. In integrative and that boosts the immune system by improving the mortality in Arizona, including several nursing functional medicine, we take an individualized productions of infection fighting cells and also organizations and leaders. The Maternal approach to health and wellness. We focus on protects cells from harmful molecules called free Mortalities (MM) and Severe Maternal Morbidity hormonal, nutritional and lifestyle balance that radicals. Not only can it decrease oxidative stress, (SMM) report was released in December promotes the body’s ability to heal, detoxify and to it has been found to help lower blood pressure, 2020 providing state policymakers, health prevent disease, inflammation and immune over- cholesterol, and uric acid levels. Liposomal vitamin C system leaders, providers, and nurses with an reactivity. increases absorption by 90% due to technology that unprecedented analysis of the urgent need to The skin is the most obvious immune organ that wraps the molecule in a microscopic phospholipid improve our perinatal care system in Arizona. serves as a barrier. Next, moist mucous membranes (fatty) sphere that promotes absorption of this Many factors contribute to the Arizona maternal that trap bacteria, fungus, parasites and viruses as powerful nutrient directly into the immune mortality and morbidity rates. For example, they enter the respiratory or gastrointestinal tracts. powerhouse.4 women living in rural areas experience worse Here, specialized cells attack and ideally destroy. In most cases, viral infections can last from a few maternal health outcomes for SMM and MM If the offending organism breaches these barriers days to sometimes weeks, depending on the health than women in urban areas. This is attributed and enters the blood stream, antibodies from the of the immune system. The strength of the immune to a range of clinical, social, and individual adaptive immune branch strike! Not only are these system is dependent on adequate vitamins C and factors. Each year in Arizona, approximately cells viscously strong, but they have a great memory D, magnesium and many other nutrients. These 70 women die within 365 days of pregnancy, and provide a record of invading organism for future nutrients are of utmost importance; however, it is of which 15–20 deaths are pregnancy-related rapid identification and attack. very important to supplement with a pharmaceutical- cases (i.e., would not have died if she had not Conditions that increase the risk of death from viral grade multivitamin that includes balanced vitamins been pregnant). Additionally, approximately illnesses are hypertension, diabetes, cardiovascular and minerals that are difficult to obtain in the typical 900 women experience SMM during labor and disease, advanced age, cancer and obesity. It American diet. Less than 3% of supplements meet delivery in an Arizona hospital (i.e., a severe and also happens that these very conditions are also the pharmaceutical grade standards of 99% purity, unexpected complication). Behavioral health associated with very low serum levels of vitamin D, bio-availability, natural (versus synthetic) and no dyes, issues and substance use disorders are noted C and magnesium. It must also be noted that many binders, additives or fillers. to be a driver of both morbidity and mortality commonly utilized medications deplete these vital One of the most important parts of promoting in Arizona. The Arizona Maternal Mortality nutrients that are imperative to a healthy immune health is simply living a healthy lifestyle. Stay well Review Committee determined that 83.6% of system. hydrated by consuming approximately 1/2 of your Pregnancy-Associated deaths were preventable Vitamin D3 enhances immune function while body weight in ounces of water per day. Get outside, and nursing plays a crucial role in being part of helping prevent abnormal immune reactions such as breathe fresh air, exercise, have fun, enjoy the the solution. the cytokine storm that is associated with a massive sunshine, play in water, laugh, love and lower stress With Arizona’s diverse socio-demographics inflammatory response with COVID-19. Vitamin levels! Cherish being with people that you love, get there is a need for innovative and targeted D suppresses infection by producing a series of plenty of rest and consume a whole-food diet that is strategies to address social determinants of health special microbe-killing proteins known collectively rich in vitamins, minerals and fermented foods. via biomedical and socio-cultural approaches and as antimicrobial peptides.1,2 Vitamin D deficiency is nurses play an important role in the solutions. associated with many cancers, autoimmune diseases, 1. Herr C et al. Expert Opin Giol Ther 2007;7:1449-61. According to Arizona Vital Records reports, depression, chronic fatigue syndrome, muscle 2. Agier J et al. Cent Etui J Immunol 2015-;40:225-35 between 2016–2017, 41% of Arizona’s births are to weakness, bone and muscle pain (fibromyalgia) and 3. Prabhala A et al. Arch Int Med 2000;160:1199-1203 Latina women, 6% of births are to American Indian neuropathy.3 It has been estimated that increasing 4. Grant WB. Eur J Clin Nutr 2011;65:1016-26 women, and 6% are to Black women (Arizona the vitamin D levels of people in the United States to 5. Cohn, Jeffery et al. Nutrients 2 (2)116-127.doi:10.3390/ Department of Health Services, 2020). Within age nu2020116 at least 40ng/mL would prevent more than 336,000 there is a significant increase in mortality rates for deaths per year. women in the youngest and oldest age groups. Vitamin D occurs naturally in fish and in small Women 19 years old and younger had a rate of amounts in eggs yolk, cheese and beef liver. It is also 159.0, while women 40 years old and older had the naturally synthesized by the skin after sun exposure; highest rate for SMM at 197.7. The recommendations however due to our tendency to wear clothing and AzNA/AzNF for action within the report focus on five primary sunblock, our exposure is often limited. categories: patients and families, providers, Vitamin D3 is the preferred form utilized for oral facilities, systems, and the community. Innovative supplementation. Recommended daily doses range Calendar of Events strategies are being called on to improve culturally from 1,000-5,000 IU per day, depending on serum sensitive care including increasing the diversity of levels, absorption, skin color, age and presence of Arizona’s health workforce, support for community illness. Optimal levels of vitamin D 25 hydroxy (which health worker programs and peer-to-peer support, is the form ordered for proper lab evaluation of levels) and innovative community-based partnerships is 60-90 ng/mL. While it is difficult to get too much with faith-based organizations, law enforcement, vitamin D, it is possible and can cause other medical and legislators. problems. For this reason, it is wise to always monitor vitamin D 25 hydroxy serum levels on a regular basis. Reference Magnesium is vital for the healthy immune Saturday, July 24, 2021 Lewandowski KS, Baer CE, Schoustra R, Indatwa A, system. It is estimated that over 50% of Americans Celaya MF, Tarango P. SB 1040 Annual Report on are deficient in this essential mineral that is 33rd Annual Southwestern Regional Maternal Fatalities and Morbidities in Arizona. Phoenix, AZ: Arizona Department of Health required for bone health, cell function, stable blood Nurse Practitioner Symposium Services; 2020. pressure, heart rhythm and nerve conduction. Location: Virtual Event Magnesium also promotes the production of lymphocytes which are immune cells that are critical for protection against viral infections and Friday & Saturday, October 1-2, 2021 cancer. Along with Vitamin D, it can also help prevent the inflammatory response and blood AzNA Membership Meeting We are hiring! clots that are lethal during a COVID-19 illness. and Annual Convention Rehabilitation Hospital of Northern Arizona is seeking Licensed The monitoring of magnesium can be very tricky Location: Wild Horse Pass Hotel and Practical Nurses (LPN) and Registered Nurses (RN) to join their team. and must be obtained as a red blood cell level. This Equal opportunity employer. reflects the amount of the mineral available inside Casino, Chandler Contact: Stacey Mattingly the cell. For the most part, it is not essential to know 717-713-7541 • [email protected] one’s magnesium level. It can be increased by consuming fresh, green, leafy vegetables, nuts, dark Registration and event information can chocolate, avocados, legumes, and salmon. There are also many forms of magnesium supplements on the be found at www.aznurse.org/events 1851 N. Gemini Drive • Flagstaff, AZ 86001 market, however the form that is best absorbed and RHNA.ERNESTHEALTH.COM Page 8 • Arizona Nurse July, August, September 2021 Epidemiology of Work-Related Musculoskeletal Disorders

Manraj Sandhu, CSEP-CEP 3) Shoulders - Repetitive reaching, holding, and lifting - Brushing your teeth Note: Please consult your healthcare provider tasks can contribute to the development - Putting your socks on before altering or trying new exercise routines. of WMSDs. - Placing and removing clothes from washing Healthcare Professionals (HCPs) routinely and drying machines perform physically demanding tasks to - Retrieving items from promote their patient’s health and well-being. lower level shelves These tasks often result in HCPs experiencing repetitive movements, deviated postures, and The trunk flexion movement normally prolonged standing during their shifts. These associated with these ADLs could instead be can contribute to the development of work- modified by using a hip hinging motion, or by related musculoskeletal disorders (WMSDs). going down on one knee, to maintain a neutral The rate of WMSDs within the healthcare field spine. can be similar to, or even greater than, those Another source of trunk flexion movements reported in the construction, manufacturing could be a person’s exercise program. Certain and mining industries (Abedini et al, 2015). exercises that are trunk flexion-based will need WMSDs in HCPs can have a significant impact to be modified because they may increase the on their physical and psychosocial health. risk of LBDs. These exercises include: - Sit-ups, with both knees bent Considerations for Interventions: - Performing toe touches i.e. hamstring stretch with the spine in a flexed position The prevalence of low back disorders (LBDs) - Pulling one’s knees to their chest when in HCPs highlights the need for interventions lying on one’s back aimed at reducing the associated costs. Some of the key goals of these interventions should The sit-ups, with both knees bent, could be be to reduce the frequency of less optimal substituted for an exercise that provides an movements and to improve the physical abdominal challenge without trunk flexion, capacity of the HCP. Areas of consideration such as the stir the pot exercise. Other trunk should include: flexion-based exercises and stretches should be modified in a way that preserves a neutral 1) Minimizing the number of trunk flexion spine. movements HCPs experience outside of their occupation It has been shown that a greater number of trunk flexion movements are associated The physical demands experienced by HCPs with a greater likelihood of developing LBDs can result in the development of WMSDs in (McGill, 2016). Trunk flexion movements that several anatomical sites. Some of the most occur during the activities of daily living (ADLs) at risk sites include the low back, neck, and should be modified in a way that promotes shoulders (Ellapen et al, 2014). spine health. For example, rather than using trunk flexion 1) Low back when tying your shoelaces, consider placing - Maintaining flexion of their trunk for a your foot on a raised surface such as a bench. prolonged period of time. This will allow you to tie your shoelaces 2) Neck without having to flex your trunk. Other trunk - Frequent neck movements such as flexion-based movements that may need to be flexion, extension and rotation can result modified, include: in discomfort in this region.

Located in Northeastern AZ Ganado, AZ Nursing Opportunities Available Nurse Positions Available! • Emergency Department RN • RN • LPN • Student Assigned • Substitute Nurses Must have authorization to work in U.S. as defined by the Immigration Reform Act of 1986 and current AZ RN • Outpatient Clinic RN or LPN license. Great Schedule, Excellent Benefits! • Community Health/Diabetes Program RN Supervisor To apply or for more information, please visit our website at: www.dvusd.org • Community Health/ Diabetes Program RN “A” Rated Pre-K–12 School District • Medical/Telemetry Unit RN • Case Manager RN • Employee Health RN Contact: Patricia Blosser, MSN, FNP-C, MBA, CNO at Have you always wanted to live in the 928-755-4559 or [email protected] White Mountains? Applications available at Enjoy the natural beauty of the White Mountains sagememorial.com/careers/ and experience "The Accord Difference" Send applications to Human Resources Accord Hospice is seeking Fax#: 928-755-4659, [email protected] qualified & compassionate nurses.

