MAMAssachusettsssachusetts RReporteport onon NNursingursing MARN is the Massachusetts Affi liate to the American Nurses Association

Vol. 6 No. 4 The Offi cial Publication of the Massachusetts Association of Registered Nurses, Inc. December 2008 PO Box 285 • Milton, MA 02186 • 617-990-2856 • [email protected] Quarterly Circulation 111,000

MARN Mourns the Passing of Nurse Leader Marie E. Snyder Some final thoughts on It is with deep sadness and loss that we share with you that Marie E. Snyder, Homelessness nurse attorney and nursing leader in Massachusetts died on Friday November 21, 2008 in Harwich, MA. Pages 6, 7 MARN will honor Marie's many contributions to the nursing profession in a memorial article in our March Issue of the MAssachusetts Report on Nursing. Requiescat in pace.

2009 Living Legends and Excellence in Nursing 8th Annual Spring Awards Dinner Convention Friday, April 3. 2009 ~ 6:00 pm-9:30 pm The Ethics Imperative in Nursing Saturday, April 4, 2009 Join MARN as we celebrate 7:30 am–8:30 am the 2009 BEST in Nursing in Continental Breakfast, Massachusetts as well as MARN’s Exhibits and Registration 8th Annual Spring Convention successes for the past 8 years! 8:30 am–9:30 am Living Legends and Excellence in Cocktail Reception The Evolution of Moral Responsibility in Nursing Awards Dinner 6:00 pm – 7:00 pm Clinical Practice Christine Mitchell, RN, MS, MTS, FAAN Friday, April 3, 2009 Dinner and Awards Ceremony 6:00 pm-9:30 pm 9:30 am–10:00 am 7:00 pm – 9:30 pm Break, Exhibits, and Raffle The Ethics Imperative in Nursing Saturday, April 4, 2009 2009 Living Legends in 10:00 am–11:15 am 7:30 am-2:45 pm Massachusetts Nursing Listening for the Gray: Shared Reflections on Ethics Narratives 2009 President’s Award Panel Presentation Featuring Keynote Speaker Excellence in Nursing Awards 11:30 am–12:30 pm Christine Mitchell MARN Business Meeting RN, MS, MTS, FAAN Ruth Lang Fitzgerald Associate Director, Memorial Scholarship 11:30 am–12:30 pm MASNA Student Forum Clinical Ethics, Harvard Arthur L. Davis Publishing Medical School, Director, 12:30 pm–1:30 pm Agency Scholarship Office of Ethics, Exhibits and Buffet Lunch Children’s Hospital Mary A. Manning 1:30 pm–2:30 pm Nurse Mentoring Award Demystifying the Ethical Dedham Hilton Hotel Issues in Genetic Testing Pamela J. Grace, PhD, APRN MARN is a Constituent Member MARN Announces the Association of the American Nurses 2:30 pm–2:45 pm Association 2009 Living Legends in Wrap-up and Evaluation Massachusetts Nursing Contact hours have been applied for. continued on page 2 MARN is honored to announce that the www.MARNonline.org following nurses have been selected as the 2009 Living Legends in Massachusetts Nursing Award Presort Standard recipients. US Postage Barbara Blakeney, MS, FNP PAID Joan Vitello-Cicciu, PhD, RN, FAAN, FAHA, CNAA Permit #14 On the inside Mary Ellen Doona, EdD, MS, RN Princeton, MN Marjory Gordon, PhD, RN, FAAN current resident or 55371

Boston Marathon Nurse They will be honored on Friday, April 3 at the MARN Annual Awards Dinner at the Dedham Volunteers Needed! Hilton Hotel. Each recipient has had a unique See page 14 career that has left lasting imprints on the profession, on nurses and the community. We hope that nurses throughout Massachusetts will join us MARN Legislative Seminar 2/6/09 on April 3 to congratulate and thank them for their See page 11 many contributions. • Page 2 • MAssachusetts Report on Nursing December 2008 Spring Conventioin (continued from page 1) Call for Posters All convention participants are welcome to PO Box 285 contribute posters. Posters will be displayed near Milton, MA 02186 Registration Information the exhibitors so that all who attend will have an 617- 9 9 0 -2856 Please include check or money order made opportunity to see them. Go to www.marnonline. [email protected] out to MARN for the exact amount or you org and fill out the poster submission form by may choose to register and pay by credit card March 13, 2009. Guidelines for poster submission online at www.MARNonline.org. are also available online. Return registration form and check to MARN, PO Box 285, Milton, MA 02186. The Ethics Imperative in Nursing Registrations MUST BE postmarked no later Saturday, April 4, 2009 ◆ 7:30 am-2:45 pm than March 21, 2009. This conference is designed for students, ❑ $65 Awards Dinner ONLY nurses, nurse administrators and nurse educators interested in improving their knowledge of PO Box 285 MARN Members nursing ethics. The convention will focus on ❑ Milton, MA 02186 $85 Convention Only 4/4/09 ethical issues in current clinical practice. You will ❑ $150 Awards Dinner 4/3/09 and 617-990-2856 hear from experts and nurses in different practice [email protected] Convention 4/4/09 areas—from the neonatal ICU to home care—who will share their experiences and give you an Board of Directors Non-Members opportunity to participate in the discussions and ❑ $115 Convention Only 4/4/09 decisions. President ❑ $180 Awards Dinner 4/3/09 and June “Toni” Abraham, MS, APRN-C Convention 4/4/09 Join us. Vice President Cidalia J. Vital, RN, MS, CNL MASNA and Full Time Students Sponsor a Nursing Student or ❑ $55 Convention Only 4/4/09 New Graduate Nurse Secretary Lindsay Gainer, RN, MSN, CPON Part Time Students and New Grads* Sponsor a nursing student or a new graduate ❑ $75 Convention Only 4/4/09 Treasurer to attend the 2009 MARN Spring Convention. Trish Bowe, RN, MS Your sponsorship will provide the opportunity Sponsor a Student Member or a New Grad Member* for novice future nurses to hear nurse experts; Directors *New Grad Member = Nurse in practice attend a special forum with MASNA students Susan Conrad, RN, PhD less than 12 months and network with nurses who share their Barbra Gray, RN, BSN ❑ $125 Member and FT Student— passion for the profession. The full convention Anne Manton, PhD, APRN, RN, FAAN Kathryn McNamara, RN, BSN Convention Only 4/4/09 rate for MASNA and full-time students has ❑ $150 Member and PT Student/New Grad* Theresa Spinelli, RN, ANP been reduced to $55.00. The part-time student Yolanda Starling, BS, RN Convention Only 4/4/09 and new graduate rate has also been reduced to $75.00. —Committee Chairs— The names of all sponsors will be listed Awards Name: ______in the MARN Newsletter and on the MARN Maura Fitzgerald, MS, RN website. Address: ______Continuing Education Sandra Reissour, BS, RN ______Dedham Hilton Hotel Jeannie Gibbs, MSN, RN City State Zip 25 Allied Drive, Dedham Health Policy Tel: 1-781-329-7900 Angela Nannini, PhD, FNP, RN Email: ______Membership Committee Phone: (___)______Directions Cidalia J. Vital, RN, MS, CNL Mentoring Task Force Fees are non-refundable. From Boston: Take I-93 South (Southeast Cynthia Ann LaSala, MS, RN Expressway) to I-95 North (Rt. 128 North) to Checks returned for insufficient funds will be exit 14. The exit will read East St., Canton St. Bylaws subject to an administrative fee. Take the second right onto Allied Drive. Cammie Townsend MS/MBA From Cape Cod: Take Rt. 3 North to Rt. 128 Nominations & Elections North (which becomes I-95 North) to exit 14. Karen Manning, MSN, RN, CRRN, CNA The exit will read East St., Canton St. Take the second right onto Allied Drive. Spring Convention Planning From the North: Take I-95 South (Rt. 128 Peggie Griffin Bretz, MSN, RN South) to exit 14. The exit will read East St., Canton St. Go around the rotary and exit on to Newsletter Editor Myra F. Cacace, MS, APRN, BC-ADM, CDE Allied Drive. From the South: Take I-95 North and exit MARN Staff onto Rt. 128 North to exit 14. The exit will read Executive Director East St., Canton St. Take the second right onto Mary Manning, MSN, RN Allied Drive. From the West: Take the Mass Pike to I-95 Administrative Assistant Heather Plumb South (Rt. 128 South) to exit 14. The exit will read East St., Canton St. Go around the rotary Acceptance of advertising does not imply endorsement or and exit onto Allied Drive. approval by the Massachusetts Association of Registered Nurses, Inc. of products advertised, the advertisers, or the claims made. Rejection of an advertisement does not imply a product offered for advertising is without merit, or that the manufacturer lacks integrity, or that this association disapproves of the product or its use. MARN and the Arthur L. Davis Publishing Agency, Inc. shall not be held liable for any consequences resulting from purchase or use of an advertiser’s product.

Policy for Accepting Announcements for the Newsletter

MARN encourages organizations and educational institutions to submit announcements about continuing education opportunities and upcoming events that are of interest to nurses. Please note: The announcement can not exceed 75 words. Fees must be included with submissions. The Fee Schedule is as follows: MARN Approved Providers/Sponsors—$25 Non MARN Approved Providers/Sponsors—$50 Payment can be mailed to MARN, PO Box 285, Milton, MA 02186. Please include a copy of the announcement and contact information (name, address, telephone, Email) with the check. Please email copy to www.MARNonline.org. For more information, contact [email protected].

Advertising Rates: Contact—Arthur L. Davis Publishing Agency, Inc., 517 Washington St., P.O. Box 216, Cedar Falls, IA 50613, 800-626-4081. The Massachusetts Association of Registered Nurses and the Arthur L. Davis Publishing Agency, Inc. reserve the right to reject any advertisement. Responsibility for errors in advertising is limited to corrections in the next issue or refund of price of advertisement. December 2008 MAssachusetts Report on Nursing • Page 3 • MARN Career Center Website: Discover the President’s Message Advantages