Contact: Ashley Frost The Navajo Health Foundation/Sage Memorial Hospital is a drug/alcohol free EOE/AA/Navajo Preference Employer Human Resource/Business Office Manager Phone (928) 271-8013 or (928) 608-5820 July, August, September 2021 Arizona Nurse • Page 9

2) Reducing the number of trunk flexion movement a person does in the Neumann, W., Wells, R., Norman, R., Frank, J., Shannon, H., & Kerr, M. (2001). A first hour after waking up in the morning posture and load sampling approach to determining low-back pain risk in Flexion movements of the trunk have a more deleterious effect on occupational settings. International Journal of Industrial Ergonomics, 27(2), 65– the spine when performed in the morning. This is due to mechanical 77. doi: 10.1016/s0169-8141(00)00038-x changes that occur to the spine during the night. While sleeping, the Ovayolu, Ö., Ovayolu, N., Genc, M., & Col-Araz, N. (2013). Frequency and severity of low back pain in nurses working in intensive care units and influential spine absorbs more water causing the intervertebral disc to expand factors. Pakistan Journal of Medical Sciences, 30(1). doi: 10.12669/pjms.301.3455 and create more tension in the ligaments (McGill 2016). This causes the Ellapen Tj, Narsigan S. (2015). Work Related Musculoskeletal Disorders among spine to be more resistant to bending and to have less mobility with Nurses: Systematic Review. Journal of Ergonomics, s4. doi: 10.4172/2165-7556. which to allow for trunk flexion movements. s4- 003 One study found that avoiding lumbar flexion in the early morning Sharafkhani, N., Khorsandi, M., Shamsi, M., & Ranjbaran, M. (2014). Low Back resulted in a notable decrease in pain symptoms (Snook et al, 1998). An Pain Preventive Behaviors Among Nurses Based on the Health Belief Model implication of this would be to reorganize one’s ADLs so that the least Constructs. SAGE Open, 4(4), 215824401455672. doi: 10.1177/2158244014556726 amount of trunk flexion is performed in the early morning. Snook, Stover H., Barbara S. Webster, Raymond W. Mcgorry, Maxwell T. Fogleman, and Kathleen B. Mccann. “The Reduction of Chronic Nonspecific Low Back Pain Through the Control of Early Morning Lumbar Flexion.” Spine 23, no. 23 (1998): 2601–7. https://doi.org/10.1097/00007632-199812010-00015. Yan, P., Li, F., Zhang, L., Yang, Y., Huang, A., Wang, Y., & Yao, H. (2017). Prevalence of Work-Related Musculoskeletal Disorders in the Nurses Working in Hospitals of Xinjiang Uygur Autonomous Region. Pain Research and Management, 2017, 1–7. doi: 10.1155/2017/5757108 All images were found on Google and are the property of their respective owners

Newly Conferred Doctor of Nursing Practice Helps Improve Virtual VA Care

Francesca Bryan-Couch, Chief of Care Coordination, has been conferred with the Doctor of Nursing Practice degree from Otterbein University in Westerville, Ohio. Dr. Bryan-Couch’s work started before Covid-19 but was able to demonstrate improvements during the pandemic restricted services. This work focused on virtual services and Veteran relationships and was based on current nursing evidence-based practice (EBP) research. 3) Develop core stability Dr. Bryan-Couch has been a VA EBP leader, advocate, and mentor for It is vital to develop the muscles that surround the spine in order to multiple VA locations over the last decade. Dr. Bryan-Couch currently ensure adequate stabilization. Spine stability is important for enhancing serves on the National VA EBP Field Advisory Council and is certified in performance, managing and reducing pain sensations, and for injury Hospice and Palliative Care. resilience. As mentioned, it would be beneficial for the HCP to avoid Bryan-Couch’s work applied Hildegard Peplau’s Interpersonal Relations trunk flexion when possible. Theory to VA virtual applications and the research data was found to be Some exercises are better for sparing the spine of unnecessary statistically significant. Dr. Bryan-Couch plans to publish findings and loading while helping to build resilience. Research (Mcgill, 2015) has encourages other VA facilities to implement virtual healthcare technology shown the “Big 3” to be especially beneficial in building fitness capacity improvements such as these. For more information about EBP or this while promoting spine hygiene. research contact Dr. Bryan-Couch at [email protected] Dr. Bryan-Couch graduated with honors and is a member of Sigma Theta The “Big 3” are: Tau. She is passionate about quality veteran care and has stated on many 1) Modified curl-up - Anterior compartment of core occasions that every day should be Veterans Day. Dr. Bryan-Couch has 2) The side bridge - Lateral compartment of core been in health care for 32 years. She currently works and lives in Tucson, 3) The bird dog (aka superman) - Posterior compartment of core Arizona with her husband and two dogs.

These exercises can help enhance the maintenance of core stability and help to reduce extra movements in the spine that could lead to tissue degeneration.

(Side Bridge) (Bird Dog/Superman)

Bibliography Abedini, R., Choobineh, A., & Hasanzadeh, J. (2015). Patient manual handling risk assessment among hospital nurses. Work, 50(4), 669–675. doi: 10.3233/wor 141826 Abedini, R., Choobineh, A., & Hasanzadeh, J. (2015). Patient manual handling risk assessment among hospital nurses. Work, 50(4), 669–675. doi: 10.3233/wor 141826 Davis, K. G., & Kotowski, S. E. (2015). Prevalence of Musculoskeletal Disorders for Nurses in Hospitals, Long-Term Care Facilities, and Home Health Care. Human Factors: The Journal of the Human Factors and Ergonomics Society, 57(5), 754– 792. doi: 10.1177/0018720815581933 Greenland, K. O., Merryweather, A. S., & Bloswick, D. S. (2013). The Effect of Lifting Speed on Cumulative and Peak Biomechanical Loading for Symmetric Lifting Tasks. Safety and Health at Work, 4(2), 105–110. doi: 10.1016/j.shaw.2013.04.001 Kulkarni, S., & n, G. D. (2013). Musculosleketal risk assesment among nurses in pateint manual handling in hospital wards – a cross sectional study. Cureus. doi: 10.7759/cureus.137 Marras, W. S. (2008). The working back. Hoboken, NJ: Wiley. McGill, S. (2015). Back mechanic: the step by step McGill method to fix back pain. Waterloo, Ontario: Backfitpro Inc. McGill, S. (2016). Low back disorders evidence-based prevention and rehabilitation. Champaign: Human Kinetics. Page 10 • Arizona Nurse July, August, September 2021 Neonatal Transport for Specialty Care and Transport Nurse, Valerie Vickers

Shannon E. Perry, RN neither doctors nor neonatal nurse practitioners Figure 1 are on the transport. As a transport nurse, Valerie Valerie Vickers, an experienced Arizona is an educator (teaching health professionals neonatal transport nurse, has a BSN and an MS at the bedside or in the classroom), a patient from the University of Arizona. Valerie has worked advocate providing family-centered care, and a in a neonatal intensive care unit (NICU) as a student (learning new skills/refreshing old skills, bedside nurse, as a pediatric pulmonary nurse, and learning a new system). She is a member of a team is certified in neonatal intensive care. She received with great diversity (physicians, hospital RNs, transport training in a week-long series of classes, respiratory therapists, paramedics, EMT drivers, and since 1980, has transported over 1,500 infants. communication specialists, pilots, mechanics) who She is certified in neonatal-pediatric transport. She are needed to complete the mission. states that “becoming a NICU was a Transports may be one-way (from the place journey of opportunities and gives me great pride, of birth to the NICU) or two-way (the team joy, and professional fulfillment.” In 2005, she from the NICU or transport service travels both began working for an air medical transportation to and from the place of birth). Upon arrival company. She now transports, teaches newborn at the sending hospital, the transport team’s resuscitation classes, S.T.A.B.L.E. (Sugar, responsibilities include receiving a report on the Temperature, Airway, Blood pressure, Lab work, birth and condition of the neonate. They assess Nurse Valerie Vickers ready for transport. Emotional support) which is a postresuscitation- the neonate, ensure a warm environment, and pretransport stabilization program, and gathers stabilize its condition for transport. This might Courtesy Valerie Vickers data for the statewide perinatal program. include administering medications, inserting The need for transport of premature and intravenous lines or chest tubes, providing oxygen critically ill neonates in Arizona came about due and ventilation, drawing blood for analysis, and to give glucose, started alprostadil (to keep the to the regionalization of perinatal care in the state obtaining x-rays. An important responsibility of the ductus open) and then transported the infant for in the 1960s (Perry, 2021). NICUs were established transport nurse is communication with the mother intensive care. The infant did well. at St. Joseph and Good Samaritan Hospitals in and father, if present, about the condition of the Valerie’s transport team also helps move infants Phoenix and Tucson Medical Center and Arizona neonate, the transport process, and the NICU to having terminal conditions to a hospice or home Medical Center in Tucson. Many infants are born which the infant will be transported. at the request of the family who do not want their in hospitals without specialized equipment or Valerie transports neonates in specialized baby to die in a hospital. Only a neonatal transport personnel to provide care. This created a need incubators by ground or rotor-wing aircraft. She team has the equipment and skill to move these for neonatal transport specialists and equipment is an expert in assessing and treating neonates. technology dependent neonates. Valerie noted to transport neonates for specialty care. Infants Valerie describes once having arrived in an that this type of transport is by far one of the most with a variety of conditions require transport. They emergency department and finding a very cold honorable, rewarding things she has ever done. may be preterm, experience respiratory distress, baby (33.5° C), with normal respirations, no While there is stress, uncertain hours, and the have congenital anomalies, or need surgery that is distress, and hypoglycemia. The infant had an outcomes of transported infants are not always available only in the regional centers. enlarged heart and a ductal dependent cardiac favorable, Valerie says “I love this job!” The transport team is composed of two nurses defect with a closing duct (the ductus arteriosus needs to remain open for adequate systemic and Reference or a nurse and cross-trained nurse or paramedic/ Perry, S. E. (2021). Regionalization of premature infant EMT. Most of the nurses are experienced NICU pulmonary blood flow). She placed the infant care in Arizona and the nurses who helped nurses who have received intensive education and under an overbed warmer, inserted an airway and make it happen: Frances L. Mast and Sister Alice supervised practice in the logistics of transport. started ventilation, placed an external jugular line Montgomery. Arizona Nurse, 74(1), 9. Transport poses challenges and adds a level of autonomy and advanced skills for the nurse since

Wellness Directors Needed Ask Nurse Melissa HIRING BONUS “My job is in the process of transitioning back I know we are starving, after all we have been from covid precautions. In a stressful time like without our regular diet for so long. As much as we this, what are some ways I can keep my passion want that big juicy burger and fries, also known as, $5,000 for nursing?” normal life, we need to take it slow and ease into our normal. Let’s start out with a clear diet and see how Hiring Full Time In charting, nurses find fulfillment in we tolerate it, implementing a gradual approach to and Part Time documenting the phrase “within normal limits.” that regular diet we have been missing. We need LPNs & RNs If we could conduct an assessment for our lives to take our time and start with small steps. For me, this last year, we could most definitely chart not after I was fully vaccinated, I started going out to within normal limits! I don’t know about you, but eat in restaurants with a few friends. It felt so nice usually I am pretty good at keeping the different to sit and talk after being separated for a year. We aspects of my life separate, not bringing negative were able to talk about what we had experienced To apply, email aspects of one part into another. However, and found comfort that we had similar emotions [email protected]. compartmentalization was almost impossible regarding the past. when there were changes and challenges in nearly I hope you take your time, do what you feel ok every aspect of life. If our lives were a physical doing. Professionals have mentioned that since we assessment, they went from normoactive bowel continuously have been in fight or flight mode, we sounds, to hypoactive, to absent in a short period may feel a bit of a letdown as we depart from being Little Colorado Medical Center is a 25-bed, critical access hospital, of time. Our usual units went to being COVID on adrenalin. Knowing this, go easy on yourself, located 50 miles east of Flagstaff, Arizona; a compassionate and only floors, children became home-schooled, don’t expect to jump back into things with a snap of caring facility in a family oriented community. Enjoy the stress free husbands and wives now worked from home, your fingers. Talk with coworkers, family members, pleasures of small town living with benefit of a fast paced stimulating family members lost their jobs, and businesses and friends on how they are adjusting. This can work environment. LCMC is seeking the following experienced staff: closed indefinitely. To continue our analogy, we prove beneficial, and help you with settling into a essentially had a nasogastric tube in place for new way of life. Registered Nurse the last year, while we let our stomachs heal. Current AZ RN license or State Compact There was so much unknown and our lives had We got this! Current BLS/CPR certification New Grads accepted with 2 year commitment been turned upside down. Finally, we passed our ♥ Melissa RN’s with 1 year experience eligible for sign-on bonus clamp trial at the beginning of this year with the Relocation Package introduction of a vaccine for COVID. And, great Have a question for Nurse Melissa? news! We got to get our tube removed as we saw If you are clinically competent, a team player and have excellent a decrease in COVID cases and an increase in Email [email protected] with “Nurse interpersonal leadership and computer skills them come excel and grow in an outstanding team environment! vaccinations. Melissa” in the subject line. Visit our website at www.lcmcwmh.com/careers and/or email: [email protected] EOE July, August, September 2021 Arizona Nurse • Page 11 The COVID-19–Cancer Connection