Over 80 million people search career websites Nurses cannot fix all the problems of society, each week. Why should you be one of them? Together, We Can but we have always found ways to break barriers Just one look at the undeniable trend of the and reach those who need us most. Everyone has internet to increase productivity gives you the Make a Difference a story about that special patient that reaffirmed answer. Career websites have virtually replaced your decision to be a nurse, whether it happened 45 years ago or six months after graduation. If traditional job search and recruitment methods. Toni Abraham MSN, APRN-C Advertising in newspapers and visiting places of you ever wondered how to make a difference, the opportunities are numerous. Service organizations business have become outdated and inefficient. In the past several issues, need for volunteers is greater than ever. The main underlying incentive for job seekers our editor asked nurses Many organizations supplement their funding and employers to go ‘online’ for job searches across the Commonwealth with sponsored walks. For example, Project Bread and recruitment leads to enormous time saving. to share their stories and holds the Walk for Hunger every May. Thousands Researching various opportunities, submitting experiences about caring for of people participate in the twenty miles to raise tailored resumes, writing cover letters and people who are homeless. money to purchase food for neighborhood food interviewing can be done with the click of a If you have never had a pantries across the Commonwealth. I listened to mouse. Any person who has ever initiated a full- conversation with someone one Worchester family tell the story about their fledged job search can attest to this. Managing a who has been ‘down on grandmother who started participating in the job search online provides opportunities for both his/her luck’ then you Walk for Hunger, years after becoming a “senior prospective employees and employers to speed up might find their letters, citizen.” She raised thousands of dollars through the process to match the perfect employee to the memoirs and poems, have Toni Abraham her efforts. After she died, her grandchildren and perfect position. enlightened you and given extended family took up her torch and continued Online career resources allow job seekers to you a better understanding about why we find our the tradition in the walk in her memory. easily retrieve a list of opportunities filtered by job chosen profession so gratifying. The ways to contribute to those in need are category, location and even required qualifications. Global economies, including our own, now numerous. In one community, middle-school On the other side, employers can receive resumes face tremendous fiscal threats. Many of us can children collected winter coats for children and and applications via email and screen candidates relate to personal stories about lay-offs, housing adults in their community. Why not head a project all with just the click of a mouse. foreclosures and loss of retirement incomes. The to collect new white socks, donate items in good Furthermore, managing recruitment online priest at my parish is asking for everyone to dig in condition to Goodwill Industries or help feed presents the opportunity to display a more detailed and give “just a little bit more” so he can pay the guests in your local soup kitchen? The possibilities job description. This helps employers paint a vivid monthly bills and make repairs that are absolutely to serve are endless! picture of what the position will entail, while necessary to get the Parish through the winter All of you are creative and resourceful. Please aiding job seekers in determining whether or not a months. Indeed, few would disagree that the share your ideas with me. What do you think you certain job is the right fit. Unfortunately outdated current economic climate is frightening. could do to help your community? There are as career services like newspaper classifieds ads are I see the impact of our economic woes in my many solutions as there are problems and nurses significantly restricted in the amount of space own work. The Family Team at Boston Health have always been part of the solution! During the allowed for a more detailed job description, Care for the Homeless Program (BHCHP) has coming year MARN will explore all avenues of leaving many unanswered questions. seen an alarming increase of families who are Volunteerism. We want to hear from you! What It is easy to see why more and more people are homeless. In our effort to accommodate those have you done lately? What unmet needs do you relying on the internet to explore and offer new in need, arrangements have been made to find see? What are your ideas to meet these needs? Talk career opportunities. What a great way to find housing for people in various motels across the to me! Together we can make a difference! the perfect candidate! Simply put, old fashioned Commonwealth. The latest census of Boston area methods can not compare to the significant homeless was more than 600 families, including advantages that online job search and recruitment school age children who can’t get to their assigned present. schools because of lack of transportation and Discover the benefits yourself by visiting the young mothers with infants and toddlers. Sadly online career resource at the MARN Career Center: the available accommodations often lack the MARNonline.org necessary equipment (including refrigeration) to “Who is logging on to career websites?” allow normal family life. Children share rooms BizReport. 11 Feb. 2008. . • Page 4 • MAssachusetts Report on Nursing December 2008 Welcome Mary-Margaret Segraves Editorial

Recently, Myra Cacace invited me to be the new This is the last edition of the MAssachusetts assistant editor of the A New Beginning report on nursing to feature articles and short stories MAssachusetts report on written by nurses who work with the homeless nursing. I welcome the Happy Holidays and Happy New Year! The population in our Commonwealth. Be sure to read opportunity to join her as I presidential election is over and we will soon see the section entitled “Some Final Thoughts about enjoy writing and editing. the historical inauguration of Barak Obama and serving the Homeless.” In these tough fiscal times I am a native of Chicago hopefully begin to see important changes in our more families are finding themselves on the streets. who has lived in Boston government that will be beneficial to all of us. Nurses But there are glimmers of hope for those people. The for nearly 20 years. My should feel proud of the fact that, as a political force Boston Health Care for the Homeless organization undergraduate degree is to be reckoned with, we helped several pro-nursing continues to make strides (and dare I say gains?) from Loyola University, Mary-Margaret candidates into office both in the state and national in their ability to provide for this most vulnerable Chicago and my master’s Segraves arenas. Yes we did!!! population. At the official opening of the Barbara degree from the University I also want to officially welcome Mary Margaret McInnis House in Boston, a very special guest shared of Illinois, Chicago campus. Seagraves, who will serve as a co-editor on the his story. The opening was featured on “Chronicle” A few years after graduation from Loyola, I Newsletter team! Mary Margaret joins the newsletter in September 2008 (There were even a few shots of moved to the United Kingdom and took a course team bringing a wealth of knowledge and experience. our own MARN President, Toni Abraham!). Be sure in midwifery. The two years I worked in the Please read about her on this page. Are you interested to read this story and the other feature articles on National Health Service was an experience that in nursing journalism? Do you have the desire to page 6. I want to thank the staff and students from dramatically shaped the course of my professional tell your story? Have you found a better way to fix Boston Healthcare for the Homeless for submitting life. a common problem? Do you write poetry? Are you the articles and stories you will read in this edition. In 2000, I received a doctorate in nursing from one of those people who always have a camera with Although this is the last edition to feature their Boston College. Currently, I work in School Health you? I urge all the camera bugs out there to send me stories, I continue to believe that this is a crucial at the Cambridge Department of Public Health. It’s pictures that we can use on the newsletter masthead subject that deserves our continued attention. I hope a privilege to work in a progressive environment in future editions! Just pick up your digital camera you agree and will consider taking action in the that has instituted innovative health programs and snap a few pictures from your worksite or your efforts to provide help to people in dire need! Can for children, families and seniors. Aside from neighborhoods or your travels around this great your unit or workplace think of ways to have an my professional life, reading, cooking, choral commonwealth. The newsletter team will even impact in your community? Remember, people are singing and travel are my passions. I sing in the publicly acknowledge the picture as yours! With your cold and hungry all year long…not just during the Back Bay Chorale and am a member of its board. help I am hoping to provide snapshots of a variety holiday seasons! How can you help? I look forward to working with Myra and aspiring of settings that show where nurses work and play! For the 2008-2009 year, the newsletter focus will contributors to maintain the high standards. Send your pictures to [email protected] change. This year we will examine the concept (deadlines to submit pictures: 9/1, 11/1, 2/1 & 5/1). of Volunteerism. What is it? Who does it? Why do Thanks! people volunteer? Where and how can you be a volunteer? In these tough fiscal times, organizations are relying more heavily on volunteers to provide crucial services. I want to hear from you about other organizations in Massachusetts that are helping to make a difference. I invite you to voice your opinion about this or any articles that peak your interest! Contact me at [email protected] or contact the MARN office at [email protected] or send mail to PO Box 285, Milton, MA 02186. Please remember that it is our stated policy that we welcome all opinions. The Newsletter Committee wants to let the voices of every nurse in the Commonwealth be heard. However we do require that letters to the editor be signed in full in order for them to be included in the newsletter. We look forward to hearing from you! December 2008 MAssachusetts Report on Nursing • Page 5 • Just Want To Clear the Air Nurse Practitioners Recognized as Primary Barbara A. Blakeney, MS, RN service. I helped poor people take charge of their issues and I helped them go to county, town and Care Providers As a young nurse during the turbulent 70’s I was state officials to push their issues. We made the a VISTA Volunteer assigned to Franklin County local newspaper with some regularity. I learned by Nancy O’Rourke, MSN, ACNP Massachusetts, the most rural county in the state. that by teaching and supporting I could help During my 2 years as a Volunteer I served in the people empower themselves and get results. I BOSTON—(BUSINESS WIRE)—Massachusetts role of community health organizer. It changed learned to listen and learned many times the has taken an important step towards addressing its my life and the trajectory of my career. I saw how answers were not within me but them. primary care provider shortage. Recently passed poverty created barriers to wellness and those Thirty plus years later I look back at that time legislation (Chapter 305), championed by Senate lessons never left me. I determined early on that with appreciation, a sense of accomplishment, President Therese Murray, addresses issues of the opportunity to make a difference was, at least and great respect for those I came to know for access, quality and transparency in health care. for me, in the community. they changed me for the better. So I must admit The recognition of nurse practitioners as primary I tried to make a difference. At a time when to being more that a bit miffed when I heard such care providers is vital to this legislation and will lead poisoning was thought to be an urban disparaging remarks about community organizers immediately and dramatically increase the number problem I fought to fund a screening program that from the Republican candidate for Vice-President. of providers available to residents. demonstrated the problem was not location but A community organizer is, in the very best since of As Massachusetts ensures health insurance poverty and the age of the housing stock. Over the word an enabler, someone who can open doors coverage for all its citizens, legislators are examining 60% of the houses were built before 1940 meaning and help empower others to accomplish shared ways to increase access in the face of a primary the walls were covered in lead based paint. The community goals. A good organizer is the person care physician shortage. More than 300,000 poverty rate was very high and many houses were who supports and encourages, who can help frame citizens, previously uninsured, are now enrolled poorly maintained. Pealing paint, cracked and the agenda and provide the words that create the in Commonwealth Care and are seeking primary broken plaster added to the risks. These were the picture and bring just the right amount of pressure care homes. In a recent report, the Massachusetts risk factors, not urban vs. rural. Our first screening to get the issues addressed. Being a community Medical Society stated that patients wait an average clinic showed an alarming number of children organizer is not for the faint of heart, it’s not for of 8-12 weeks for a primary care appointment. Many with elevated lead levels. We got the children into those who need to be out front leading the charge. physicians are not accepting any new patients at all. treatment. It is for those who have a passion to help right Nancy O’Rourke, president of the Massachusetts We screened elementary school children for some wrongs, to help create level playing fields Coalition of Nurse Practitioners said, “Nurse speech and language delays and were able to get and a better society. It’s about those who see a practitioners are highly educated professionals a speech therapy program into a school system wrong and try to right it. It’s not about hand outs, who are trained to provide primary care. We can that didn’t think it had a problem. We got other it’s about hand ups. diagnose, treat and prescribe medications in all free clinics started thus providing much needed Just wanted to clear the air. 50 states. Over the past 30 years, studies show that care provided by nurse practitioners is equal to care provided by primary care physicians.” For the first time, all health insurers in Massachusetts are required by law to recognize nurse Economy’s Slide Results in State Budget Woes practitioners as primary care providers, allowing consumers to choose them to coordinate and direct and Action Plan by Governor Deval Patrick their care. The Massachusetts Medical Society recently reported that more than half of all patients by Craven & Ober Policy Strategists, LLC budgets. This action further minimizes the need presenting to a primary care practice who see a nurse to cut important state-funded health and human practitioner make a deliberate choice to do so. The federal bailout of our banks has leveled service programs for children, elders and the “Patients recognize that nurse practitioners tremendous debt on American taxpayers. Wall mentally ill. The Governor’s approach preserves provide high-quality, patient-centered care,” said Street’s latest plunge has had a ripple effect key, targeted investments in education, public O’Rourke. “Nurse practitioners have the training on the state’s revenues that support our entire safety and the safety net. To review details of and expertise to provide care and manage chronic public infrastructure; schools, public safety the Governor’s plan, go to www.mass.gov and disease, making them a perfect solution to the personnel, our judicial system and other day- search for the 10.15.08 Fiscal Action Plan. shortage of primary care providers in Massachusetts, to-day community necessities that we rely on to Craven & Ober Policy Strategists, LLC is a and nationwide.” function. Faced with these realities, Governor full service Massachusetts-based government Massachusetts joins 24 other states that recognize Patrick issued a fiscal action plan on October relations firm dedicated to credible, assertive nurse practitioners as primary care providers. 15, 2008 that would ensure that state spending advocacy and to the dissemination of reliable Also included in this legislation is a section which is aligned with state revenue collections. Times public policy information. grants tuition remission for physicians and nurse like these test the leadership skills of our practitioners who choose a career in primary care. public officials and the Governor continues to i Estes, A., "Tax Cut Campaign Proposals Under This creates a strong incentive for graduates of demonstrate his superior leadership skills. Fire, Three Gubernatorial Candidates Seek Rollback," medical school and nurse practitioner programs to The Boston Globe, September 3, 2006. During the 2006 gubernatorial campaign, join the primary care workforce. “Chapter 305 is a three of the four candidates called for a rollback comprehensive legislative vehicle to increase access of the state income tax despite warnings to primary care at a time when Massachusetts is in from some budget specialists who cited that dire need of more providers,” said O’Rourke. Massachusetts could not afford to lose that revenue. At the time, Michael Widmer, executive director of the business funded Massachusetts Taxpayers Foundation noted, “We need to be cautious about building in either tax cuts or spending increases we can’t support.”i In 2006 the state budget not balanced, and Deval Patrick was the only candidate to take an unpopular, but honest position on taxes with the voters. In crafting the October fiscal action plan, Governor Patrick was forced to make some tough decisions regarding the public programs that would receive 9C funding cuts. Massachusetts General Laws Chapter 29: Section 9C entitled “Deficiency of Revenue,” authorizes the Governor to reduce funding to parts of government under his control. Whenever available revenues are determined insufficient for authorized expenditures, the Governor and his staff undertook a serious analysis of the shortfall for this year’s state budget and issued significant cuts consistent with projected revenue collections for the remainder of this fiscal year. His goal was to exercise one cut that would allow programs to complete the year without fear of a repeated cut and eliminate unpredictable budgeting for the remainder of the funding cycle. The governor has no Ann Hargreaves attended the 50th Wedding Anniversary of long time friend and former student promises that additional cuts will be needed (Boston University Class of 1958), Ann Burgess, a long time faculty member at Boston College. later this fiscal year. Additionally, the Governor Joining the celebration were 10 of Ann Burgess' classmates: (seated) Marie Karagosian, Ann has garnered the voluntary cooperation from Burgess, Ann Hargreaves, (standing): Margaret Derian, Ann Divise, Nancy Simmonds, Nancy executive heads whose budgets are outside Zaramba, Selma Levin, Tillie Sweet, Marilyn, Given Fineburg and Helen Dobbins. Photo by his control, for example the Legislature and Marcelyn Karagosian. state Treasurer, to reduce their administrative • Page 6 • MAssachusetts Report on Nursing December 2008 Some Final Thoughts on Homelessness . . .

Boston Health Care For The Homeless Program A Home Of Our Own Campaign (Reprinted with permission from Boston Home Care for the Homeless Program) years before. Life, “changed forever,” has worked treat a patient at any major hospital. They speak to The Kresge Challenge: out well for me. them by name and look them in the eye. They treat At the same time I got sober, someone else very them with respect and dignity. I was expecting a A Home Of Our Own dear to me did not. Two years younger than my depressing place. And while the cases they treat brother Wally, I grew up following in his footsteps. are serious and troubling, Barbara McInnis House Boston Health Care for the Homeless Program My early success in baseball came from playing is a hopeful place, with energy and life filling the (BHCHP) has bridged the distance between the with him and his friends who were bigger and halls. They have not given up on the women and main stream health care system and Boston’s better. I had to compete at their level to be able to men who get respite medical care there. Though homeless women, men and children by providing play with them. their patients are homeless, they are not hopeless. comprehensive health care services since 1985. I was making a name for myself in the big While we will be maintaining our services leagues, traveling on chartered jets from city to A Message of Hope in over 70 sites throughout the city we are city and Wally was traveling on freight trains. I I am struck by the optimism and positive renovating a venerable old building at the corner compared myself to him. I wasn’t an alcoholic demeanor of all the doctors and nurses with of Massachusetts Avenue and Albany Street into because I wasn’t “as bad as Wally.” We led very Boston Health Care for the Homeless Program. At A Home of Our Own. In that building we will different lives but shared a common problem. McInnis House, on the streets of Boston, in their unite the core elements of our operation under Wally started drinking heavily in his late teens. hospital based clinics and in the shelter clinics one roof, including an expanded respite care unit, He left home and was off to the races at 18. He the patients are treated with respect, dignity and ambulatory, dental and mental health care, and a got married young, had a child, was in and out of hope. pharmacy. jobs and was spiraling out of control. Eventually, My hope is to bring attention to the homeless At this critical time, the Kresge Foundation has he ended up on the streets and we lost touch. He people in Boston by supporting the important awarded BHCHP a challenge grant of $2 million would randomly show up in cities where I was work of Boston Health Care for the Homeless. What toward A Home of Our Own capital campaign. playing. At a game in Milwaukee, a teammate greater cause is there than giving another human The Kresge Foundation is nationally renowned for came to me when I was warming up in the bull being dignity and hope? Please read about their using challenge grants to provide endorsement, pen, and said, “There’s a guy hanging over the dug capital campaign project. Please share in that work opportunity and leverage for organizations that out who looks like Charles Manson. He says he’s and that hope. I know what a difference your help benefit the well-being of humanity. Grants of this your brother.” My heart dropped to my stomach. I will make. I know that lives can “change forever.” size are usually given to hospitals and universities. knew it was Wally. However, the Trustees of the Kresge Foundation Another time, at spring training in Winterhaven said they wanted to signal their substantial (Florida), I was in my hotel room on the first floor, endorsement of our work. standing in front of the mirror. In the reflection To receive the grant, BHCHP is required to raise I noticed a man standing in front of the sliding the final $6 million for their $42 million capital glass door. I was startled. It was my brother. His campaign. We are looking to a broad spectrum face was purple and his scent was horrifying. I of Boston’s foundation and business community could hardly recognize him. I was scared and as well as to individual donors for continued shaken to see him this way. I brought him in, got assistance as we improve both the efficiency and him cleaned up, gave him some of my clothes and quality of our services in A Home of Our Own. some money. I took him to the airport where he got Please support this work. Now is the time. a flight back home. He tried to get sober then but it Success is within reach. The Kresge Challenge didn’t last. Within a few weeks he was back on the adds great opportunity and a note of urgency to road. your generosity. For additional information please A life of hard drinking, hard living, and contact us: homelessness led Wally to terrible circumstances. Cheryl D. Kane, RN, M.ED. His life “changed forever” in Colorado. In a Director of Development drunken stupor, he stole a car. The owner of that ckane@bhchp, 857-654-1045 Novice Nurses from car, a woman in her 50’s, was still in the car. Linda O’Connor, Street Team Nurse Capital When the police apprehended him, they charged Simmons College Give Campaign Director him with attempted kidnapping. He has spent the [email protected], 857-654-1050 twenty years of his life since that fateful night in Back to the Pine Street Inn 729 Massachusetts Avenue prison. Boston, MA 02118-2318 My brother and I are both recovering alcoholics by Community Health Nursing Students, today but life, “changed forever,” has not worked Nursing 337, Simmons College out as well for Wally. I’ve seen help make a Lives Changed Forever: difference. I’ve seen the depths of drinking and We are six nursing students from Simmons how it can ravage a life. Most people can’t say College who had the privilege to have a clinical Boston Health Care for they know someone who was homeless or who is rotation at the Pine Street Inn (located in Boston’s in prison, let alone their own flesh and blood. I’m South End) during our 2008 Fall semester. We the Homeless Program sharing my story with you so that I can tell you started working with the nursing staff of Boston’s that “the homeless” are not a nameless, faceless Health Care for the Homeless, on September 16, by Dennis Eckersley group. They are people who, for whatever reasons 2008. Early in the semester, we brainstormed about (Reprinted with permission from Boston or tragic circumstances, find themselves living a project to support the shelter’s outreach programs Health Care for the Homeless Program) on the street.” They are brothers, husbands, in order to make a contribution to the shelter for sisters, fathers, wives, friends, mothers, sons and allowing us the opportunity to have our clinical My connection to Boston dates back almost daughters. They are people. They could be me or experience there. We thought that the population thirty years. I have a lot of incredible memories you. served by the Pine Street Inn could benefit from here in Boston: the ‘78 team, the 1999 All Star I met some of these people when I toured the an onsite smoking cessation program. Game and the 2004 World Series. Boston has Barbara McInnis House in Jamaica Plain. Barbara First we had to determine whether this program become a very big part of my life. My wife Jennifer McInnis House is a medical respite facility run would be beneficial, so we decided to conduct a and I make our home here. We have come to care by Boston Health Care for the Homeless Program, feasibility study in order to survey the residents’ a lot about this city, not only because I played where homeless men and women receive medical interest in such a program. We designed a survey here and work here, but because it’s a beautiful, attention before and after their hospital stay. The with ten questions, to learn how long participants interesting and compassionate place. patients there are well enough to leave the hospital had smoked, the number of cigarettes they smoked Life has changed forever… but not well enough to return to the streets or daily, and most importantly, their desire to quit. The greatest moment of my career was when I shelters. Terminally ill men and women who We randomly selected 50 residents to participate. was inducted into the Hall of Fame. It was the are homeless also live there with medical care, Our results showed that residents had a strong happiest moment of my life. I’ll never forget the hopeful assistance and dignity for their remaining desire to receive help to quit smoking and agreed call from the Baseball Writers Association on days. to participate in such a program. January 6, 2004. They said, “Welcome to the Hall I was uneasy when walking up to the front After confirming their interest, we conducted of Fame. Your life is changed forever.” It was not doors of the facility. I didn’t know what to expect. I focus groups to access more input from the the first time my life “changed forever.” was greeted by a friendly, outgoing guy who shook residents in an open, but structured venue. It had happened several years before when I got my hand with a smile and asked for my autograph. The Pine Street Inn provides services for men sober. I am a recovering alcoholic and have fought His name was Tim and he was one of the homeless and women, so we arranged two focus groups the battle of alcoholism for a good part of my life. patients. My guard dropped immediately. I was in November. Each focus group had 10-14 I got sober 12 years into my career. Sober, I went at ease after that first encounter. But it didn’t end participants each and lasted for approximately one into the bullpen and went on to play another 12 there. Each patient that I met was real, and human, hour. We also received nutritional support from years in major league baseball. Those 12 years and kind, and grateful. Pfizer Pharmaceuticals. led me to the Hall of Fame and onto my work on Dr. Jim O’Connell and the entire staff at We want to thank our clinical instructor, NESN. My career and life could have been over McInnis House treat each patient as they would continued on page 7 December 2008 MAssachusetts Report on Nursing • Page 7 • Learning to Care for Massachusetts Homeless

Novice Nurses from Simmons College Give Back . . . (continued from page 6) Red Line Nativity