Deborah Boyle, RN shortage, future forecasts compel us to anticipate The author takes full responsibility for this and plan for an altered practice paradigm. What content and did not receive honoraria or disclose Note. From “The COVID-19-Cancer Connection,” skills will remain unique to nursing? any relevant financial relationships. by D. Boyle, 2021, Clinical Journal of Oncology This question reminded me of a past keynote Nursing, 25(3), pp. 235-236 (https://cjon.ons.org/ presentation message addressing nursing’s future. REFERENCES cjon/25/3/covid-19-cancer-connection). Copyright Consider what nursing looked like when you Dzau, V.J., Kirch, D., & Nasca, T. (2020). Preventing 2021 by the Society. Reprinted started your career and what it looks like now—for a parallel pandemic—A national strategy to with permission. me, there has been dramatic change. Therefore, protect clinicians’ well-being. New England you must anticipate equivalent remodeling in the Journal of Medicine, 383(6), 513–515. https://doi. org/10.1056/NEJMp2011027 I recently completed work at a large-scale, future. The nursing of tomorrow will not look like it Fauteux, N. (2021). What lies ahead for drive-through COVID-19 vaccination initiative does today. To a great degree, the COVID-19 crisis nursing? American Journal of Nursing, and was immediately struck by its military parallel has prematurely triggered such transformation. 121(4), 57–60. https://doi.org/ 10.1097/01. in mobilizing this emergent medical response. From my ongoing review of the COVID-19 NAJ.0000742536.77302.f8 Federal personnel were deployed quickly to assist literature, five themes have the potential to Jacobs, A. (2021, February 4). A parallel pandemic hits the local workforce untested in a public health endure long-term and have special relevance to health care workers: Trauma and exhaustion. domain. The expansive integration of technology oncology nursing (Dzau et al., 2020; Fauteux, 2021; New York Times. https://www.nytimes. was at a level I had not previously witnessed. Meti et al., 2020; Muturi et al., 2020; Pham et al., com/2021/02/04/health/health-care-workers- burned-out-quitting.html Meti, N., Rossos, P.G., Cheung, M.C., & Singh, S (2020). Virtual cancer care during and beyond the COVID-19 pandemic: We need to get it right. Journal of Oncology Practice, 16(9), 527– “Often, psychological first aid and brief 529. https://doi.org/10.1200/OP.20.00281 Muturi, I., Freeman, S., & Banner, D. (2020). Virtual damage control is all we can render.” funerals: A feasible and safer option during the COVID-19 pandemic. Journal of the American Geriatrics Society, 68(11), 2472–2473. https://doi. org/10.1111/jgs.16774 Computerized algorithms organized the flow of 2020; Shah et al., 2021; Yackzan & Mahon, 2021; National Cancer Institute. (2021). National Cancer cars through a huge fairground (think Disneyland Act of 1971. https://cancer.gov/about-nci/ Zanville et al., 2021): Park). Databases were created to register the overview/history/national-cancer-act-1971 Achieving enhanced understanding of others’ public, make appointments, and document the ■ Nightingale, F. (1888). Florence Nightingale: The roles, learning how to practice together, and specifics of vaccination administration. From day Nightingale School. In L. McDonald (Ed.), The engaging in skilled communication one, the pharmacy tent was in constant overdrive collected works of Florence Nightingale (Vol. Reclaiming nursing’s public health roots by to ensure vaccine supply was in sync with hourly ■ 12). Wilfrid Laurier University Press. focusing more on community based care Pham, Q., Hearn, J., Gao, B., Brown, I., Hamilton, demand. The interface of all these platforms Practicing—not just talking about—diversity R.J., Berlin, A., . . . Feifer, A. (2020). Virtual vaccinated 2,300 people per day. ■ and inclusion care models for cancer survivorship. Digital I also witnessed considerable stress in those Rapidly adopting telehealth and virtual care Medicine, 3, 113. https://doi.org/10.1038/s41746- waiting in line. Ongoing uncertainty, weekly—or ■ Acknowledging historic mental health 020-00321-3 at times daily—new information about COVID-19, ■ Shah, M., Roggenkamp, M., Ferrer, L., Burger, V., & neglect through pervasive prevention and and rampant hearsay prompted unease. I was Brassil K.J. (2021). Mental health and COVID-19: wellness program integration repeatedly asked questions such as, “How The psychological implications of a pandemic effective is this vaccination?” and “I hear the for nurses. Clinical Journal of Oncology This year, I celebrate 50 years as a nurse and Pfizer one works better than the others. Is that Nursing, 25(1), 69–75. https://doi.org/10.1188/21. recognize common ground between then and true?” The isolation of many older adults was CJON.69-75 now. My oncology nursing career began during a Yackzan, S., & Mahon, S.M. (2021). COVID-19 poignantly shared (“I miss my grandchildren so crisis. In 1971, President Nixon signed the National pandemic 101: An epidemiology and public much.” “We haven’t left our house in over 300 Cancer Act (National Cancer Institute, 2021) health primer for oncology nurses. Clinical days.”), as was their sense of loss (“Both of my in response to cancer’s growing prominence. Journal of Oncology Nursing, 25(1), 33–40. neighbors died from [COVID-19].”). I realized Professional education, resource allocation, and https://doi.org/10.1188/21.CJON.33-40 many of these comments paralleled those I’ve a designated federal structure were needed to Zanville, N., Cohen, B., Gray, T.F., Phillips, J., Linder, heard in oncology practice. L., Starkweather, A., . . . Cooley, M.E. (2021). The leverage specialty practice and research. However, Our work environment as oncology nurses is Oncology Nursing Society rapid review and oncology nursing and medical oncology had not dominated by the emotional angst our patients research priorities for cancer care in the context been formally established in 1971. At that time, in and families struggle to contain. Rampant of COVID-19. Oncology Nursing Forum, 48(2), the absence of clinical evidence-based guidelines, misinformation is the norm. We often lack 131–145. https://doi.org/10.1188/21.ONF.131-145 nurses and fellows in the chemotherapy clinic definitive answers to the pressing questions where I practiced had to rely on each other. We patients pose. Time spent with those we nurse is truly worked as a team, questioning each other for brief. Disparity prevails. High-functioning teams lessons learned from past experiences, engaging are needed rather than solo interventions. Often, in critical thinking, and employing innovative psychological first aid and brief damage control problem-solving in making care decisions. Five is all we can render. We feel pressured to pack a decades later, I again have found myself in new considerable amount of nursing into only minutes territory that is requiring me to think outside the of care. In pondering these constraints common box as the COVID-19 crisis prevails. to COVID-19 and cancer nursing, I ask, would Florence Nightingale said, “Every nurse must increasing staff numbers resolve these problems? grow. No nurse can stand still; she must go forward, Or is it more about how we can practice or she will go backward, every year” (Nightingale, differently? 1888, p. 864). Perhaps we need to reframe our This massive vaccination initiative was staffed thinking about the COVID-19 pandemic. Although by nearly 200 individuals; I was one of only five it has been characterized as the most horrendous RNs employed. In our supervisory role, we acted global scourge in modern times, it has forced us as mentors and resources in symptom assessment. to think quickly, design solutions with only partial We responded to questions and offered education evidence, and do the best we can with limited at the point of care. We monitored at-risk public resources. It has also elevated awareness of a for anaphylaxis and counseled the anxious. We hidden domain of our everyday practice, namely taught and supervised nursing students who were our compromised mental health (Jacobs, 2021). there for clinical time because hospital access This is a pressing practice affliction we cannot was not open to them. We role-modeled how to ignore as our future materializes on the horizon. talk to those who felt panicked and de-escalated mounting distress. Deborah A. Boyle, MSN, RN, We did not vaccinate; paramedics, medical AOCNS, FAAN, is an oncology assistants, the National Guard, and the National clinical nurse specialist at Advanced Disaster Medical System staff administered the Oncology Nursing Resources in vaccine. At first, I was taken aback by this. Shouldn’t Phoenix, AZ. Boyle can be reached this be done by a nurse? Is it a problem with supply at [email protected], with copy to and demand that others were assuming what [email protected]. nurses traditionally do? Or perhaps I should ask myself, “Why not?” With the impending nursing Page 12 • Arizona Nurse July, August, September 2021 NeoECHO: Lessons Learned During a Virtual Learning Community Intervention

Christina Wyles, RN Findings: We reached seven NICUs in three states over a three-month period. Of the 90 unique NICU clinicians that participated, the majority (83%) represented To implement evidence-based practice (EBP), diverse stakeholders work either registered nurses (53%, of which 1/3 were bedside RN’s), physicians together to critique evidence, identify local priorities and weigh the risks and (18%), or NICU nurse practitioners (12%). The remaining 15% represented other benefits of adopting new strategies in practice. Learning communities and disciplines. All participants identified an actionable strategy to avoid NEC from nursing educators are beneficial in the EBP process but our experience revealed the sessions. Teams learned from each other and from the experts. Over 30% of that neonatal intensive care units (NICUs) in the southwest had few resources and participants attended > 3 sessions. Reaching NICUs with NeoECHO was feasible limited time to engage in learning communities. With the advent of technology, and acceptable to support NEC EBP and family-centered care. engagement strategies increasingly use diverse approaches to encourage broad Discussion: participation from many stakeholders. Engagement interventions offer positive • The quality improvement teams deeply learned about the NEC-Zero toolkit benefits (Cosgrove et al., 2013) while facilitating the implementation of evidence and strategies to implement NEC avoidance practices in reliable, consistent, in practice (Nesmith et al., 2020). One recent example of a telehealth-delivered and repeatable ways. engagement intervention is NeoECHO. • NeoECHO’s design (e.g., case conferences, didactic and expert Intervention Approach: We used a neonatal Project ECHO (i.e. NeoECHO) to recommendations) encouraged sharing best-practices between NICU units reach neonatal intensive care unit (NICU) teams and help them implement EBP while acknowledging strengths and opportunities for change. to prevent necrotizing enterocolitis (NEC) in fragile infants. NEC is an intestinal • Each site had a local internal facilitator who presented a case. Presenting disease of prematurity, is the chief cause of neonatal emergency surgery and the de-identified case helped NICU teams identify opportunities for local leads to death 30% of the time. NeoECHO was modeled after the international improvement. “Project ECHO” movement that started at the University of New Mexico (www. • NeoECHO helped us share the NEC-Zero toolkit and helped teams form echo.unm.edu) (Arora et al., 2017) with a guiding value that “all teach, and all locally around one goal: reducing NEC over time. learn.” • Offering continuing education credits was a motivator for some but not all. Implementation Process: Each neonatal intensive care unit (NICU) identified a • Arizona Telemedicine Program’s technology support was helpful to our core team to participate in the NeoECHO sessions so they could learn, critique team and the NICUs throughout the process. and apply evidence locally to avoid neonatal complications. The evidence that was shared centered on the “NEC-Zero toolkit” which is freely accessible at Conclusion: NeoECHO helped us to reach NICUs and help them implement neczero.nursing.arizona.edu. The NEC-Zero bundle prioritizes use of human NEC EBP. We showed in this feasibility study that the Project ECHO model could milk, engaging and educating families in prevention and watching out for NEC, be used to reach NICU teams and be led by a nursing expert team. For units standardized feeding guidelines, medication stewardship and a structured with low education resources, NeoECHO effectively reached clinicians with NEC approach to timely NEC recognition using the GutCheckNEC risk score and SBAR education and fostered NEC EBP to bridge the quality gap. communication tool. Clinicians were informed of the evidence underlying NEC If you are interested in learning more about NeoECHO, NEC prevention with prevention, and learned together about clinical complexities and controversies NEC-Zero, or would like your unit considered for the next cohort of NeoECHO, around NEC (Gephart et al., 2017; Profit et al., 2017). Additionally, we encouraged contact Dr. Sheila Gephart at [email protected]. units to use the NEC-Zero toolkit, especially to engage with parents as team members (Gephart et al., 2020). Clinician support materials were made freely Christina Wyles, MLIS, MS, RN is the NeoECHO Engagement Leader. available for access and use. After each session, each NICU decided if and how they would apply the lesson learned in their unit. References Available at: https://docs.google.com/document/d/1DN17_ teEPFJQfJsSgebx40BrnwMdDMDvqqtaEcmMHsE/edit?usp=sharing

Phoenix / Prescott July, August, September 2021 Arizona Nurse • Page 13 Courage in Everyday Nursing Practice