All my life, I never imagined myself on the front When he came, he came quickly Pine Street Inn Shelter Clinical Site page of The Boston Globe. but I wasn’t afraid, I knew exactly what I had to do; Things might have been different, but I have a medical background, no one even offered me a seat, Nurse’s Aide, and I do not understand all the way in from Braintree. why the papers made such a deal about my not asking for help. I saw the obstetrician the day before. No one even noticed me until He said I was just one centimeter dilated, it was almost over, and by then no baby yet, but call when contractions I would not give them the satisfaction start to come close. of feeling heroic, coming to my aid. Members: Amy Goudreau, SCnS, nursing Liaison: So I dragged back out to that tiny room When my father was born Treasurer in the Motel 6, where the welfare my grandmother buried the placenta Jacqueline Metjian, SCnS, ALAnA nursing people so graciously put me up, out in the yard, and planted a tree on it Liaison: Sr. rep. with my two bored teenagers, to grow tall and strong along with him. Linda Poteau, SCnS, ALAnA nursing Liaison: and the TV that never blinks, I have no home, no land Vice President and the cube fridge and microwave, only a healthy baby boy, Charlene C. Hollins, SCnS, ALAnA nursing and the cans of donated food and so I left his placenta Liaison: President I cannot make a decent meal from, and my water and blood Kathleen Connolly, SCnS, ALAnA nursing on the subway platform Liaison: Sr. rep and I waited. to plant a seed in the memories nicole Willis, SCnS of you, dear Globe readers It wasn’t that my waters broke so that the next time, maybe, Claire Murphy NP, for her help in the designing or the cramping started, I just you will know your manners. and developing the model for the focus group woke up feeling poorly, and I knew content material based on the Roy Adaptation I needed to be seen, so I got the bus Robbie Gamble 8/9/03 Model. She also served as the moderator for each in to the Red Line, and then the train session and recorded the residents’ perspectives all the long way into Boston. on smoking cessation. We chose Roy’s model to help us to provide a framework of evidence-based practice and comprehensive nursing care. The Roy Adaptation model was our guide to understanding a crowded shelter, which would be a shock to most a forte of nursing and this is shown to enhance the residents’ thoughts about nicotine dependency, anyone. When I consider my own practice, I reflect patient resilience in turn. Hartling (2008) asserts that identify stimuli that reinforces smoking behavior, on their strength under such terrible conditions. “resilience can be strengthened through engagement and to identify barriers that prevent smoking The experience of nursing in the homeless in relationships” increasing “sense of worth, sense cessation. community is one of resilience (McGee, 2006). of competence, sense of empowerment, and sense We analyzed the data that we collected at Recognizing resilience in this vulnerable population of connection.” This is found in similar literature the focus groups and presented our findings can help nurses to build relationships. Settings for regarding poverty which is also associated with and recommendations to the Pine Street Inn on encounters can range widely from street outreach to poor health outcomes. Better connection to social December 2, 2008. Our ultimate goal as novice in-patient care. Regardless of the setting, engaging the networks and increased engagement improves nurses was to advocate for the residents at the persons will enhance resilience that creates a sense of “health resilience to poverty” which serves to soften Pine Street Inn and help them to understand the empowerment and connection that can lead toward the blow and lessen the harmful effects of poverty negative outcomes of smoking. This experience improved outcomes. Acknowledging individuals’ (Sanders et al 2008). showed us that nurses can have a major impact resilience can help preserve a person’s dignity and These connections, this advocacy, and this on health by teaching others to make better health integrity. perspective shift to recognize resilience follows a care decisions to improve their overall health. This concept has been applied to a variety of holistic view and falls under the purview of nursing. disciplines, and has also been developed as a As previously mentioned, this is a characteristic theme in nursing in various clinical contexts. The that is shared by the nurses who work in the shelter condition of homelessness is more often associated clinics and outreach vans. Indeed, longtime Pine Resiliency in the Homeless: with the word “impairment” and there are plenty Street Inn nursing director Eileen McGee (2006) of co-morbidities which bear this out, including uses “resilience” to describe the experience of a Nursing Perspective fractured family histories, violence, mental illness nursing in the homeless community. As this is a and addiction. From another perspective however, a community which is occupied and shared by our by Michael O’Connor case can be made for the appreciation of the ability clients, it is appropriate to extend this recognition of of human beings to adapt to the extremes of poverty, resilience and to thereby encourage it in our clients. Reflecting on my practice of caring for Boston’s environment and social stigma, and the myriad other Homeless people “who perceive themselves as homeless population generates lessons for nursing stressors of homelessness. Following along this line resilient … survive by adapting to street life and by in compassion, sharing, outreach and engagement. of sight, nurses working with homeless clients in a becoming self-reliant.” (Rew et al 2001). Reflecting The nurses and caregivers who care for these men, variety of settings, from inpatient to outpatient clinic and enhancing this perception might lead to better women and children show exemplary dedication to shelter to street outreach, can consider and elicit alliance, better engagement and better health to their work. For this, nurses working among the the resiliency of the client in a strength-based model. outcomes. It may be worthwhile to consider resiliency community of homeless persons deserve recognition While providing care with dignity is a minimal and a strength-based perspective in homeless health for their willingness to provide care under requirement, nursing can go a step further and reflect care practice and in further research. extraordinary conditions. Caring for this population back to the patient as attitude of authentic respect. might be called an avocation because of the diverse “Being a squeaky wheel” becomes “being a good self references settings in which nurses have to practice. While advocate.” “You missed your appointment” becomes McGee, E, (2006) The healing circle: resiliency in nurses. “you are here now.” “You keep relapsing after you Issues in Mental Health Nursing. 27(1):43-57. we acknowledge and admire the resiliency of those Sanders AE; Sanders AE; Lim S; Sohn W. (2008) nurses who work among this population, this quality leave detox” becomes “it seems like you keep trying detox, you deserve a lot of credit for that, it must be Resilience to urban poverty: theoretical and empirical of resilience is also evident in the homeless men and considerations for population health. American Journal of women with whom we share the journey. It is this a hard row to hoe.” Keeping the resiliency of the Public Health 98(6): 1101-6. quality of resiliency that is part of the bond between homeless patient in mind makes for easier recognition Hartling LM; (2008). Strengthening resilience in a risky nurse and homeless people that allow us to share the of these strengths, and builds a therapeutic alliance world: it's all about relationships. Women & Therapy 31 (2- journey with them. between patient and caregiver which is associated 4):51-70. Resilience is not unique to nursing practice. with better health outcomes (Jones 2006). Jones T. (2006) Resilience in homeless adults: a review Margalit (2004) described it as the ability to “adapt Consider that the concept of resiliency is of literature. Journal of National Black Nurses' Association in the context of significant adversity.” Although a characteristic that can be found among any 17(1): 36-44. population and it is not difficult to find this strength Rew L; Taylor-Seehafer M; Thomas NY; Yockey RD. being homeless is often considered, persons who are (2001) Correlates of resilience in homeless adolescents. homeless have developed resiliency in their lives. in our homeless patients. They wake up in a crowded shelter, an emotional shock that would already be a Journal of Nursing Scholarship 33 (1): 33-40. Their life stories include those of addiction, violence Margalit, M. (2004). Second-generation research on and mental illness, to name a few. Family separations stressor to many of us. They cope with poor nutrition, resilience: Social-emotional aspects of children with are also common. They have also become accustomed the potential for violence, and being turned out of the learning disabilities. Learning Disabilities Research & to living with extremes in climate, social stigma shelter early in the morning to face the additional Practice, 19(1): 45-48. and poverty. Homeless persons survive street life stressors of extreme weather, wet; heat or cold, and Gillespie, BM, Chaboyer, W, Wallis M. (2007) through self-reliance (Rew, Taylor-Seehafer, Thomas this is all before they arrive in morning clinic! It is Development of a theoretically derived model of and Yockey, 2001). Resiliency is easy to identify not difficult to be genuine in reflecting back these resilience through concept analysis. Contemporary among the homeless. Many might find themselves in strengths. Engaging the client has traditionally been Nurse. 25 (1): 124-35. • Page 8 • MAssachusetts Report on Nursing December 2008 Just one year before they had met in Boston at altruism” (1912, 198). Her love for the new the Niagara Movement’s third annual convention. profession is evident in her insistence on its being There, in Faneuil Hall that had cradled America’s inclusive. She decried the “anti-social feeling” founding principles and in the city where William and the barriers that were being erected as nursing Clio’s Lloyd Garrison’s (1805-1879) Liberator had grew in size. She vowed that that “injustice” spoken out against slavery, the “disturbers of the would not be done … in the impersonal realm of unjust peace” as Vernon Jordan (2008) would call education and state examination” (1912, 198). Corner such heroes one hundred years later, prepared The NACGN with Service for Humanity as its Mary Ellen Doona themselves for what lay ahead. In 1908 these motto met the next August in Boston. The NACGN Progressives decided they would use the upcoming chose the sixty-three year old Mary Eliza Mahoney rn, EdD centennial of Abraham Lincoln’s birthday –12 (1845-1926) to personify the new organization. February 1909- as the occasion to measure the The petit Mahoney –she was under five feet tall nation’s progress since Lincoln’s death. They and less than one hundred pounds– praised issued The Call to sixty prominent people “to her training school, the New England Hospital join in a national conference for the discussion for Women and Children, for its pioneering 1908 And The Establishment of present evils, the voicing of protests, and the inclusiveness. Its correction of an injustice in 1878 Of The NACGN: The National renewal of the struggle for civil and political had made possible for Mahoney to earn her living liberty” (1909). as a trained nurse for thirty years. Association Of Colored Ever on the side of social justice, nursing’s So it was in 1908 that the NACGN disturbed public health nurse Lillian Wald, was among the nursing’s unjust peace. In 1951 the NACGN was Graduate Nurses sixty distinguished invitees. Her Henry Street absorbed into the American Nurses Association, Settlement House in New York’s lower East Side signifying that its goals of advancing nursing Mary Ellen Doona hosted the opening reception on May 30, 1909. standards, breaking down discrimination and Later, she persuaded financer Jacob Schiff, whose developing leadership among colored nurses had One hundred years ago colored* nurses philanthropy underwrote the health services been achieved. founded the National Association of Colored provided by Henry Street, to extend his generosity Graduate Nurses (NACGN) during a time when to the new organization that evolved: the National Works cited: racial prejudice was growing in the United States. Association for the Advancement of Colored Dock, Lavinia. A History of Nursing, vol III, (New In 1908 the force of state laws in the South and People (NAACP). Ironically, a few months before York: G. P. Putnam’s Sons, 1912). indifference in the North increasingly separated when Springfield, Illinois celebrated the Great Jordan, Vernon. “Reflections: The Jordan Gospel.” the races with the Supreme Court countenancing Emancipator’s Centennial no colored people were Newsweek, 3 November 2008, 52-53. the violation of Constitutional rights. The Court’s Kellogg, Charles Flint. NAACP: A History of the invited to attend. America’s house was divided National Association for the Advancement of Colored 1896 decision (Plessey v. Ferguson) that children then and would remain divided for some time to could be educated in racially separated schools People. (Baltimore, Md.: The Johns Hopkins University come. Press, 1967). gave tacit approval to the Jim Crow “laws” Lillian Wald and her colleagues proved the The Call (1909). In Kellogg, 1967. that followed in other public spheres, such as, exception to the rule. Just as she had provided transportation, hotels, restrooms and workplaces. meeting space at Henry Street for the fledging The lawlessness that was common in the South NAACP, she did the same for New York’s colored Please let Clio's Corner know the name of erupted in Springfield, Illinois in mid August nurses seeking their rights as Americans and the first African American graduate of your 1908. For two days people rioted against colored professionals. The record is silent on how she nursing program. people culminating in several being lynched, and the nurses became partners in forming others killed and still others wounded. That such the National Association for Colored Graduate nurse School of nursing Date a riot could occur so near where Abraham Lincoln Nurses (NACGN) in 1908. It seems likely that (1809-1865), the Emancipator, once lived, spoke to the relationship arose from the colored nurses Mary Eliza New England Hospital of 1879 the rising tide of prejudice against colored people she employed at Henry Street as visiting nurses. Mahoney Women and Children in the North. Progressives, shaped by Theodore Lavinia Dock, nursing’s premier historian, who Roosevelt’s Square Deal policies decided the time had witnessed their practice testified to their had come to exchange patience for active protest value as good nurses and noted their “intelligent *Contemporary term used. against the “new slavery” (Kellogg, 1967, 7).

Helping You Make the Right Doctor Choice: Justaskanurse.net

Merrimac, Mass, Oct 29, 2008—An innovative concept in providing consumer-driven health- care has arrived to the internet. The JAAN Group LLC, a newcomer in the field of healthcare, was established in June 2008. JAAN is owned and operated solely by a team of dedicated nurses, whose mission is to help consumers make the right doctor choice for themselves and their families. Justaskanurse.net (JAAN) is a resource site established to provide the healthcare consumer with nurse-based physician recommendations. Who do the nurses go to for medical care? As professionals, patient advocates, and healthcare consumers, nurses are often asked for physician recommendations. Wouldn’t it be wonderful to be able to refer to a website where this information is affiliation, board certifications, and insurance available? provider status. JAAN believes that even one Utilizing a nurse survey as our tool to establish recommendation by an informed, knowledgeable, a database, data for the recommendations made and trusted nurse is an important endorsement by the nurses who manage the website is gathered and will provide an enormous service to the and presented on this website. Never before have community. nurses been polled on a scale this large in an effort Representatives from JAAN have attended to provide consumers with specific tools to help several recent nursing events in New England, them make an informed choice when choosing a including the MARN clinical conference in family physician. October 2008, and were greeted enthusiastically JAAN believes that nurses hold the key to by nurses and other exhibitors, “I love this idea!” quality healthcare because they have a unique and “Nurses do know the best doctors.” relationship with physicians. Nurses are the JAAN’s goal is to help consumers make the eyes and ears of healthcare. Nurses work closely right doctor choice. We believe healthcare should with physicians every day. They choose the best be consumer driven. Let’s put the “care" back physicians for themselves and their families, and in healthcare. All you have to do is...Just Ask A now they want to share this information with Nurse! consumers. Ultimately each healthcare consumer Visit us today, @ www.justaskanurse.net will be able to utilize this database when faced The JAAN Group LLC with challenging and emotional task of choosing Nancy Justin RN their own doctor. Deb Ciampa RN Recommendations for physicians will be listed PO Box 73, Merrimac MA, 01860 by specialty, and will include information about [email protected] 617-697-1424 office location and contact information, hospital December 2008 MAssachusetts Report on Nursing • Page 9 • Fall into Lifelong Learning Habits to Cultivate Brainfitness Channel: Lifelong Learning available at “Because lifelong learning is increasingly Pause for a few moments now and critically http://bfc.positscience.com/resources/lifelong.php being appreciated as an essential ingredient for reflect on your learning styles, needs, Critical Thinking Community (2008). Foundation ensuring high quality of patient care, it would opportunities, and patterns. Do you want to for Critical thinking. Available at http://www.critical seem that employers and employees need to be improve your mental health, your resiliency, and thinking.org/aboutCT/definingCT.cfm DeSilets, L. & Dickerson, P. (2008). Recommendations sensitive to and nurture all mechanisms that your capacities? Are you seeking to renew life can facilitate this” (Gopee, 2002, p. 608) for improving health care through lifelong learning. - explore new knowledge & enjoyments despite The Journal of Continuing Education in Nursing, 39(3): the challenges you face each day? What have you 100-101. yearned for? Do you have a longing to become a Gambrill, E. (2006). Critical Thinking in Clinical Learning is a primary goal of this year’s Focus master gardener, a sushi chef, a kennel owner, an Practice: Improving Quality of Judgments and on Health—assessing and learning what you need advanced practitioner, or perhaps simply a more Decisions. 2nd Ed. John Wiley and Sons: San Francisco. and want to do to improve your health! physically fit person? Gopee, N. (2002). Human and social capital as Take an action. Many universities, local school facilitators of lifelong learning in nursing. Nurse Lifelong Learning districts, and private organizations have life long Education Today, 22: 608–616 Lifelong learning is more than just education learning institutes or programs. Type ‘life long Hammond, C. (2004). Impacts of Lifelong Learning and training beyond formal schooling. A lifelong learning’ and your particular interest into your upon Emotional Resilience, Psychological and Mental Health: Fieldwork Evidence. Oxford Review of learning framework encompasses learning favorite search engine and see what you find. throughout the life cycle, from birth to grave and Education, 30(4): 551-568. Check out some of the resources listed below. Join Huggins, C. (2004). Lifelong learning—the key to in different learning environments, formal, non- a book club. Take a class offered though your local competence in the intensive care unit? Intensive and formal and informal. Lifelong learning provides parks & recreation department. You may find that Critical Care Nursing, 20: 38-44 opportunities for intellectual, social, spiritual, and you feel better and have more to offer yourself, Learnativity.com available at http://www.learnativity. cultural exploration and development. Frequently your family and friends, and your patients! com/index.html lifelong learners are individuals (or groups of folks Susan Vorce Crocker, PhD, RN Lifelong Learning Resources: North Carolina State with diverse backgrounds and shared interests) University available at http://distance.ncsu.edu/virtual_ seeking to develop appreciation and knowledge references and resources orientation/6/lleResources.html in new areas. Life long learning involves self Academy of Lifelong Learning, University of Midwest Center for Life-Long Learning in Public leadership and is self directed learning at its best. Delaware available at http://www.academy.udel.edu/ Health: University of Minnesota School of Public Health Nurses have a responsibility to be self-directed, index.html available at http://cpheo.sph.umn.edu/mclph/ to grow both personally, and professionally. As nurses assume leadership roles in the health care system, we must strive to contribute to the improvement of nursing as a profession through innovation, evaluation, and participation in continuing nursing education activities that are both professionally and socially relevant. Lifelong Massachusetts School Nurses Attend learning, along with the employment of critical thinking, is essential to effective nursing practice and to the health and wellbeing of individuals National Conference in New Mexico and the profession at large. Competency issues and lifelong learning are well established in the Albuquerque, new Mexico: Thirty school deliver nursing services, provide leadership, literature (DeSilets & Dickerson, 2008; Huggins, nurses from Massachusetts attended the 40th coordinate services between school and 2004) yet few of us may know that it is also good Annual Conference of the National Association of community, and support health education for for our health! School Nurses (NASN) June 28-July 1, 2008. They students. In March, we reviewed the concept of resiliency were among more than a thousand school nurses At the all-conference awards ceremony, as it relates to wellbeing. There is evidence to and other experts from around the country who Marjory McEttrick-Maloney was recognized as the support the notion that life long learning has a address school health issues on a daily basis. The Massachusetts School Nurse Administrator of the positive effect on health outcomes. Participation National Association of School Nurses has over Year and Marsha Sharkey, RN of the Ashburnham- in lifelong learning has been reported as having 14,000 members in all 50 states, Washington, DC Westminster School District was acknowledged consequences upon health outcomes including and abroad. Its core purpose/mission is to advance as the Massachusetts School Nurse of the Year. well-being, protection and recovery from mental the delivery of professional school health services Mary Ann Gapinski received a research award health difficulties, and the capacity to cope to promote optimal learning in students. to support her efforts with an on-going research with potentially stress-inducing circumstances The theme of this year’s conference, project. including the onset and progression of chronic “Transforming School Communities: Voices The National Conference comes to Boston illness and disability. These effects were for Students’ Health,” focused on advancing next year, June 25-28. School nurses are already mediated by fairly direct impacts of learning upon the specialty practice of school nursing by saving the date and making plans to share their resiliency in terms of psychosocial qualities; self- strengthening school nursing skills needed to expertise. esteem, self-efficacy, a sense of purpose and hope, competences, and social integration. Learning generated positive health outcomes when matched with the interests, strengths and needs of the learner (Hammond, 2004).

The Critical Thinking Element of Lifelong Learning Critical thinking consists of mental processes of discernment, analysis and evaluation (Gambrill, 2006). It includes possible processes of reflecting upon actual or elusive things in order to form a solid judgment that reconciles scientific evidence with common sense. In contemporary usage "critical" has a certain negative connotation that does not apply here. Critical thinkers gather information from all senses, verbal and/or written expressions, reflection, observation, experience and reasoning. Critical thinking has its basis in intellectual criteria that go beyond subject-matter divisions and include: clarity, credibility, accuracy, precision, relevance, depth, breadth, logic, significance and fairness (Critical Thinking Community, 2008). This is just the sort of process that is involved in personal holistic health assessments and in nursing practice at large. • Page 10 • MAssachusetts Report on Nursing December 2008 MARN Fall Clinical Conference Highlights

Clinical Simulation: The Future of Nursing Practice and Education Friday, October 17, 2008 Lombard’s Conference & Function Facility, Randolph, MA

“This was the best conference yet…what a great way to increase our skills…I learned so much…” “The presentations were great!” MARN Thanks the A day of learning, networking and catching up with old friends and family… Wonderful Sponsors and Exhibitors Arthur L. Davis Publishing Agency, Inc. Brigham and Women’s Hospital The Institute for Patient Care, Massachusetts General Hospital Massachusetts Hospital Association

Exhibitors American International Conference committee member, Brian College French introduces the Keynote Speaker, Dr. Daniel Raemer, PhD, who kept all gathered alert and engaged.

Beacon Health Care Products

Guldmann, Inc.

JAAn “justaskanurse.net”

Laerdel

MARN President Toni Abraham welcomes the conference attendees. METI

World Point

Claire Lamontigne, MS, RN, CNE, discussed the nuts and bolts of Developing a Successful MARN Conference Chair Lindsay Gainor. Simulation Program in any setting December 2008 MAssachusetts Report on Nursing • Page 11 • MARN Fall Clinical Conference Highlights

Poster Presentations added validity to the day’s experiences… other institutions are using simulation in a variety of ways! A special thank you to all the poster presenters:

A Model for Integrating Clinical An Evaluation of the Influence Enhancing the Confidence of Innovative Education at BIDMC: Simulation and Evaluation into of Simulation on the New Graduate Nurses Using What Do They a School of Nursing Curriculum Development of Critical High Fidelity Simulation, Say They Need? Thinking Among Novice Nurses: Didactic Lecture, and Erin T. Lamoureux, a Pilot Study in Progress Hands on Practice A Survey Among Nurses APrn, MS, BC Allison McHugh, rn, BSn, MHS Margaret Curnin, rn, MSn Allison McHugh, rn, BSn, MHS Beth M. nagle, MSn, rn Helene Cunningham, rn, MS Shelly Calder, rn, MSn, CnS Jeanne McHale, MSn, rn Beth Israel Deaconess Joan roche, rn, PhD Patricia H. Folcarelli, rn, PhD Gail Alexander, BSn, rn Medical Center Anna Johannson, PhD Ellen Mahoney, DnSc, rn University of Massachusetts Amherst Beth Israel Deaconess Massachusetts General Hospital Medical Center

Simulation and Team Training Simulation as a Transition to a Simulation Education Simulation Enhanced in Pediatric Hematopoetic Stem New Work Environment Resource Center Curriculum in a Cell Transplant New Graduate Nurse Miriam Greenspan, rn, MS John Flattery, BSn, rn Orientation Program within a Lindsay A. Gainer, rn, MSn, CPOn Dorothy Bradley, rn, MS Pam Almada, rn Pediatric Institution Marcie Brostoff, MS, rn Diane Campbell, rn, BSn Leslie Lehmann, MD Carol Luppi, rn, BSn Jordan Hospital Josephine Faller, MS, rn, CnS Caroline Costello, BSn, MBA Karen Conwell, MS, rn, CPnP CPOn(r), Greg Durkin, MEd, rn Brigham and Women’s Hospital, Wendy Ouellette, rn, CPOn Kathleen Houlahan, MS, rn Center for nursing Excellence Amanda Berube Amanda Berube Marcie Brostoff, MS, rn Kim Hazekamp, BSn, rn nancy E. Kline, Children's Hospital Boston PhD, rn, CPnP, FAAn Children's Hospital Boston

Students for Change Using Interdisciplinary Simulation to Promote the Advocacy Beyond the Bedside: Erin T. Lamoureux, Assessment and Management Nurses Influencing the Political Process in Massachusetts APrn, MS, BC of a Patient with a Change in Mental Status Elina Troshin, Sn Friday, February 6, 2009 Stephanie Vasilchuk, Sn Wellesley Gateway, 93 Worcester Street (Rte 9) Jeanne McHale, MSn, rn University of Massachusetts Beth M. nagle, MSn, rn This program is designed to increase knowledge of the effective steps that Amherst Gail Alexander, BSn, rn nurses can take to shape Massachusetts health care policy. Monique Mitchell Theodore Stern 9:00 am – 9:30 am Registration and Continental Breakfast