Carol Dobos PhD, RN-BC, NEA-BC required only one move. Although my plan was successfully implemented, my Courage is an important attribute in life and in your nursing practice. As Helen action caused me to fall out of favor with the administrator and eventually resulted Keller said, in my having to move on to another position. In both instances, I had to put my patients first because when I became a member of the nursing profession, I made “Security is mostly a superstition. It does not exist in nature nor do the children a promise to protect them. of men as a whole experience it. Avoiding danger is no safer in the long run than outright exposure. Life is either a daring adventure, or nothing.” Why We May Not Take Personal Risks Understanding scarcity is key to understanding why nurses may not take Nursing is a noble profession that is not for the faint of heart. Opportunities justified risks. The three components of scarcity are shame, comparison, and to choose courageous acts present themselves on a regular basis because risk is disengagement. everywhere. You can attempt to minimize the risks by playing it safe. However, Shame is the fear of ridicule and belittling often used to control people and there are risks to yourself, your colleagues, your profession, and those you serve to keep them in line. Shame-based cultures are very unhealthy for nurses and when you don’t take risks in showing up, speaking up, or practicing according to patients. The killer of innovation is shame. In these cultures, covert or sometimes the highest standards of evidence-based practice. overt messages are common, such as to dare not, you’re not good enough, Choosing to practice courageously, consistent with your personal and who do you think you are, don’t you dare get too big for your britches.” Shame professional values, will cause some discomfort, bumps, and bruises to you and becomes fear, fear leads to risk aversion, and risk aversion kills innovation and can your career. It will also bring professional and personal fulfillment, strengthen the lead to unsafe patient care. Shame is the intensely painful feeling or experience of profession, and improve patient outcomes. You will know that you are making a believing that we are flawed and therefore unworthy of belonging. Shame makes difference in your daily practice and throughout your nursing career. us feel unworthy of connection. Resilience to shame occurs when recognizing and One way to cultivate courageous behavior is through personal risk-taking (PRT), speaking openly about shame, practicing critical awareness, and reaching out to but first you need to understand the nature of risk and its related concept, positive others. deviance. Healthy competition can be beneficial, but constant overt or covert comparing What is Risk? and ranking suffocates creativity and risk taking. If nurses are held to one narrow Risk is defined as the possibility of losing something of value, which could be standard, they may not question the relevance of a course of action to a specific physical, psychological, or economic. Common risks include falling out of favor situation and embrace evidence- based practice. with others in authority, losing support, or damaging essential relationships. Any of Disengagement occurs when people are afraid to take risks and try new things. these events could lead to losing status or influence at work, or even losing one’s Too often it is easier to stay quiet than to share stories, experiences, and ideas. It position or employment. is important to do what is right, not what is easy. The best way through a difficult A related concept called “positive deviance” refers to an intentional act of situation is to address the situation directly with honesty and integrity, sharing your breaking the rules to serve the greater good. Positive deviance is intentional and story and asking for what you need. An excellent resource for nurses is the book honorable behavior that departs or differs from an established norm. It contains Crucial Conversations. Often what we fear does not happen, but even if it does, we elements of innovation, creativity, adaptability, or a combination thereof; and it have retained our self-respect and commitment to professional values. involves risk for the nurse. Courageous Practice For most nurses, whether a particular action is right or wrong will often be I hope you choose to practice courageously, doing the right things for the right judged by others in charge of rules enforcement. The decision to engage in positive reasons. As Theodore Roosevelt said, deviance, however, lies entirely with the nurse. “Far better it is to dare mighty things, to win glorious triumphs, even though Personal Risk-Taking checkered by failure, than to take rank with those poor spirits who neither enjoy PRT is behavior that is consciously and freely chosen among available alternatives, much nor suffer much, because they live in the gray twilight that knows not victory some of which are known to incur less risk than the chosen action. It is supported nor defeat.” by the strength and belief of personal convictions. Courageous action upholds principles. Calculated inaction due to fear leaves one powerless, with values Selected references compromised. Dobos C. Defining risk from the perspective of nurses in clinical roles. J Adv Nur. Nurses promote courageous action by sharing courageous behavior, also called 1992;17:1303-9. hero stories. This can be done formally and informally, verbally and in writing, Dobos C. Understanding personal risk taking among staff nurses: critical information for nurse executives. J Nurs Adm. 1997;27(1):1-2. one on one or in groups, during staff meetings, during change of shift report, or Gary JC, Exploring the concept and use of positive deviance in nursing. Am J Nurs. rounds. We create a culture based on what we talk about, what we value, and what 2013;113(8):26-34. Haag-Heitman B. The development of expert performance in we support and reward. Sometimes we stand alone, and sometimes we influence nursing. J Nurses Staff Dev. 2008;24(5):203-11. others to follow our lead and take their own personal risks. In one study, risk taking Brown B. Daring Greatly: How the Courage to be Vulnerable Transforms the Way We Live, was found to be one of the key elements in attaining expert nursing practice, which Love, Parent, and Lead. Gotham Books; 2012. supports effective and quality-based healthcare outcomes. Risk taking also was Patterson K, Grenny J, McMillan R, et al. Crucial Conversations: Tools for Talking When found to enhance clinical and professional development. Stakes are High, 2nd ed. New York, NY: McGraw-Hill; 2011. Rather than sitting on the sidelines and hurling judgment or advice at others (for Carol Dobos lives in Phoenix Arizona and is the past-president of the Arizona example, “Someone needs to do something about this.”), we must dare to show up Association for Nursing Professional Development, a state affiliate of the Association and let ourselves be seen, which can result in change. (See Success story.) for Nursing Professional Development.

Success story When residents were not interacting appropriately with pediatric patients, risking psychological harm, I discussed this with the chief and arranged education. I advised our team that in identifying this issue, relationships might become strained, but we had an obligation to our patients to address this problem. I often used the mantra “I am doing the right thing for the right reason” stating it over and over in my head to help me stay the course and follow through with my convictions. As feared, the residents and even an attending physician demonstrated passive aggressive behavior towards us. The care of the children did improve, however, and we knew we had Now Hiring for Registered Nurses for the made the right call. following Departments: (Some departments include working 72 hours and getting paid for 80 hours) We pay a price when we shut down and disengage, failing to take action. I have Medical/Surgical Operating Room/Surgery heard nurses talk about “staying under the radar.” In doing so they pay a dear price. Emergency Room Intensive Care Pediatric Acute Labor & Delivery Their talents, wisdom, knowledge, and values are not being shared to positively influence care and support the development of new nurse graduates and other colleagues through courageous role modeling. Vulnerability occurs in sharing an We are looking for strong, driven, compassionate unpopular opinion, standing up for oneself or others such as a colleague who is Nurse Leaders, come join us. being bullied, being accountable, asking for help, trying something new, admitting Sign on Bonus Excellent Benefits Package uncertainty, and asking for forgiveness. When courage and fear meet, it often feels Subsidized Housing options Very Competitive rates awkward and scary; however, “being all in” is to be alive. To act in alignment with Loan Repayments options available your values is key to personal and professional happiness. www.tchealth.org • 928-283-2432 PRT and Promoting Patient Safety Failing to take risks and practice courageously can lead to threats to patient [email protected] safety. Focusing on my obligation to “First do no harm,” I made the decision not to 1 hour from Grand Canyon, Monument Valley, deploy a transport team until all the team members demonstrated competency. I Lake Powell and Flagstaff. was transparent in discussing my concern and contingency plan to send another team with my medical and administrative colleagues. I was told that this was a “career-limiting move.” I simply stated, “I have to be able to sleep at night.” In another organization, I disagreed with a plan to move critically ill patients multiple times to accommodate unit renovation. I identified an alternative that

July, August, September 2021 Arizona Nurse • Page 15 An Educator’s Three Act Journey: Navigating the Pandemic

Sharon Akes-Caves, RN of purpose. For me, this involved maintaining Limit the number of online class participants, Carmela Theresa De Leon, RN-BC the same work and end-of-day schedule as if I allowing you to pay more attention to non- was on campus. This familiar work-life balance verbal student cues. Transitioning from on-ground to online instruction anchored me through the stress of online • Pause and repeat: Stopping and waiting was best described as a challenging marathon teaching. for students to digest concepts in an on- with an uncertain end, a crisis of increased stress, • Take scheduled breaks: As pressure and ground environment is difficult. The online anxiety, fear, and uncertainty for nursing faculty and demand of learning online teaching mounted, environment makes it even more so. Home students (Cicco, 2020). As personal faculty stories it was vital to stop and recharge. One cannot distractions and the haze of online fatigue emerged, it seemed helpful to share my Three Act sprint through the pandemic teaching make it important to be patient, pause more, Journey of finding my best teacher self. Allow me marathon. Pay attention to the physiologic and repeat key statements. to share Act I educator, Act II student, and Act III signals of your body. Place emphasis on self- • Harness technology and gradual change: resource-centered reflections. care (Daniel, 2020; Stone, 2020). Sitting for Embrace the opportunity to integrate online hours in front of the computer doing virtual applications and programs that would not Act I: Getting to know my best-educator again teaching makes it important to maintain some have been tried in an on-ground setting. Parse’s Human becoming Theory (Parse, 1999) form of activity. Exercising; deep-muscle Allow for the learning curve of faculty of working with one’s own internal and external relaxation; mindfulness and meditation; deep and students. Appreciate the diversity of environments highlighted for me the need to breathing; and journaling reduced the stressful delivery styles and management system reflect and reassess my strengths and capabilities and demanding daily regimen of online expertise brought by students and co- as I prepared to transition and meet these online teaching (Cicco,2020). faculty (Belastock, 2020). challenges. Reflections on “Becoming My Best vs Reacting to Act II: Leading the student Act III: Looking into today and tomorrow’s crystal ball The Uncertainties”: • Less is more: Students in the online environment • Transform and evolve: As on-ground classes • Maintain your routine: In times of turbulence, are bombarded with unexpected distractions. slowly return, look at the pros and cons of abrupt and ever-changing recommendations, Break content into smaller segments than our yearlong online environment; identify stick to a rhythm that provides you with a sense previously done with on-ground classes. and retain the good ones; learn from the ineffective methods and experiences; and reflect on how to avoid those pitfalls in on- ground learning. If a similar crisis happens again, faculty and administrators need to emphasize better faculty development and Arizona Affiliate of the American College training; acknowledge the differences in the online classroom climate and culture of Nurse Midwives Scholarship Recipient especially for students; and make technical support resources more readily available As part of our action plan, the Arizona Affiliate of (Cicco, 2020). the American College of Nurse Midwives (ACNM) voted to offer a scholarship to an indigenous References Belastock, E. (2020). How to improve teacher training nurse who is studying to become a for more successful remote learning. EdTech and plans to practice in Arizona after graduation. Insider. Retrieved from https://edtechmagazine. When brainstorming a name for the scholarship, com/k12/article/2020/08/how-improve-teacher- Ursula Knoki Wilson came up as a Navajo nurse trainingmore-successful-remote-learning midwife who has always been generous in sharing Cicco, G. (2020). Online instruction during a her journey and her culture. pandemic: Faculty collaboration and self- We were able to record an interview with Ursula care. I-Manager’s Journal of Educational last fall. Ursula’s home is in the center of the Technology, 17(3), 1-5. doi:http://dx.doi. Navajo Nation, a beautiful area near Canyon De org/10.26634/jet.17.3.17545 Chelly. She shared fond memories of time spent Daniel, J. (2020). Education and the COVID-19 pandemic. Prospects. Retrieved from https:// with her grandparents and even going with her link.springer.c om/content/pdf/10.1007/s11125- mother to births. She recalled that her mother was 020-09464-3.pdf sometimes asked to help when sheep were having Parse R (1999) Hope: An international human difficult births and because her hands were small, becoming perspective. Jones and Bartlett, her mother had her reach into the ewe to find the Besides clinical work, she shared cultural Boston lamb’s hooves and bring the legs down and out. teaching with the staff of the various hospitals who Stone, A. (2020). How schools are taking SEL and She attended both public school and Saint had come from other places and cultures. Ursula mental health online. Ed.Tech Insider. Retrieved Michaels Catholic School growing up and has participated in research and was one of the from https://edtechmagazine.com/k12/ followed her sister to a college in Colorado, principal researchers in a study by the University article/2020/08/howschools-are-taking-sel-and- where she earned a bachelor’s degree in nursing. of New Mexico on the needs of native students, to mental-health-online She returned to the reservation and worked as a succeed in health professions. She shared with us nurse. She loved teaching the patients and was the similarities of the life stages represented by the Sharon Akes-Caves, MSN, MS ,RN, currently works drawn to public health. The University of Utah four directions in Navajo teachings and the nursing as an Advisory Consultant. recruited her for their Nurse Midwifery program process. which she completed in 1973, and returned to the Details of the scholarship for indigenous nurses Carmela Theresa De Leon, PhD, RN-BC, CCRN, is reservation. Ursula worked as a nurse, midwife at to study midwifery can be found on the Arizona a faculty member at Pima Medical Institute, Mesa the Fort Defiance Indian Hospital and then at the Affiliate of the American College of Nurse Midwives’ Campus. Chinle Comprehensive Health Care Facility. website http://www.aznursemidwives.org

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Shown from left to right: Beth McManis Find events (AZACNM Affiliate President), Heidi Young for nursing professionals in your area. Blackgoat (Scholarship Recipient, CNM), and Regula Jackson (AZACNM Affiliate Treasurer). Your always-on resource for nursing jobs, research, and events. Page 16 • Arizona Nurse July, August, September 2021 Fallen Nurses Nomination for Nurse of LeAnne Prenovost, RN the Year 2021

For many years, the Arizona State Nurses Association (AZNA) has provided Sylvia Galloway, MSN, RN a ‘moment of silence’ at the annual state convention for nurse colleagues who had passed away that year. Because of the COVID-19 pandemic, AZNA I am a registered nurse working at Haven Health in Sedona Arizona. I did not host a 2020 annual state convention, therefore this moment of silence also work part-time as a Professor of Nursing at Northern Arizona University to honor those Arizona nurses who died within the last year did not occur. Flagstaff. I was given the opportunity to nominate a nurse this year by my A group of AZNA members gathered as a planning committee to host employer, Haven Health. a Fallen Heroes tribute. It was apparent that every nurse on the planning This past year has been extremely challenging, to say the least. The nurses committee had been impacted by the loss of a nurse colleague during at Haven Health have collectively, as one, worked together to provide care the past 18 months. COVID-19 had already robbed nurses in our state of for patients and residents having Covid-19. I will never forget looking into so much, including final goodbyes to fellow colleagues who had died. It the eyes of my dementia residents who could not express verbally how they was important to the planning committee to organize a tribute as soon as felt. Instead, the suffering was portrayed in their eyes. Having had Covid-19 possible, even if it was necessary for this event to occur virtually. Nelson myself, I knew what they were feeling. It made caring for them even more and Lange (2020) commented on how nurses, in times of crisis, tend to special, and I could truly empathize with what they were experiencing. One compartmentalize their emotions altogether in order to continue moving by one they recovered, but not all. That was heartbreaking. forward caring for their patients and families. This avoidance behavior can During this time, the nurses at Haven Health in Sedona worked overtime often lead to unresolved grief. Furthermore, during these times of social to provide the best care possible, some even while recovering themselves. distancing when death occurs, this increases the potential for complicated In retrospect, I could not choose only one nurse to nominate. We truly came grief and unhealthy grieving behaviors. together and became one and I am honored to be among them. To help mitigate unhealthy grieving, it was decided that hosting a I believe it would not be in keeping with the sacrifice and effort that the remembrance of our Fallen Nurse Heroes during Nurses Week 2021 would nurses have endured during this global pandemic, to choose only one nurse pay tribute to our nurse colleagues who had died within the last years. to nominate. In addition, this year, there already exists enough division. All Another goal of this tribute was to provide AZ nurses a safe place to grieve, the nurses I am fortunate to work with are exceptional, and I could list them begin their grief process journey, and offer a path to wellness and self-care. all along with their best qualities. According to Howard et al. (2021), nurses are drawn together through shared This year my nomination for “Nurse of the Year” goes to all the nurses at experiences and become a shared family to each other. These bonds make Haven of Sedona. I would not feel right singling out just one, because we the loss of a colleague extremely difficult. When a nurse colleague is lost together are one fierce, front-line worker. Thank you for this opportunity. tragically, the fabric of this extended family is torn. Honoring the memory of lost colleagues can be heartbreaking but is vital to help nurses heal. With support from each other, nurses can heal together. The Fallen Nurse Heroes Tribute was coordinated by AZNA, the AZ Korean Nurses Association, the Philippine Nurses Association, the Black Nurses Association, the Hispanic Nurses Association, and the Native American Nurses Association in the state as a collaborative, professional effort. A live virtual presentation included songs, poems, a personal call We Know We Are Home out of each nurse lost, and a bell toll. The presentation was beautifully and empathetically executed and although there was significant work that went Zengzeng Lu, RN into the production of this event, the really hard work involved finding the fallen heroes from family, colleagues, and friends and listening to their As the tides ebb and flow in San Francisco Bay stories. There were nurses working the front lines who died of COVID-19, As the melancholy sound of the fog horn drifts in and out there were nurse suicides, there were nurses who died from domestic As the sweet smell of eucalyptus wafts on the breeze violence, nurses who died on their way to or from work, nurses who died We know we are home of tragic unexpected accidents, nurses who had terminal illnesses and worked right up until the end, and nurses who died of natural causes. It was As you awaken from your slumber, we greet you gut-wrenching to hear and read about the stories that came in, but it was As breakfast is served, medication is distributed and daily ablutions are made an honor to hear these stories and pay tribute to these nurses. By sharing As lunch is cleared and we get a chance to chat these stories, many families and colleagues began their healing journey. By We know we are home producing the event, nurses in our state were empowered to care for our profession at a larger level and help nurses heal together. The importance As family calls, as newspapers are read, as movies are watched of the Fallen Heroes Tribute is apparent to nurses in the state of Arizona and As a favorite game is played, as a familiar tune is heard this event will continue yearly as well as a living legacy of a future healing As the last bite of supper becomes one bite too much garden in Flagstaff to honor our fallen heroes. We know we are home To our nurse colleagues who we have lost, we love you, we miss you, and thank you for your service. May you now rest in peace. As night falls As the darkness brings on sweet dreams References As the gentle hum of evening envelopes us Howard, M. S., Buck, M., Carpenter, H., & McMillan, K. (2021). Navigating the loss We know we are home and grief of a nurse suicide: With employer support, nurses can help each other after a colleague’s death. American Nurse Today, 16(3), 14–16. We welcome you here when living needs a helping hand Nelson, K., & Lange, R. (2020). Navigating loss induced by COVID-19. American We are here because we have dedicated ourselves to caring for you Nurse Today, 16(3), 18. Together, we move through our lives knowing that we make a difference for each other LeAnne Prenovost, DNP, RN, CNE, CHSE is an Arizona Nurse Educator. We know we are home There are many places we could work There are many things we could do There are many people we could be with But here We know we are home We’re Looking for the Best! By caring for you By being together on good days and not-so-good days Now Hiring Full-Time, Per Diem By sharing your joys and helping to deal with sorrows We have come together & Seasonal Experienced RNs Gratefully Sign-On Bonuses May Be Available for Core Positions! We know we are home. ©2021 Zengzeng Lu, RN BSN www.NorthwestHealthcareJobs.com An Equal Opportunity Employer/VEVRAA July, August, September 2021 Arizona Nurse • Page 17 The Cures Act: What Nursing Professionals Need to Know

Georgia Reiner, MS final rule is aligned with the information in HIPAA, Majumder MA, Guerrini CJ, Bollinger JM, Cook-Deegan, so it’s important that nurses are aware of what R, McGuire AL. Sharing data under the 21st In December 2016, President Obama signed the falls under PHI; more information can be found at Century Cures Act. Genet Med. 2017;19(12):1289- 21st Century Cures Act (“Cures Act”) into law, and www.hhs.gov/hipaa/for-professionals/privacy. 1294. the US Department of Health and Human Services Posnack S. Pssst…information blocking practices, your published the final rule on May 1, 2020. The act has How can nurses protect themselves? days are numbered…pass it on. HealthIT Buzz. 2020. www.healthit.gov/buzz-blog/information- several elements of interest to healthcare providers, Nurses, other healthcare providers, blocking/pssst-information-blocking-practices- including regulations designed to facilitate sharing administrators, and IT personnel should understand your-days-are-numberedpass-it-on. of data for research purposes, thereby accelerating the act’s requirements, particularly as they relate to Primeau D, James J. Game planning the information drug and device development, and those designed information blocking, including the eight exceptions blocking final rule. J AHIMA. 2020. https://journal. to improve interoperability so that patients have that will not result in penalties for information ahima.org/game-planning-the-information- easier access to their health information. blocking, listed above. Before proceeding with blocking-final-rule. However, the act has the potential to create acting under an exception, nurses should consult Office of the National Coordinator for Health difficulties for both patients and healthcare with a risk manager. Information Technology. Cures Act final rule. providers. Nurse practitioners, registered nurses, It’s also important to know nurses still need to Information blocking exceptions. www.healthit. and other nursing professionals need to understand adhere to state requirements for sharing EHI. If, for gov/topic/information-blocking. US Department of Health and Human Services. 21st the act, its benefits and potential risks, and how to example, state law prohibits sharing certain EHI, Century Cures Act: interoperability, information protect themselves against legal action. nurses should follow the law. And, of course, nurses blocking, and the ONC Health IT Certification need to adhere to HIPAA requirements, which Program. 2020. www.federalregister.gov/ What is the Cures Act? include PHI in paper, electronic, and verbal formats. documents/2020/05/01/2020-07419/21st-century- One of the goals of the Cures Act is to promote More data may prompt patients to ask more cures-act-interoperability-information-blocking- patients’ ready access to information in their questions. Therefore, it’s a good time for nurses to and-the-onc-health-it-certification. . Although patients already remember to document patient counseling fully in US Department of Health and Human Services. have the right to access their information under the the health record so they are protected in case of Summary of the HIPAA privacy rule. OCR Privacy Health Insurance Portability and Accountability Act legal action. Brief. 2013. www.hhs.gov/hipaa/for-professionals/ (HIPAA), the Cures Act focuses on quick, free access privacy/laws-regulations/index.html. to electronic health information (EHI), including Meeting information needs What is protected health information? HIPAA J. 2018. www.hipaajournal.com/what-is-protected-health- consultation notes, discharge and summary As awareness of the act increases, more patients information. notes, history and physical, imaging narratives, are demanding access to their EHI. Nurses need lab report narratives, pathology report narratives, to ensure that this access is available, while Disclaimer: The information offered within this article procedure notes, and progress notes. The act remembering that it’s up to them to help patients reflects general principles only and does not constitute requires organizations to have a secure “application interpret that information correctly and to document legal advice by Nurses Service Organization (NSO) programming interface” so patients can access this education and counseling efforts completely in the or establish appropriate or acceptable standards of information via apps on their personal devices. health record to protect themselves from liability. professional conduct. Readers should consult with an Failure to provide patients with access can result attorney if they have specific concerns. Neither Affinity in penalties related to “information blocking.” The Georgia Reiner, MS, is a Senior Risk Specialist with the Insurance Services, Inc. nor NSO assumes any liability act defines information blocking as practices “likely Nurses Service Organization (NSO) for how this information is applied in practice or for the to interfere with, prevent, or materially discourage accuracy of this information. RESOURCES access, exchange, or use of electronic health This risk management information was provided by Aebel ES, Newlon AJ. Increased patient access under information,” which includes delays in giving access. Nurses Service Organization (NSO), the nation’s largest the 21st Century Cures Act: what it means for The Office of the National Coordinator for Health provider of nurses’ professional liability insurance providers. Trennan Law. 2020. www.trenam.com/ Information Technology has issued eight exceptions coverage for over 550,000 nurses since 1976. The individual trenam-news/increased-patient-access-under- that will not result in penalties for information professional liability insurance policy administered the-21st-century-cures-act-what-it-means-for- through NSO is underwritten by American Casualty blocking: providers. Company of Reading, Pennsylvania, a CNA company. • preventing harm Ambulatory Surgery Center Association. 2020 Cures Reproduction without permission of the publisher is • privacy Act final rule. 2020. www.ascassociation.org/asca/ prohibited. For questions, send an e-mail to service@nso. • security federalregulations/overview/cures-act com or call 1-800-247-1500. www.nso.com. • infeasibility Federal Register. 2020;85(85). 45 CFR Parts 170 and 171. • health information technology (IT) performance • content and manner • fees • licensing.