Massachusetts General 9:30 am – 10:45 am Lessons from the State House: The Nurse Hospital Legislator Perspective Mary Grant, RN, MS - State Representative Kay Kahn, RN, MS - State Representative Jennifer Callahan, RN, EdD - State Representative Christine Canavan, RN, BSN - State Nurses Needed for a Unique Representative 10:45 am – 11:00 am Break Professional Opportunity 11:00 am – 12:00 pm Influencing Legislation: A Strategic Approach Karen Daley, RN, MPH, MS, PhD(c) and Angela Nannini, PhD, FNP MARN is seeking nurses to participate as mentors or mentees in its grant funded program “Mentoring Matters: ANCC Approved Contact Hours Pending In the event of snow, please call MARN a Pilot Program for Novice Nurses” at 617-990-2856 for information. For directions to the Wellesley Gateway  If you are an RN currently employed in a full/part time visit MARN at www.MARNonline.org position with a minimum of 3 years of consecutive full time clinical experience, consider applying as a ------mentor. Fee: $10.00 for MARN members, students and nursing faculty $30.00 for all others  If you are an RN currently employed in nursing, in first 18 months of practice, and have completed your Name: ______preceptorship or formal orientation program, consider Member / Student / Faculty / Other (Circle One) applying as a mentee. Address: ______Visit the MARN Website www.MARNonline.org for more information and an application. Phone: ( ) ______Deadline: January 16, 2009 Email: ______

“Mentoring Matters: a Pilot Program for Novice Nurses” Mail check to: MARN, PO Box 285, Milton, MA 02186 is funded by the Center for American Nurses. Deadline: January 30, 2009. Please note: seating is limited. • Page 12 • MAssachusetts Report on Nursing December 2008 Presence MARN Welcomes Susan by Diane Garrow Conrad, PhD as Director

She held his hand and stroked his brow Dr. Conrad’s CV is 18 pages long and is His suffering evident testament to the fact that she comes to the MARN Board of Directors as a well qualified and As interns re-examined each and every experienced nurse. She started her nursing career Clinical change after graduating from the University of Evansville And ordered new tests in Indiana. She is presently the Nursing Faculty She knew he was dying Chairperson at Framingham State University (where she has taught since 1984) after serving His eyes expressed his own acceptance as faculty at various universities around the Of his plight country. She is no stranger to staff nursing which contributes to her success as a faculty member. Why was only she able to understand? Dr. Conrad has been an active member of ANA since 1970 and is a charter member of MARN, Few words were spoken as his essence serving on the Finance Committee before joining diminished the Board. She is also a member of various nursing professional organizations, Sigma Theta Tau, to Yet the nurse remained steadfast name one. She has won many awards for her work To deliver presence in nursing, has done countless presentations and And compassion has authored several grant proposals and journal articles. Please join me in welcoming Susan As his spirit bade farewell to all familiar Conrad to the MARN Board of Directors. December 2008 MAssachusetts Report on Nursing • Page 13 • Physical Activity, ‘Mindful’ Movement and Wellbeing by Susan Vorce Crocker, PhD, RN lipoproteins (HDL or the "good" cholesterol) activity, at work or home on most days of the • Lower the risk of developing high blood week. For most people, greater health benefits It is exercise alone that supports the spirits, pressure can be obtained by engaging in physical activity and keeps the mind in vigor (Cicero). In January • Help reduce blood pressure in people who of more vigorous intensity or longer duration. To 2008, a call was sent: an open invitation issued to already have hypertension help manage body weight and prevent gradual, engage monthly in a holistic nursing assessment of • Reduce the risk of developing colon cancer unhealthy body weight gain in adulthood: your own personal wellness. Wellness topics have • Reduce feelings of depression and anxiety • Engage in approximately 60 minutes of been explored from several perspectives, offering • Promote psychological well-being and reduce moderate– to vigorous-intensity activity on options for you to contemplate, to research, to feelings of stress most days of the week while not exceeding explore potential benefits or fallacies, and to Major aspects of physical activity include caloric intake requirements. present challenges to your current thinking. improved: • Consider the personal benefits of the ‘mindful This author does not intend these pieces to be • Aerobic/cardiovascular (endurance), movement’ approach and incorporate a the ‘final word’ on any topic. The key is that you, • Anaerobic (speed/strength), program with these aspects into your the reader, get involved in the activity or topic • Flexibility, program visited by thinking about it yourself. Evaluate • Coordination, each idea presented and determine what feels like • Health & vitality Any Cautions? a possibility for you. Expert discussions call for Knowing the basics of physical activity and opposing viewpoints and indeed welcome them Holistic Considerations of ‘Mindful Movement’ movement practices is important to prevent —honest inquiry recognizes that there is not ‘one While many types of aerobic and anaerobic injuries and maximize the health yield. ‘Mindful truth’ but many viewpoints in obtaining wisdom. exercise promote physical and mental well-being, movement’ practices are certainly physically and Critical thinking is required. This concept, there are specific “schools” of physical activity mentally beneficial. However, overly strenuous central to all professional nursing practice, will with a more distinct mind-body approach. For physical activity can lead to injury. Check with be explored next month as it relates to life-long example: a healthcare practitioner before beginning any learning. Now, let us move on—and talk about • Qigong is a Chinese practice using movement, exercise regime. Find a qualified teacher and share motion as it relates to our physical health! affirmations, ‘breath work’, visualizations, any specific health issues you have. And be sure and meditation to improve the flow of “qi” to listen to your own body and do only what feels Get Moving! or life force, restore internal harmony, and comfortable to you. According to the Dietary Guidelines for restore the practitioner’s harmony with In conclusion, mull over this affirmation from American 2005 (USDA/HHS, 2005), the Center nature. the following systematic review undertaken by for Disease Control and Prevention (CDC) reports • Tai Chi is a Chinese system of physical Warburton, Nicol, & Bredin (2006), Cardiovascular that Americans tend to be relatively inactive. exercises that is believed to facilitate the Physiology and Rehabilitation Laboratory, In 2002, 25 percent of adult Americans had not flow of Qi (life force) in the body, promoting University of British Columbia: “There is participated in any leisure time physical activities good health and vitality. Tai Chi utilizes incontrovertible evidence that regular physical in the previous month, and in 2003, 38 percent movements that are Yin Yang opposites: activity contributes to the primary and secondary of students in grades 9 to 12 reported viewing softness and strength, forward and backward, prevention of several chronic diseases and is 3 or more hours of television per day. Regular action and calm. associated with a reduced risk of premature physical activity and physical fitness make central • Yoga is a multidimensional system that death. There appears to be a graded linear contributions to one's health, sense of well-being, includes stretching and strengthening relation between the volume of physical activity and maintenance of a healthy body weight. poses, breathing exercises and ethical and and health status, such that the most physically Physical activity is any movement that uses meditation practices. It uses body, breath, active people are at the lowest risk. However, the energy. Physical activity includes a wide range and senses to reconnect the person with the greatest improvements in health status are seen of activities from running, jumping, biking, and universe and move emotions and thoughts when people who are least fit become physically swimming to jumping rope, dancing, skating and into tranquility. active… Health promotion programs should target walking, and aids in managing mild to moderate According to the University of Minnesota people of all ages, since the risk of chronic disease depression and anxiety (CDC, 2007). The CDC (McCall, 2008), ‘mindful movement’ is an effective starts in childhood and increases with age (p. 807). describes physical fitness, as opposed to physical way to reduce stress and its physical consequences. The upshot is that nurses, like all people in our activity, as a complex quality related to the ability In addition, there are specific physical benefits society, need to ‘get physical’—intentionally chose to perform physical activity. Maintenance of good associated with each of these ‘mindful movement’ to engage in physical activity and keep moving physical fitness enables one to meet the physical practices. Research shows yoga, for example, to avoid chronic illness, improve vitality, and demands of work and leisure comfortably. People has health benefits including increased strength maintain wellbeing! As U. S. sport manufacture with higher levels of physical fitness are also and flexibility, better balance and coordination, Nike says, JUST DO IT®! at lower risk of developing chronic disease. improved reaction times, better lung function, Similarly, a sedentary lifestyle increases risk for heightened cardiovascular conditioning, and References and Resources weight and obesity and many chronic diseases, weight loss. Psychological benefits of these Astin, J.A., Berman, B. M., Bausell, B., Lee, W.L., including coronary artery disease, hypertension, movement practices include relaxation, greater Hochberg, M., & Forys, K.L. (2003.) The efficacy of type 2 diabetes, osteoporosis, and certain types of composure, better concentration, and improved mindfulness meditation plus Qigong movement cancer. Overall, mortality rates from all causes of mood. Scientific studies have found yoga as a therapy in the treatment of fibromyalgia: A randomized death are lower in physically active people than in useful adjunct to the care of such conditions controlled trial. Journal of Rheumatology, Oct. 30 (10): sedentary people. 2088-9. as asthma, arthritis, carpal tunnel syndrome, Centers for Disease Control and Prevention (CDC), Experts tell us that one achieves physical multiple sclerosis, and heart disease. (2007), Physical activity. Accessed July 29, 2008. fitness by including cardiovascular conditioning, Available at http://www.cdc.gov/nccdphp/dnpa/ stretching exercises for flexibility, and resistance Shaping your Physical Movement Program physical/index.htm exercises or calisthenics for muscle strength So, where does the rubber meet the Khalsa SB. (2004). Yoga as a therapeutic intervention: and endurance. In terms of our physical bodies, road? Practicing what we preach to our a bibliometric analysis of published research studies. movement can be defined as an act of changing patients! Frequently due to time limitation or Indian Journal of Physiologic Pharmacology, 48(3):269- location or position. Our bodies are made for overzealousness, many people who go to the 85. movement (think about the physiology of our gym jump onto the tread-mill or stair machine Meta, M. (2000.) How to Use Yoga: A Step-by-Step Guide to the Iyengar Method of Yoga, for Relaxation, muscles, joints, ligaments, tendons etc.) and like and immediately start exercising at full speed. nutrition, physical activity is essential for good Health and Well-Being. Berkeley, CA: Rodmell Press However, this may increase your risk for muscle McCall, T. (2008). Center of Taking Charge of Your health. injuries or soreness, which can then discourage Health: Mind Body Therapies. University of Minnesota. For example, weight-bearing exercises (like you from exercising again for several days after Retrieved July 29, 2008 available at http://takingcharge. walking, jogging, weight-lifting) help build which you may lose the motivation to exercise. csh.umn.edu/therapies/mind-body/mindful_movement stronger bones. Physical activity is not just limited This vicious cycle may be prevented by warming Roberts, C.K. & Barnard, R.J. (2005). Effects of to working out at the gym or playing sports, it can up and stretching properly as well as choosing exercise and diet on chronic disease. Journal of Applied also be walking, gardening or simply cleaning the an intensity level that’s appropriate for your Physiology, 98: 3-30. house. Physical movement and exercise is a critical current fitness level. To get the most out of your United States Department of Agriculture (USDA) component for health and well-being. Be creative! exercise program, the Centers for Disease Control & Department of Health and Human Services (HHS). Dietary Guidelines for Americans 2005 Retrieved recommends including all of the following Health Benefits of Physical Activity July 29, 2008 Available at http://www. health.gov/ components: DietaryGuidelines/dga2005/document/html/chapter4. Many people exercise to lose weight, tone and • Warm-up htm strengthen their muscles or simply just to “look • Exercise training activities Wang, C., Collet, J., & Lau, J. (2004.) The effect of fit.” As a nurse, you may know all or many of the • Aerobic (for cardiovascular benefit) Tai Chi on health outcomes in patients with chronic significant health benefits of physical activity. • Weight training (to build strength) conditions: a systematic review. Archives of Internal Do you intentionally practice any? Regular • Stretching (for increased flexibility) Medicine. 164(22): 2503. moderate-level activity can… • Cool-down Warburton, D., Nicol, C., & Bredin, S. (2006) Health • Help build and maintain healthy bones, benefits of physical activity: the evidence. Canadian muscles, and joints Summing Up Movement Fundamentals Medical Association Journal (CMAJ), 174(6), 801–809 • Lower the risk of developing Type 2 diabetes Engage in regular physical activity and • Reduce the risk of developing coronary heart reduce sedentary activities to promote health, NOTE: This information is not intended to take disease (CHD) psychological well-being, and a healthy body the place of advice from a healthcare professional. • Reduce the risk of stroke weight. To reduce the risk of chronic disease Check with your health care provider before • Lower both total blood cholesterol and in adulthood: Engage in at least 30 minutes of starting any exercise program. triglycerides and increases high-density moderate intensity physical activity, above usual • Page 14 • MAssachusetts Report on Nursing December 2008 Bulletin Board

Mark your Calendar Call for Nominations Members This program has sought approval by the Only Seeking MARN Members for Leadership Massachusetts Association of Registered Positions Nurses, an accredited approver of continuing nursing education by the American Nurses Credentialing Center’s The MARN Nominations and Elections $1000 Scholarship Available for Committee is currently seeking nominations Commission on Accreditation. MARN Member or Family Member and recommendations from the membership for the following elected offices: MARN is seeking applications for Join the Volunteer Team MARN the Arthur L. Davis Publishing Agency Vice President (elect 1, for a two year term) at the Boston Marathon Scholarship. Treasurer (elect 1, for a two year term) The scholarship is for a MARN member Board of Directors On Monday, April 20, 2009, the 113th Boston to pursue a further degree in nursing or (3 seats, each for a two year term) Marathon will be held. The Boston Marathon is for a child or significant other of a MARN Nominations & Elections Committee the world's oldest annual marathon and ranks as member who has been accepted into a (elect 2 seats, each for a two year term) one of the world's prestigious road racing events. nursing education program. The $1000 scholarship can only be applied to tuition The deadline for the submission of all This year MARN will be organizing its member and fees. The scholarship will be awarded medical volunteer team. If you are interested nominations materials (the Consent to Serve and want to participate on TEAM MARN, at the MARN Awards Dinner on April 3, Form and a brief Narrative) contact MARN at [email protected] 2009. is January 31 at 5 p.m. or by phone 617-990-2856.