The “preventing harm” exception is of particular interest to healthcare providers and states: “It will not be information blocking for an actor [healthcare provider] to engage in practices that are reasonable and necessary to prevent harm to a patient or another person, provided certain conditions are met.” It’s beyond the scope of this article to review each exception and its associated conditions; more information can be found at www.healthit.gov/ topic/information-blocking. The deadline for compliance with most of the act’s parameters that directly impact healthcare providers was April 5, 2021; full compliance with all information-blocking provisions will be required on October 6, 2022. Established in 1926, and like the tenacious Western spirit that built Wickenburg, at our rural Community Hospital and Clinics, taking What are the potential risks? care of our patients, families, and community comes first. Our team is Although providing patients with access to committed to providing quality, health, and wellness services to our residents information is a worthy goal, that access can create and surrounding communities within approximately 3,300 square miles. problems. For example, a patient with slight chest discomfort who is waiting in the ED to see a provider Being a smaller organization, Wickenburg Community Hospital offers the may access their lab results via their smartphone app opportunity for more personal care to our patients while being close and incorrectly assume they don’t have a problem enough to a major city to enjoy all that Phoenix has to offer. because no test is marked “abnormal.” The patient If you have the passion for caring for patients may then leave without seeing the provider but later “Out Wickenburg Way,” explore the possibilities! return with serious heart damage. Another challenge is balancing access with privacy protection. There has been confusion as to what is meant by EHI and how it relates to electronic “protected health information (PHI)” Or contact Dina Steinberg at 928-668-1822. listed under HIPAA. The definition of EHI in the Page 18 • Arizona Nurse July, August, September 2021 The Need for PhD-prepared Nurse Scientists to Stem the Faculty Shortage Sheila M. Gephart, RN of their lives. To compensate, more faculty will be hired who are not nurses. Leadership positions may be shared, more and more, by faculty with PhD’s in In spring of 2019, I lumbered down the hallway at the University of Arizona other disciplines. into my friend’s office, who had just returned from Florida and the AACN The cost of the degree and concerns about return on the investment may Doctoral Education Conference. I had wanted to go but couldn’t squeeze in impact decisions about which degree to pursue and when. In Arizona, we have another trip, so I jealously asked him what he thought of the meeting. Leaning three public universities, and two of the three prepare PhD’s. Nurse faculty back in his chair, he shared about a speaker who asked attendees to stand across the three state schools may be eligible for qualified tuition reduction up if they planned to retire in the next five years. He said that half the room which will dramatically slash the cost of the degree. For others, they may find stood up. Why does that matter? Don’t those who have invested their lives in that the Nurse Faculty Loan Program (NFLP) offers help to defray the cost academic nursing deserve to retire if they want? Won’t the rest of us simply of the PhD. The NFLP is a federal loan forgiveness program that is a perfect pick up the slack and figure it out? Yes, and perhaps yes with ingenuity but fit for PhD students who want to pursue a faculty position after graduation. here is the problem- the people at that meeting represented the academic NFLP graduates qualify for up to 85% of loan forgiveness after working for nursing leaders across the whole country! That means that if roughly half of four years in an accredited school of nursing. It is useful to consider when our most senior leaders retire by 2024 (now just three years away), we will face evaluating salaries that faculty salaries are often calculated over nine-month a major academic leadership shortage in nursing. Who will lead next? contracts, leaving three months a year to take off or engage in other work. In Nationally, we are doing a great job of preparing nurse practitioners with Arizona, faculty also qualify for reduced tuition for their dependents, state the Doctor of Nursing Practice (DNP) degree. Our ability to meet the demand pension benefits, and strong university health and life insurance benefits. For in the PhD workforce is at high risk unless more nurses decide to pursue the those who go onto the highest leadership positions in academia, their income PhD. The discipline of nursing is strengthened by the diverse contributions near retirement will exceed that of nurse practitioners and nurse anesthetists. and collaboration between DNP and PhD prepared nurses. The PhD, One of the things I love best about having a PhD is that I can pursue exciting or Doctor of Philosophy degree is awarded to candidates who complete areas of inquiry, grapple with tough questions, make decisions that impact rigorous coursework, demonstrate depth and breadth of knowledge the future of the discipline, and mentor others to lead and impact health and through passing the comprehensive examination, and conduct meaningful healthcare. Teaching and mentoring bring lasting impact as I work with others discovery research in the dissertation. The PhD-prepared nurse scientist is to help them achieve their goals and research is exciting! Perhaps now is the prepared in philosophy, theory, research methods, and leadership to build time to consider pursuing your PhD? The discipline needs you. the discipline of nursing by contributing to its evidence base. The PhD provides disciplinary leadership and pursues research to discover answers For more information about the faculty shortage: https://www.aacnnursing. to the burning questions derived from practice. What do nurse scientists org/news-information/fact-sheets/nursing-faculty-shortage do? They often teach, conduct research, mentor, write, speak, and lead in interdisciplinary and intradisciplinary circles. Many will work in universities, Sheila M. Gephart, PhD, RN, FAAN is an Interim PhD Program Director University hospital systems, or government positions. It is a wonderful degree for of Arizona someone who loves to think, muse about a better way, solve big problems, and inspire others to grow. We need more nurses to pursue PhD’s and we must not wait. What happens Using the Evidence to Make Your Patient if the discipline fails to supply PhD-prepared nurses to lead in academia? Across the country today, many academic departments are grappling with Education Most Effective and Efficient that challenge as retirement age faculty enter the well-deserved next stage Fran London, RN

The Patient Education Practice Guidelines for Health Care Professionals was developed by the Health Care Education Association to provide direction for healthcare professionals. Over 10,000 articles and resources were reviewed to identify evidence-based practice for patient education. These guidelines are based on the four essential components of the patient education process: assessment, planning, implementation and evaluation (APIE). The guidelines suggest that ideally, education is interactive and focused on the desired patient behavior and patient priorities.

To learn more and to view the Patient Education Practice Guidelines for Health Care Professionals, visit https://www.hcea-info.org/patient- education-practice-guidelines-for-health-care-professionals.

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APPLY AT WARMC.com Or, visit us in person on any Wednesday with your resume in-hand. If selected to be hired, you will be made an offer on the spot. For information, contact the HR Dept. at 928-763-0267. July, August, September 2021 Arizona Nurse • Page 19 Fun Facts about PACs Carol Stevens, PhD, RN contributions to candidates or parties. They • Similar to Super PACs, AZ has a MEGA-PAC AzNA-PAC Secretary do, however, make independent expenditures status where contributions from 500 or more in federal races - running ads, sending mail, or individuals in the amounts of $10 or more are You may know that a Political Action Committee communicating in other ways with messages made to the candidate in the four years prior (aka “PAC”) is an organization that raises and that specifically advocate the election or to applying to the Sec of State. A MEGA- distributes funds to candidates seeking offices, defeat of a specific candidate. There are PAC status may contribute twice the limit to exists on both state and national levels and is no limits or restrictions on the sources candidate committees per election cycle. typically formed by corporations, associations, of funds that may be used by Super PACs unions, or organizations. You may also know that (Open Secrets.org) • The AzNA-PAC (www.aznurse.org/pac) AzNA and many other professional associations, raises funds to support endorsed candidates including ANA have their own PAC. • Since June 2008, Leadership PACs have been and educate nurses about political action. a way of raising money for politicians seeking The PAC Board of Trustees evaluates, But did you know …… leadership positions in Congress or for endorses, and contributes to candidates for higher offices. A breakdown of which PAC is the state Legislature in Arizona who have • National PACs have been around since supporting which politician can be found at clearly demonstrated responsible awareness 1944 when the Congress of Industrial spending by Leadership PACs (OpenSecrets. of nurses’ needs based upon the principles Organizations (CIO) formed a PAC to raise org). of the AzNA Public Policy Agenda. By law, money for the re-election of President the AzNA PAC cannot contribute to any Franklin D. Roosevelt. The PAC’s money came • At the state level, an organization becomes candidate running for federal office. AzNA’s from voluntary contributions from union a PAC according to the state’s election parent organization, ANA, has a PAC that members, not union dues (OpenSecrets.org) laws. Arizona Revised Statutes §§ 16-901 endorses candidates running for Congress through 16-931 contain the Arizona laws (https://www.nursingworld.org/news/ • National PACs must register with the Federal governing Arizona PACs. Similar to national news-releases/2018/ana-pac-additional- Election Commission (FEC)(www.fec.gov) PACs, candidates and PACs in every state endorsements/). within 10 days of its formation. National PACs are required to submit detailed records of have grown from around 600 in the early their donations and expenditures to a state • In the past two election cycles, the AzNA 1970s to over 4,000 today and play a huge agency; in Arizona, it is the AZ Secretary of PAC has endorsed and contributed the full part in influencing elections, both nationally State office (https://azsos.gov/)(Transparency donation amount to Arizona nurses running and locally (Center for Responsive Politics, USA). in the general election for state offices. This 2020; Wikipedia, 2021) was made possible because of donations • The AZ statewide limit is biennially-adjusted; to the PAC. You can be part of this effort • National PACs can give $5,000 to a candidate current limits allow PACs to give $5,300 to by donating to the AzNA PAC here: https:// committee per election (primary, general an individual candidate yet amounts are www.aznurse.org/page/PACdonate or special). National PACs can also give up unlimited if given to another PAC or political to $15,000 annually to any national party party (https://azsos.gov). For the 2020 AZ Needless to say, there are millions if not billions committee, and $5,000 annually to any other Legislative elections, over 21.7 million was of dollars going in and out of PACs with the sole PAC (OpenSecrets.org). raised by Arizona PACs (Transparency USA). purpose of influencing an election. PACs are There are only 27 super PACs in AZ. • Created in 2010, Super PACs make no important to nurses because so much of healthcare is impacted by law, and legislators make laws and people elect legislators. PACs are clearly a way to support the right people for the right legislative seat. PACs can be powerful, but only with funds to help them do their job. With your contribution, the AzNA PAC can be your go-to source for all Because of AzNA nurses can say YES primary and general AZ elections. For more information and options for donating, visit https://www.aznurse.org/page/PACabout or there is a strong state-wide promotion of a healthy contact the AzNA-PAC Chair, Colleen Hallberg at YES voice for nursing YES Arizona [email protected].

nurses influence laws, rules nationally accredited YES and Scope of Practice YES continuing education

collaboration on the local nurses have access to YES and national level YES mentors and role models www.aznurse.org

aznurse.org/JoinToday Page 20 • Arizona Nurse July, August, September 2021 Caring During COVID-19: Nursing Education