Deadline for application: March 15, 2009. Visit the MARN web site at Openings are limited—so sign up early. Application may be found www.MARNonline.org on MARN website: for detailed descriptions of each position www.MARNonline.org. and the required forms.

Registered Nurse Participants Sought for New Nursing Study Exploring the Experience of Sharps Injuries MINDFULNESS-BASED STRESS REDUCTION PROGRAM Every year, it is estimated that hundreds of thousands of US healthcare workers sustain sharps injuries. Those injuries account for up to 80 percent of occupational bloodborne pathogen exposures, including Mindfulness-Based Stress Reduction exposures to HIV, hepatitis B and hepatitis C. Nurses report the majority of these work-related injuries. program for YOUR self-care… while also Despite clear indications that suggest they contribute to nurses’ job stress and detract from nurses’ ability learning holistic interventions for patients. to care for patients, no prior research exists that provides an in-depth understanding of the experience of The MBSR program consists of 8 weekly sharps injury, including its aftermath and meanings. 2-hour classes, taught by stress management Karen Daley, a PhD candidate in the nursing program at Boston College, is conducting dissertation expert and board-certified holistic nurse, research designed to provide a better understanding of the impact and meanings associated with the experience of sharps injuries. Registered nurse volunteers from Massachusetts, Rhode Island, New Pamela Katz Ressler, RN, BSN, HN-BC. Hampshire and Maine are being sought as participants for this study. Nurses who have sustained their 2009 Classes begin on January 22 in injury within the previous 24 months are eligible for participation, which involves one or more face-to-face Concord, MA. (Thursday evening or Friday interviews. morning classes are available.) A clearer understanding of the impact and meanings of this experience will better inform the care CE: 16 contact hours. This continuing provided to nurses and other healthcare workers who sustain these injuries. For more information, please nursing education activity was approved by contact the investigator, Karen Daley, RN by phone at (617) 596-1381 or email: [email protected]. the Massachusetts Association of Registered Nurses, Inc., an accredited approver of by the American Nurses Credentialing Center’s Save the Date Commission on Accreditation. Tuition: $350 (includes CDs, manual, and MARN 2009 Annual Awards Dinner and Spring Convention: text), BCBS discount available The Ethics Imperative in Nursing Contact: Stress Resources (www.stress April 3 and 4, 2009 at the Dedham Hilton resources.com) or 978-369-5243. December 2008 MAssachusetts Report on Nursing • Page 15 • Bulletin Board

MEMBER BENEFITS This program did not seek approval Your guide to the benefits of ANA/MARN membership...It pays for itself by the Massachusetts Association of Registered Nurses, an accredited approver • Dell Computers—MARN and ANA are Promote yourself: professional development of continuing nursing education by the pleased to announce a new member benefit. tools and opportunities American Nurses Credentialing Center’s MARN and ANA members can now receive • Members save up to $140 on certification Commission on Accreditation. 5%-10% off purchases of Dell Computers. To through ANCC. take advantage of this valuable offer, or for more details, call 1-800-695-8133 or Visit • Online continuing education available Dell's Web site at www.Dell.com at a discount or free to members. Conflict Resolution Skills Training • Walt Disney World Swan and Dolphin • Conferences and educational events at Hotel the national and local level offered at a This conflict resolution skills training • Professional Liability Insurance—a must discount to members. program teaches nurses conflict theory have for every nurse, offered at a special • Member discounts on nursesbooks.org— and effective communication skills to member price. ANA's publications arm. help them work successfully with patients and their families. It is recommended for • Nurses Banking Center—free checking, • Find a new job on Nurse's Career professionals who work with multiple online bill paying and high yield savings Center—developed in cooperation with family members who may disagree about all available to you 24/7 to fit any shift or Monster.com. difficult decisions they need to make. schedule at an affordable price—Liability/ Date: January, 29, 2009 or May 5, 2009 Malpractice, Health Insurance, Dental and Stay informed: publications that Time: 9:00-3:00 Vision. keep you current Location: Newton, MA (specific • CBCA Life and Health Insurance Plans— • Free subscription to The American information will be sent upon registration) Disability Income, Long Term Care, Medical Nurse—a $20 Value. Fee: $195 Early Registration (6 weeks prior Catastrophe, Medicare Supplement, Cancer • Free online access to OJIN—the Online to program), $225 Regular Registration Insurance and Life Insurance Plans Journal of Issues in Nursing. Contact Hours: 4.75 provided by CBCA Insurance Services. Registration Info: • Free subscription to the MAssachusetts • Discounts on auto rental through Avis and Report on Nursing—a $20 value www.ElderDecisions.com or Budget: Call Avis 1-800-331-2212 and give email [email protected], ID# B865000 Call Budget—1-800-527-0700 • Free access to ANA's Informative 617-621-7009 and give ID# X359100 listserves including—Capitol Update and Members Insider. For more information, contact Blair Trippe, • Save on your hotel stays at Days Inn, Ramada Inn, Howard Johnson and more. • Access to the new Members Only web Partner Agreement Resources, LLC site of NursingWorld.org. 30 Walpole Street • Online discounts on all your floral needs Norwood, MA 02062 through KaBloom. • Free access to MARN’s Member-Only Main Number: Listserve (617) 621-7009 [email protected] Attention Night Shift Nurses: Join MARN The MARN Approver Unit Director Policy for Accepting Barbara Gray Announcements for the Newsletter: The only Professional Nursing Organization and participate ANCC Approver Unit in the Commonwealth in increasing MARN encourages organizations of higher Program reviewers: available to review your understanding education to submit announcements nursing education programs any time. about sleep about continuing education opportunities For up to date information about how to deprivation! and upcoming events that are of interest become an approved provider (for a single to nurses. Fees must be included with activity or as an organization) please visit the WGBH/Boston & submissions. MARN Website Harvard Medical www.marnonline.org School's Division Barbara Gray The Fee Schedule is as follows: of Sleep Medicine Non-MARN Approved Providers/ Collaborate: Create a Sponsors—$50 Series of Educational Web sites About Sleep MARN Approved Providers/Sponsors—$25 Module 1: An overview of sleep: why it matters, an intro to sleep physiology, and how Payment can be mailed to MARN, PO Box to optimize sleep. 285, Milton, MA 02186. Please include a Module 2: Will address the causes and MARN Update is an up to date copy of the announcement and contact consequences of sleep deprivation and will information service about a variety information (name, address, telephone, Email) with the check. Please email copy to feature a series of video story lines about of issues important to nurses in the real experiences of workers in different www.MARNonline.org. professions who experience sleep deprivation. Massachusetts. You must be a MARN Needed: A night-shift nurse who is member to be included, so join today! Announcements are limited aware of being sleep deprived (getting less to 75 words. than 6 hours sleep on a regular basis). We MARN member: Have you gotten want to know how working the night shift your MARN Update message? If affects your quality of life at work and at not, then we don’t have your correct home. Are you struggling with fatigue, poor concentration, moodiness, even health issues? email address. If you want to begin A qualified candidate must be interested in receiving this important information, making some changes to current sleep habits just send an email to: info@ and patterns that will enable continuation in marnonline.org with “ADD” and Happy present job with greater effectiveness leading your name on the subject line. to an improved standard of living. Your story might be featured on the Web site, so you must be comfortable with sharing your story We also welcome any pictures that Holidays with the general public. show MARN members in action…at If you fit this profile and are interested in work or at play. Interested persons, getting more information about the project: please contact Myra Cacace at myra@ Contact Jayne Sportelli at from net1plus.com. [email protected] or call 617-300-3859. If you are interested in learning more about the Project, go to MARN http://healthysleep.med.harvard.edu • Page 16 • MAssachusetts Report on Nursing December 2008 is relatively easy to teach patients and/or their CE Unit significant others. Therefore, patients can be discharged safely with a PICC line for continued An Introduction to Peripherally Inserted intravenous therapy at home. Definitions: Central Venous Catheters Central Venous Catheter (CVC): for the purpose of this self-study only traditional percutaneous Ohio Nurses Foundation OBJECTIVES (via needle-puncture of the skin) CVCs will be ONF-07-44-I Upon completion of this independent study, the discussed. A CVC is a catheter placed into a INDEPENDENT STUDY learner will be able to: large vein in the neck, chest or groin. They are 1. Review the terminology associated with inserted by physicians using the Seldinger or This independent study has been developed to vascular access devices. modified Seldinger technique when the patient improve the nurse’s knowledge and understanding 2. Identify the indications and contraindications needs more intensive cardiovascular monitoring, regarding the use and care of PICCs. for PICC placement. for assessment of fluid status, and for increased 1.5 contact hour will be awarded for successful 3. Describe appropriate care and maintenance viability of intravenous drugs and fluids. The completion of this independent study. for PICCs. most commonly used veins are the internal The Ohio Nurses Foundation (OBN-001-91) is 4. Explain the complications associated with jugular, subclavian and femoral. CVCs placed in accredited as a provider of continuing education PICCs. the internal jugular and subclavian veins should in nursing by the American Nurses Credentialing 5. Discuss PICC removal. terminate proximal to the junction of the superior Center's Commission on Accreditation. This independent study was developed by: vena cava and the right atrium (cavo-atrial Expires 12/2009 Nancy L. Stone, RN, CCRN, Manager of PICC junction). A chest radiograph should be obtained Services, Lancaster, Ohio. The author has no to determine location of the catheter tip and to DIRECTIONS financial vested interest. exclude pnuemothorax or catheter malposition. 1. Please read carefully the enclosed article "An The planners and faculty have no conflict of The distal tip of a femoral CVC lies within the Introduction to Peripherally Inserted Central interest. There is no commercial support for this inferior vena cava, below the diaphragm. Dwell Venous Catheters.” independent study. time for a CVC is usually considered seven to ten 2. Complete the post-test, evaluation form and days. the registration form. Intravenous (IV): means "within a vein." It 3. When you have completed all of the usually refers to giving medications or fluids information, return the following to the Ohio through a needle or tube inserted into a vein, An Introduction to Peripherally Inserted which allows immediate access to the blood Nurses Foundation, Dept.LB-12, P. O. Box Central Venous Catheters (PICC) 183134, Columbus, Ohio 43218-3134. supply. Modified Seldinger Technique: a vein is A. The post-test; accessed with a regular hypodermic needle, an Introduction: intravenous catheter or an echogenic needle. A B. The completed registration form; Peripheral intravenous injections and infusions C. The evaluation form; and thin, soft, flexible guide wire is then threaded into were used as early as 1670. Werner Forssamn, a the vein through the needle or catheter several D. The fee: $25.00 (plus shipping/handling) surgical intern, first reported insertion of a Central for MARN members and $35 for non- inches. The guide wire is never advanced past Venous Catheter (CVC) in a human in 1929; he the shoulder. Once the guide wire is placed, the MARN members cannulized his own right atrium via the cephalic The post-test will be reviewed. If a score of needle is removed, leaving just the guide wire vein. In 1953, Sven-Ivar Seldinger developed a in place. A nick is made into the skin beside the 70 percent or better is achieved, a certificate technique that facilitated catheter placement in will be sent to you. If a score of 70 percent is guide wire, and an introducer sheath with dilator lumens and body cavities. The Seldinger technique is inserted over the guide wire into the vein. Then not achieved, a letter of notification of the final revolutionized medicine by allowing the central score and a second post-test will be sent to you. the guide wire and dilator are removed; the PICC venous system to be accessed safely and easily. catheter is inserted through the introducer sheath, We recommend that this independent study be Nurses began inserting peripheral intravenous reviewed prior to taking the second post-test. If a which is then peeled away. access devices (hand/arm) in the 1940’s. In the Midline: is a peripherally inserted 6-8-inch score of 70 percent is achieved on the second post- late 1970’s and early 1980’s training programs for test, a certificate will be issued. catheter that may be used in patients requiring Peripherally Inserted Central Venous Catheters intermediate duration (i.e., several weeks) of If you have any questions, please feel free to (PICC) began teaching nurses the intricacies of call Zandra Ohri, MA, MS, RN, Director, Nursing physiologically compatible intravenous (IV) peripheral central line insertion. By 1990 most therapy. Unlike conventional short peripheral IV Education, ext. 1027, or Sandy Dale, ext. 1030, Ohio Boards of Nursing had accepted central line Nurses Association at (614) 237-5414. catheters, the midline catheter does not require insertion by nurses, specific to PICC placement as changes every 72-96 hours. The technique and within the scope of nursing practice. Initially the veins used for Midline placement are the same for success rate for PICC insertion by nurses ranged PICC placement. The catheter tip ideally lies in the from 70% to 80%. Today, portable ultrasound axillary vein. A chest radiograph is not needed for options for vein identification have pushed catheter tip verification. Only nurses certified in successful PICC insertions by nurses to greater PICC/Midline placement may insert a Midline IV. than 90%. Peripheral Intravenous Catheter (PIV): is PICC placement continued to have increased the most common intravenous access method popularity throughout the 1990’s and in to the used in hospitals. A peripheral IV line consists next century. Lower infection rates and longer of a short catheter (1/2 inch to 2 inches long) dwell times than traditionally placed CVC lines inserted through the skin into a peripheral vein. are the two main reasons that PICCs continue to A peripheral vein is defined as any vein that gain popularity. Lower cost of insertion, ability to is not in the chest or abdomen. Arm and hand train existing staff and low incidence of serious veins are typically used. However, leg and foot complications continue to create a situation for veins can be used. Refer to the facility’s policy PICC usage to increase. PICC care and maintenance regarding the use of leg/foot veins for peripheral IV access. A peripheral IV cannot be left in the vein indefinitely, because of the risk of insertion- site infection leading to phlebitis, cellulitis and bacteremia. The Infusion Nurses Society (2006) recommends that every peripheral IV be replaced within 72-96 hours to avoid infection at the insertion site. Peripherally Inserted Central Venous Catheter (PICC): is a form of intravenous access that can be used for a prolonged period of time. The PICC is inserted into a peripheral vein such as the cephalic vein, basilic vein, or brachial vein using a modified Seldinger technique under ultrasound guidance; then advanced through increasingly larger veins, toward the heart until the tip rests in the distal superior vena cava or cavo-atrial junction. Physicians, physician assistants and registered nurses trained and certified in the insertion technique, may place PICCs. A chest radiograph should be obtained to determine location of the catheter tip and to exclude catheter malposition. Depending on the purpose for which the PICC was inserted along with appropriate care and maintenance a PICC can remain in place for up to one year.