Mary Eve Rice, DNP, MSN, CPNP, stress management webinars via zoom, with prizes. helped to clarify concerns and fears amongst the Bettina Shank, DNP, MSN, RN, CNE, A pedagogy of care includes an added focus on faculty, staff, and students. At all levels, policymakers Terri Clark, MSN, RN, flexibility, connection, empowerment, prediction, worked creatively and with innovation to ensure Michele Robertson, DNP, MSN, APRN, FNP-BC, and preparation. Faculty allowed more flexible educational and workforce needs were met while Amy S. Hamlin, PhD, MSN, APRN, FNP-BC, deadlines and opportunities for revision submissions maintaining public safety and sufficient access to Tasha Ruffin, DNP, RN, without lessening quality work expectations. healthcare. & Debra Rose Wilson, PhD, MSN, RN, IBCLC, Faculty consistently made extra efforts to reach out AHN-BC, CHT to students, assessing stress levels and evaluating Taking Care Through Leadership students’ overall mental health. Follow-up emails and In March 2020, leaders in nursing education Reprinted with permission from telephone calls reminded students that the faculty programs had to adapt quickly and lead with Tennessee Nurse May 2021 issue cared. Faculty played a crucial role in empowering conviction. Leadership skills had to evolve to students to persevere. accommodate the continually changing virus The COVID-19 pandemic has challenged challenges for the faculty and the students. To individuals and systems across the planet, and in Taking Care of Teaching and Learning establish a culture of connection during a socially the world of nursing, innovative approaches were Before the pandemic, the use of technology in distanced period was fostered through weekly zoom required, and valuable lessons are still being learned. nursing education was not uncommon. Nursing faculty meetings among the faculty and weekly student The world has seen nurses step up to the plate to and students were familiar with learning management communication to keep all informed. The Nursing manage the care of the ill and then to vaccinate the systems, video conferencing, virtual quizzing, Director created and posted YouTube videos for masses. Nursing education had to also step up to the simulation, and other online technologies. With the the students and faculty to view, providing uplifting plate to ensure that there are graduates stepping into sudden impact of the pandemic, transitioning to an messages to ease anxiety and improve morale. practice. This article reviews some of the challenges online platform became necessary. Student learning Leadership focused on providing transparent, that nursing education in Tennessee has overcome outcomes could not be compromised. Zoom sessions positive communication by attempting to deliver and gives honor to nursing schools across the focused on academic issues but were also adapted to the right message, at the right time, in the right way state who found creative, safe, and thorough ways include logistical, technical, and emotional support. during the ever-changing havoc experienced day-to- of preparing students for practice. This is written Zoom meetings allowed opportunities for review day. Positive feedback from faculty, thank you emails, through the eyes of nursing professors from Austin or further instruction. Assignments were adapted and reassuring calls solidified leadership efforts Peay State University, TN. to support online learning and included developing and helped rejuvenate leadership for the continued Nursing faculty were faced with the difficult act of a virtual “telehealth” visit experience for nurse challenges. balancing a quality nursing education with navigating practitioner students, online teaching opportunities the challenges of living through a pandemic. for nurse educator students, and online simulation for Taking Care of Faculty COVID-19 impacted teaching methods, clinical traditional pre-licensure students. Holistic nurses are taught to put their own “oxygen experiences, existing policies, styles of leadership, Test proctoring services were shut down when mask on first” to care for another, as is wisely advised personal and academic lives of nursing students, the outsourced proctors went on lockdown. Some in every pre-flight safety lecture. Peer-reviewed and nursing faculty’s professional and personal students needed reliable computer equipment research reminds nurses to care for themselves, draw lives. During these unprecedented times, leaders and reliable internet to stream online lectures, and on resilience, seek out online resources, and extend worldwide faced the obstacles head-on, with creative the university assisted. Concerns with the Family compassion to others. Activities that helped regulate ideas, collaboration, and flexible hearts to care for Educational Rights and Privacy Act (FERPA) and the community and boost faculty morale included those we serve. student privacy arose from video conferencing’s weekly email messages from leadership, regular Zoom exponential use. Solutions included proctoring meetings to check-in, and a surprise Zoom wedding Taking Care of Students students via online video conferencing, bringing small shower for a nursing faculty member. Additionally, is known for intense rigor and groups to campus lab activities while maintaining celebrating birthdays, successes, and milestones via demanding requirements. Nursing students were social distancing and personal protective equipment Zoom helped normalize the need to celebrate life already tackling the stressors of obtaining a nursing (PPE), and avatar-based online simulation. events and remain a supportive community. The degree when the COVID-19 pandemic compounded School of Nursing held a civility challenge during an this into what seemed to be an impossible challenge. Taking Care of Clinical established “Civility Week.” This week encouraged Nursing instruction changed drastically and abruptly. Clinical learning is a staple for nurses and different cohorts of faculty to try to “out-civil” each Students struggled to adjust while facing numerous healthcare professionals. Public safety and the need other. The week ended with planned team-building hurdles with their children at home full-time and to develop new colleagues in the healthcare sector activities, prizes, laughter, and encouragement. In unstable income sources for their family. Many collided. Fortunately, multiple large community difficult times, nurses must remember to step back, nursing students (RN to BSN and graduate students) hospitals collaborated and continued to allow breathe, rest, and intentionally choose self-care were not only students but also essential workers. modified clinical experiences for nursing students. as an internal resource. Working during a world Going to school and working in healthcare during a Long term care facilities, some hospitals, and other crisis impacts personal lives, as well as professional pandemic is incredibly strenuous and overwhelming. community partners could not allow students. But, practice. Nurturing healthy relationships, choosing Faculty made efforts to alleviate stress by offering as clinical agencies closed their doors to students, one’s battles carefully, seeking mindfulness and the Tennessee State Board of Nursing began offering compassion training, taking breaks, getting outside, educational programs guidance. The guidance and sharing gratitude, are examples of ways to allowed undergraduate nursing programs to increase incorporate deliberate self-care. virtual simulation and on-ground labs to account for up to 50% of clinical hours. For graduate students, the Conclusion National Organization of Nurse Practitioner Faculties During COVID-19, nurse educators across (NONPF) sent a statement to all programs reaffirming Tennessee are finding successful new teaching the minimum requirement of 500 direct patient methods and lessons far beyond coping. Lessons clinical hours for NP programs. NONPF stated that learned help direct continued restructuring and programs requiring greater than the 500 minimum program improvement. Despite a worldwide direct hours could waive the additional hours if a pandemic, positive reflections and outcomes have student had demonstrated educational outcomes arisen. Unity was a crucial element of success. Faculty GREAT OPPORTUNITIES AT and competencies or use virtual simulation. Later, as and students kept the focus on as much of a positive the vaccine became available, APSU student nurses experience as possible. Transparency and inclusion LA PAZ REGIONAL HOSPITAL & and their faculty (like many other Schools of Nursing for all aided in the fluid teaching environment. CLINICS IN PARKER, AZ across TN) provided immunization sites for the State Nursing students and faculty have been TIME FOR A CHANGE? LOOK NO FURTHER! of TN. tremendously affected financially, academically, and psychologically. COVID-19 turned the world upside WE ARE RECRUITING FOR RNs FOR ED, Taking Care of Policy down in a matter of days and weeks, and those MED/SURG/ICU & OR DEPARTMENTS With COVID-19 also came many policy addendums, impacts still exist. The silver lining to the pandemic from classroom spaces to clinical placements, and is that successful innovative teaching and learning most importantly, considerations to faculty, staff, modalities were developed and will continue. Schools We offer competitive wages, great benefits, tuition and student safety. A campus COVID-19 Task Force of Nursing across Tennessee remain committed to reimbursement, relocation assistance and sign-on was formed and kept everyone abreast of the viral empowering students to become critical thinkers, healthcare leaders, excellent communicators, and bonus for the right applicants. threat and thresholds. Community partners from within the community, university, and state banded life-long learners. These lessons were only enhanced To apply, visit www.lapazhospital.org or together to make uniform informed changes with through the challenges of COVID-19. email [email protected] safety, healthy work environments, and education at the heart of each decision in an unprecedented way. This research/manuscript did not receive any Clinical sites, external partners, and the state board specific grant from funding agencies in the public, of nursing helped guide decisions. Networking and commercial, or not-for-profit sectors. collaboration were a staple of quality leadership in education during COVID-19 and policy changes References available upon request. July, August, September 2021 Arizona Nurse • Page 21 Real Talk About Burnout

Bree Becker, MSN, NP-C, RNC-MNN [email protected]

Reprinted with permission from Georgia Nursing April 2021 issue

Recently I was putting my son to bed. We read one of my favorite children’s books, The Giving Tree by Shel Silverstein. Despite reading this story many times, I was struck by the visceral sadness of the tale. It’s a children’s story with a simple Calling all NPs and NP Students! We’re bringing the speakers and education to plot. A boy is climbing a tree (personified as a woman), and he happily swings from you! her branches, devouring her apples and enjoying all the comfort the tree provides. On July 24, 2021, join with your Nurse Practitioner Colleagues for a full day of Readers follow the boy on his journey through adolescents, adulthood, and then as virtual intensive programming, offering education to review and update current a tired elderly man. Throughout his life, the boy takes, and the tree gives. Whatever concepts in clinical and practice management for advanced practice nurses and his needs are at each stage of his life, the tree is happy to provide a piece of herself advanced practice nursing students. to help. She gives her branches for shade, then her wood to help build a house. Keynote Speaker: Finally, with her resources depleted, she dwindles to a stump. And even then, she manages to provide a place for the boy, who is now an elderly man, to sit. How to Protect Your Career: I realized the tree’s exhausted state represents how many nurses feel. For Legal Basics for Nurse Practitioners us, The Giving Tree is an all too familiar story. The depleted tree personifies the exhaustion and burnout most of us are experiencing today. I receive daily articles Dr. Carolyn Buppert that reference burnout and company ads that offer a solution specifically for me. Let’s dissect the legal pitfalls of advanced practice. But at the end of the day, the responsibility of executing the proposed solution This discussion will focus on the law governing Nurse falls back on me. “Here is something else for you to do to help you with your Practitioners’ activities, what went wrong for Nurse burnout.” Burnout was identified as an issue decades ago, and is only getting Practitioners in selected cases, and what Nurse worse. Despite public awareness, nurses are still being asked to do more with Practitioners can learn from the cases to avoid getting less. The pandemic highlighted nurses struggle with the mental and physical toll into legal trouble of their own. Carolyn will analyze strategies for avoiding of the job. Instead of offering a cliche intervention for burnout, I want to have a malpractice, discuss how NPs have gotten into trouble when prescribing opioids, real conversation. Let’s ask hard questions. Let’s stop pretending we know how and look into federal prosecution of individual NPs for taking kickbacks, violating to fix a problem that’s plagued us for decades. HIPAA rules, and billing Medicare and Medicaid outside of the rules. My personal problem with many of the resources designed to address burnout is that it creates more work for me. Now don’t get me wrong, I like learning about Also Featuring: yoga and I actually believe things like exercise and diet have a positive effect on • An Exciting Variety of Breakout Sessions your mental health. But the reason I feel exhausted as a nurse is not because I • Interactive Virtual Exhibit Hall don’t exercise or eat healthy. I have always adopted a healthy lifestyle even before • Annual AzNPC Membership Meeting I was a nurse. I do think that my healthy lifestyle allowed me to push myself • Presentations by Novo Nordisk and Abbott physically and mentally as a nurse. The long hours, constant stress, and erratic Register today at www.aznurse.org/events schedule didn’t catch up with me for a decade. But I eventually burned out. And no amount of green smoothies or yoga could cure me. I found myself becoming overly cynical, feeling like I was not making an impact, and dreading work. Burnout is the symptom of a larger disease: it’s the result of poor processes within institutions and the larger healthcare system overall. Nurses experienced burnout long before this pandemic. The pandemic has only cast a light on an ugly truth most of us have been aware of for a long time. If burnout is not the healthcare worker’s problem alone to solve, who is responsible for solving it? Here are real problems, I don’t have the answers. But I know we are too fragile to continue this way. Last year, I was clueless about the horror the world was about to experience due to COVID. While I knew our medical system was broken and that healthcare workers were being stretched beyond capacity, I didn’t realize • Completely online • No out-of-state tuition what a pandemic would do to our profession. I didn’t realize how vulnerable we • Finish in as little as 2 semesters are. The future is now. The what-ifs and maybes are reality. We can’t afford to • Part-time and full-time enrollment available hobble along anymore. We have to be willing to talk about the real issues and the • Admission available twice each fall, spring and summer semesters first step is asking hard questions. • DSU has low costs for the students I know I can’t fix this today and I know I can’t fix this alone. To me, it’s a fight • Ranked as the 12th most affordable and 16th best worth fighting. And maybe, by the time I retire, nurses won’t suffer the way I’ve quality RN-BSN online program in the nation seen my peers suffer over the last decade. And maybe, unlike The Giving Tree, nurses won’t give until we are depleted and we will be empowered to care for For more information and to apply, visit https://dxl.dixie.edu/rn-bsn/ ourselves the way we care for others. Program questions, call 435.879.4519 or email [email protected] Page 22 • Arizona Nurse July, August, September 2021

Two Year Anniversary Members AzNA’s Superstars March – May 2021 Happy Anniversary to our dedicated AzNA members celebrating these Avondale Goodyear Phoenix Surprise special milestones for this past quarter: Maria Lourdes Brobo Iesha Floyd Nneka Adams Elizabeth Mullican March – May 2021 Amanda Hicks Penny Jefferson Shannon Bitza Karen Whitt Rose Lopez Theresa Casillas 5-Year Members Michelle Sutton Buckeye Tonya Mays Elaine Chanin Taylor Robert Adams Ardilia Cross Ashley Valencia Edna Felix Healey Matthew Scott Jessica Swanson Samantha Ence Marlene Gantert Folake Alimi Mary Tulinnye Greybull Timothy German Tempe Deana Anderson Candice Turrieta Casa Grande Tadd Greenfield Jeanene Griffor Amina Aden Candace Angel Stacy Vineyard Rachael Tobie Nureet Gross Karen Ellis Cassandra Archer Lorrie White Keams Canyon Cyndi Krause Sandra Marken- Gayle Belshe Daena Zamora Cave Creek Jose Burgos Heather Lucas George Linda Black Lilly Carpenter Andrea McCray Anne Meyer Mara Scaramella Kingman Robert McJunkins Duane Mullen Sherri Brown 10-Year Members Amina Loucas Danica Oparnica Terri Brown Aida Amado Chandler Lea Palmer Tolleson Amanda Bugarin Mary E Dominguez Laurice Basha Laveen Rebecca Priest Diana Soto Carolyn Burcham Mary Fazio Poorman Jenniffer Canning Sara Santos Janet Burns Stacey Gregory Teri Schmitt Marisol Moreno Leon Lisa Schniers Tubac Courtney Campbell Deborah Hunt Michele Sims Anna Janet Trejo Christy Somner Lori Cannon Michael Zadakis Litchfield Park Candice Vaughan Lesley Lightsey Connie Canada Griffin Tucson Kimberly Cannon Gregg Smith Chinle Melissa Zuber Johannah Blake Karyn Carlson Roberta Draper Lynnfield Francesca Bryan- Christina Chudomelka 15-Year Members Ellen Kiesewetter Pinetop Couch Kyndall Cline DianaJean Baratta Chino Valley Marcy Schlaufman Michele Burkhart Abby Cockburn J. Camille Beauchamp Suzanne Gullotta Marana Kerry Wilson Erica Castillo Courtney Davis Judith Climenson Vivienne Abrugena Casandra Crowson Flagstaff Marc Kelly Prescott Margaret Eisele Trisha Deason Deborah Kirkpatrick Kimberly Callahan Margie Neish Sherryl Hoyt Claudia Guerrero Tanya Dempsey C. Suzanne Lee Kerry Chapley Stephanie Jordan Ofelia Figueroa-Perez Karin Sherrill Adrien Gupton Mesa Queen Creek Karen Kennedy-Evans Brooke Finley Christopher Anne Aballe Kari Bjornberg Shelia Lerma Colleen Ford 20-Year Members Rodriguez Heidi Annest Danielle Garcia Donna Morgan Lacey Fudge Trista Campbell Branwyn Walker Nicole Bartreau Suzette Hathcock Kiinani Mulvihill Kendra Garcia Maria Del Carmen Terry Watson Stephanie Murray Kathleen LuPone Florence Castillo Susan Woods Vanessa Nguyen Tandra Garvin Connie Neal Christine Banda Jennifer Cerna Ali Parent Sara Gonzales Jean Nelson Norma Fuqua San Tan Valley Linda Perez Jessica Green Patricia Park Fountain Hills Shannon Gervais Ashleigh Gage Anita Redford Jacquelyn Hall Margaret Englisch Selina Hanson Antoinette Gatlin Melissa Ritchey June Helbig 25+-Year Members Kelly Huffaker Richard Wade Kirk Tjalas Katherine Helsel Charlotte Barkhauer Fresno Jenifer Lieber Bonnie Westra Lawanda Rainey Melinda Loya Scottsdale Sarah Wright Sierra Holloway Kathyrne Barnoski Reena Pathak Nichole Brown Gregory Jones Caroline Bentley Ganado Irina Peters Nilsa Criado Waddell Arianne Leivdal Carol Chavez Colleen Frank Lucy Porembski Mary Ellen Cindy McBroom Marlena Lopez Jeannine Dahl Melissa Rothlisberger Cunningham Jean Lynch Margaret De Vries Gilbert Shiny Thomas Nicolle Fier Woodbridge Lisa Mace Mary Griffith Julie Bales Michele Fiore Christina Ruggiero Brittney Collyar Page Kristine Fletcher Regina Martin Ida Heath Sara Crance Brittany Fat- Cynthia Hughes Yuma Sonia Massoud Ada Hinshaw Kathleen Gallagher Denatsosie Alexia Lombardi Bridgett Allen Laura Maurer David Hrabe Kelly Garrison Annye Nichols Carissa Augustyn Jennifer May P. Ellen Jost Christina Joyave Parks Ana Schwartz Dinah Baney James McKee Tracy King Amanda Keenhold Katherine Sherman Daniel Smith Meredith Cardenas Laura McMeley Terance Kranz Robert Larson Kimberli St John Bola Falegan Brenda Mitchell Loraine Langfeldt Kayla Newby Paulden Christina Worley Afton Mack Brittany Reynolds Winnifred Shelby Deedra Zabokrtsky Jane Matias Gloriajean Nelson Loretta Lukens Carolina Monte Diane Ortega Ida Moore Glendale Peoria Show Low Pauline Okwuosa Wendy Owen Brenda Morris Joseph Darocki Virginia Orcutt Bernadyne Agan Jophena Ransey Sheng Peng Ana Murphy Joseph Hudson Diana Percival Griselda Rendon Elizabeth Porter Allen Prettyman Machrina Leach Sarah Vazquez Sierra Vista Elizabeth Rossell Sheryl Shantz Regina R Morris Geneva Woodards Pamela Enright Vanessa Reese Jennifer Rossetti Colleen Speidell Christina Trifanoff Peridot Sun City S. Dianne Samarin Jean Stengel Maria Victoria Zimmer Manuel Abeyta Suzanne Alderden Monika Sanchez Carmen Traill Trina Staton Therese Sargent Helen Tull Globe Wendi Sears Gregory Uhles Lynmarie Purdin Molly Slape Kimberly Vana Weslynne Smith Ada Hinshaw July, August, September 2021 Arizona Nurse • Page 23

New & Returning AzNA Members March – May 2021

Anthem Glendale Irene Quinones Patricia Trafford Show Low Anna Masciola Donna Patterson Virginia Burnett Sheila Spanbauer Elizabeth Waack Sarah Rogers Kyli McCorkle-Olbin Jana Cooper-Bloxham Heather Stears Savannah Welsh Adrienne Mejia Avondale Ibukun Fagbuyi Martha Steiner Nicole Yanez Sierra Vista Alvin Mercer Charisse Tan Pamela Franken Rebecca Stoops Renae Rote Kerstin Moyer Taylor Tolman Patricia Keilman Prescott Corinne Narra Kristin Lock New River Dianne Tobin Sun City Kaylee Navarro Buckeye Charlotte Myers Marla Sample-Ormes LeShawne Elliott Natalie Norem Kenisha Brown Jessica Quintero Prescott Valley Marie Pond Diane King Jaime Saiz Oro Valley Karen Amoscato Surprise Marisol Ramirez Brianna Reyes Anne Varner Tawni Espinosa Jeanie Bach Madison Richards Lisa Howard Queen Creek Asia Bell Kacie Roxas Cave Creek Globe Melissa Spector Michele Farabee Sally Irelan Kris Silverman Karen Roth Jessica Madrid- Jamie Gibson Roberta Murphy Mary Smartt Warden Parker Kari Rounds Macie Stutz Chandler Megan Martinez Luciana De La Torre Tempe Andrea Trejo Eva Olszewski Melinda White Rio Rico Emma Taylor Katharine Valencia Matthew Pittman Peoria Lymy Beth Toenies Jessica Zopfi Stefanie Rogers Goodyear Michelle Alland Tolleson Dodie Serafini Brett Brown Francine Bretz Sahuarita Jesika McKenzie Vail Paul Sokolowski Kristina Donbroski Helen Brogan Tarra Noble Angelica Lentner Catherine Napier Fleshia Davis Kathleen Shemberger Tucson Fern Quigg Chino Valley Debra Wertzberger Rosselie Del Mundo Kyra Barstad Daniel Brubaker Nelson Flores San Tan Valley Sarah Clemans Waddell Hereford Lynne Gardner Hilary Davison Martha Columbus Elisabeth Mancha Clarkdale Judith Lyle Kimberlyn Hendren- Meredith Hardt Kevin Condon Jacquelyn Lavery Dirubio Lindsay Radcliffe Patricia Daly Winslow Kingman Veronica Hidalgo Tammy Do Stephanie Crihfield Coolidge Stacey Meier Jemmalane Lopez Scottsdale Patricia Duenas Sara Romero Diana Peters Samantha Raleigh Christopher Parrish Claire Anderson Melissa Edwards Joy Pollard-Stoiber Emily Bonneau Gladis Figueroa Yuma Cottonwood Lake Havasu City Rowena Mae Bennie Clonts Camren Gerner Petra Altamirano Elidia Gerardo Baez Norman Lee Dockins Wangeline Amy Dang Melissa Goetting Kellie Brooksher Rachel Hernandez Alyssa Koulentis Kathryn Hughes Morgan Hodges El Mirage Phoenix Jennifer Mancebo Marcee Kahan Danae Jackson Jennifer Welch Laveen Stacy Al-Saleh Patricia Melde Inna Lehrer Jovan Ramirez Cheryl Dodson Katie Andrusaitis Julie Moore Kerina Mariana Flagstaff Alma Lopez Laurie Atchley Jane Northern Holly Blankenship Vanessa Cruz Carly Seeger Becca Harris Litchfield Park Dasia Dennis Jordana Wayne Jennifer Moore Sheena Hill-Dilla Darla Dunn Melanie Platt Jennifer Fendler Melody Rhodes Lupton Taylor Gibbs Lee Ann Goodluck Desirae Guerrero Florence Jennifer Hannon Adriana Hirales Marana Lesley Hunt Dawn Maciver Mariano Felix Amira Jalaghi Robin Heiselt Amina Kabadeh Fort Mohave Kimarie Jeffreys Allie Kenney Gabriel Alvarez Angelita King Maricopa Samantha Kragel NOWNOW HIRING!HIRING! Fountain Hills Catherine Canter Brittany Lawler Day and Night Shifts Eileen Doench Samuel Makatai Bonnie Lenyard Amanda Smith Nesrin Mendy Lauren Linnborn For the following positions: Susan Wamboldt Zengzeng Lu • Certified Nursing Assistants Mesa Anju Mathai • Registered Nurses Gilbert Lindsey Aguirre Barbara Morgan • Licensed Practical Nurses Janet Armour Alicia Amos Paula Munch Nicole Chemali Susan Benedetti Kimberly Munneke Shannon Clark Corinne Dixon Heather Naylor Tawna Cooksey-James Nancy Fulmore Vanessa Nguyen Lizette Galsim Brittany Gomez Ramona Perry Qualified applicants must have: Yvonne Johnston Colene Guzman Danielle Rosenbaum Ginamarie Natarelli Kylee Huebsch Genna Sampaga • AZ State Certification as a Nursing Assistant & CPR Certification • AZ State Licensure as an LPN or RN & CPR/BLS certification Esther Ndegwa-Wanje Melanie Knight Therese Schertl • AZ Dept of Public Safety Fingerprint Clearance Card Rebecca Shaw Amber Kool Emily Snyder Please apply at WWW.GRHC.ORG/CAREERS Ampili Umayamma Victor Lachica Jennifer Sweilem Questions – Email Ylesia Jones at [email protected] or Cameron Wells Sheryl Marrero Krystal Tobin Call 520-562-3321 EXT. 1712 or 520-610-0595. Mark Williams Bobbie Morgan Karen Tolliver Health Professional Resources

Health Professional Webinars • Diabetes and Dairy: Research, Recommendations and Real World: Click Here • A World Well Nourished: Dairy’s Role in Health and Sustainable Food Systems: Click Here • Dairy DYK: Your Top Questions Answered: Click Here • Get Cultured on Fermented Dairy Foods: Click Here • Fat or Fiction: The Science of Whole Milk Dairy Foods Within Healthy Eating Patterns: Click Here Dairy Nourishes Network National Dairy Council’s Dairy Nourishes Network brings together food, nutrition and health professionals to discuss how dairy foods are part of nourishing people and communities, while also being mindful of the planet. Join here Science Summaries This is a sample of the Science Summaries published by National Dairy Council®. Click here to see more on NDC’s website. • Dairy in Healthy Eating Plans: Click Here • Dairy and Type 2 Diabetes: Click Here • Cardiovascular Disease: Click Here • Yogurt and Your Health: Click Here • Cheese and Your Health: Click Here

Food Models https://arizonamilk.org/ National Dairy Council’s food models can help make teaching nutrition easy and fun. They are for-schools/virtual-learning- versatile, printer-friendly and bring the 2015 Dietary Guidelines for Americans (DGA) and MyPlate resources/#healthprofessionals recommendations to life. When printed on 8.5-by-11-inch paper, these food models represent true-to-life serving sizes of the individual foods. Nutrient information is provided on the back of the images in a format similar to the updated 2018 Nutrition Facts labels.

Nutrition Education Resources

Standards-based Nutrition Curriculum Dairy Council® of Arizona has partnered with Dairy Council® of California to bring AZ teachers award winning, standards-based curriculum packages for K through Middle School! Both paper and digital versions available. Check them out here! Order Free Nutrition Education Materials The Dairy Council© of Arizona and Nevada provides award winning, age-specific nutrition education materials throughout the states of Arizona and Nevada at no charge. See the catalog here.

If you are not an Arizona or Nevada resident, and are interested in nutrition education materials, please visit the National Dairy Council’s website to find the Dairy Council office that serves your area. Please allow 2-4 weeks to receive the requested materials.

Downloadable Nutrition Resources Dairy Council® of Arizona provides nutrition education materials on a variety of topics. Click here to access downloadable resources that can be reproduced for educational purposes.

https://arizonamilk.org/ Dairy Toolkit - A Moo-velous Resource and for-schools/virtual-learning- resources/#nutritioneducation Education Toolkit This toolkit for educators and parents is packed with information about many aspects of dairy: nutrition, kid-friendly recipes, on the farm information, dairy food safety, all about milk, and fun activity sheets to expand learning. It can be used in school or at home to help kids understand dairy – where it comes from and why it’s good for them.

Please download this toolkit and feel free to print and share any of the materials you find here.