continued on page 17 December 2008 MAssachusetts Report on Nursing • Page 17 • Peripherally Inserted Central Venous Catheters of vein selection, the ideal point of insertion is continued from page 16 Table 1. Examples of IV Medications that are above the antecubital fossa in order to minimize Irritants or Vesicants (including vasopressors) the mechanical problems associated with arm Indications/Contraindications for PICC Insertion: bending. A PICC is an effective intermediate and long- Acyclovir Ganciclovir Phenytoin An RN who has been educated and certified term central venous vascular access device. Its sodium sodium in PICC line placement may insert a PICC. functions are compatible with those of other Certification usually requires an eight-hour percutaneously inserted central venous catheters. Amphotercin B Iron dextran High- seminar in PICC placement, complications, A PICC should be considered in patients requiring concentration removal and care. It also involves three successful IV therapy for more than seven days or who have potassium PICC placements in the presence of a preceptor. poor peripheral venous access and/or require chloride Insertion requires maximal sterile barrier frequent blood draws. Other indications include precautions to reduce the risk of contamination infusion of Total Parenteral Nutrition (TPN), Ampicillin Mannitol Promethazine and subsequent catheter-related bloodstream vesicants such as chemotherapy agents or drugs sodium hydrochloride infections. Maximal sterile barrier precautions known to be irritants. Vesicants are IV fluids with include the use of a mask, sterile gown, hair cover, a pH less than 5 or greater than 9 or an osmolality Ampicillin Meperidine Sodium sterile gloves, and large sterile drapes. greater than 600 mOsm/L. Vesicants can cause an sodium/ hydrochloride bicarbonate The Infusion Nurses Association (2006) now injection site reaction (blistering) often referred to sulbactam recommends the use of visualization technologies as chemical cellulitis if the drug escapes from the sodium such as portable ultrasound that aid in vein vein or IV catheter into the skin (extravasation). identification and selection. Ultrasound not only IV medications and solutions considered Ciproflaxin Morphine Sodium increases the rate of successful PICC insertions irritants cause a short-lived and usually limited Sulfate nitroprusside but also increases safety. By using ultrasound irritation to the vein. In addition, a PICC should the nurse can identify arteries, nerves and veins. be considered for the infusion of vasopressor Dextrose 10% Nafcillin Tiracillin Visualization technologies also allow the nurse to agents such as Dopamine and Norepinephrine. or greater sodium disodium measure the circumference of the selected vein to Vasopressors (considered a vesicant) can cause assist in optimal catheter selection. In addition, tissue necrosis and skin sloughing when infused Dopamine Norepine- Vancomycin the use of ultrasound allows PICC’s to be placed through a peripheral IV that extravasates. The phrine higher in the arm, where the veins are larger and tissue necrosis is caused by severe vasoconstriction the incidence of thrombus formation is lower of the blood supply to surrounding tissue. Erythromycin Oxacillin Most due to higher flow rates of blood. Prior to the The Infusion Nurses Society (2006) defines sodium chemotherapeutic availability of portable ultrasound machines, PICC extravasation as the “inadvertent administration agents placement by nurses was limited to palpable veins of a vesicant medication or solution into the one to two inches above or below the antecubital surrounding tissue." Infiltration is defined as the Fluconazole PPN (high space. PICCs come in a variety of brands and sizes “inadvertent administration of a non-vesicant osmolarity) (ranging from 16 to 23 gauge). They also come medication or solution into the surrounding and TPN with the option of single, double or triple lumens. tissue." Infusion of vesicants, irritants and (partial and Appropriate vein and catheter selection are vital to vasopressors through a central vein allow for total the prevention of complications. Recently the Food better hemodilution. A PICC may also be used to parenteral and Drug Administration approved certain PICCs measure and/or monitor central venous pressure. nutrition) for use in power injections. Often referred to as PICCs are the preferred central venous access site “Power PICCs,” they are designed to withstand for patients with increased intracranial pressure, the high pressure associated with radiocontrast suffering from trauma or burns resulting in PICC Insertion Considerations: studies. chest injury, or if the patient has respiratory Insertion of a PICC requires a physician order Prior to PICC insertion, the procedure should compromise due to chronic obstructive pulmonary and, based on facility policy, a signed consent be explained to the patient including risks and disease, a mediastinal mass, cystic fibrosis, or form prior to insertion. A PICC may be inserted benefits. Depending on the facility’s policy, the pneumothorax. through the basilic, cephalic or brachial veins. patient may need to give informed consent prior An upper extremity vein cannot be used However, research shows that the basilic vein is to insertion. The manufacturer’s guidelines are for PICC insertion if there is a history of any optimal for placement. The basilic vein has the followed for placement. Most PICCs are placed of the following within the region of that largest diameter and the greatest blood flow of using a modified Seldinger technique. PICCs upper extremity: vascular surgery (including the peripheral arm veins. The basilic vein also inserted by a nurse are rarely sutured in place; hemodialysis shunts), radiation therapy, venous offers the straightest route to the superior vena instead a sterile securement device is used to thrombosis, or axillary lymph node dissection. cava. While the brachial vein is smaller than the prevent catheter movement. In addition, local dermatitis, cellulitis, burn cephalic vein and has a variable course, it usually Documentation post insertion includes patient injury, abscess, or infections in or near the region offers the second best insertion choice. This is education and any problems encountered with of planned insertion site are contraindications because the brachial vein often takes a direct path catheter placement. In addition, document the size, for using that extremity for the procedure. to the basilic vein and then on to the superior Caution should be used when placing a PICC vena cava. The cephalic vein is the third insertion continued on page 18 in patients with Permanent Pacemakers and choice, because it often narrows along its path and Automated Internal Cardiac Defibrillators (AICD). may form a sharp angle where it joins the axillary In these patients, the PICC should be placed in vein. Both of these issues increase the risk of the arm on the opposite side of the Pacemaker catheter related mechanical phlebitis. Regardless or AICD placement in the chest to prevent potential dislodgement of the Pacemaker or AICD intravenous wires. Lastly, patients with chronic renal failure and end-stage renal disease are not appropriate candidates for PICC placement. The need to preserve peripheral veins for future dialysis fistulas is a critical issue for these patients. • Page 18 • MAssachusetts Report on Nursing December 2008 Peripherally Inserted Central Venous Catheters type of catheter, infusate and patient’s a foreign body reaction or chemical phlebitis. continued from page 17 allergy history. Many facilities have steered Development of an insertion site infection away from the routine use of heparin requires removal of the catheter. The distal tip length and type of catheter as well as the insertion flushes due to the risk of heparin-induced of the catheter should be cultured after removal location. Arm circumference, measured half way thrombocytopenia. Normal saline used anytime an infection is suspected. between the insertion site and the shoulder should for PICC flushing should be preservative Systemic catheter-related infections are usually also be documented. The PICC should not be used free. If heparin is used for flushing, keep related to bloodstream infections. Other systemic until radiographic verification of tip placement is these pointers in mind: use the SASH catheter-related infections include: suppurative received and documented. The ideal placement of (saline, administer medication, saline, thrombophlebitis and distant complications the catheter tip is the cavo-atrial junction. heparin) protocol when giving medications such as endocarditis or metastatic abscesses. incompatible with heparin. Bloodstream infections related to PICC and other Care and Maintenance of PICCs: 5) When obtaining blood draws from the CVCs usually occur through contamination of the Proper maintenance and care of PICCs is vital to PICC follow facility policy. No matter what catheter hub leading to intraluminal colonization the longevity (dwell time) and to the prevention of method is used, stop all infusions before of the catheter. Catheter- related bloodstream complications. Maintenance and care includes: drawing blood and do not reinfuse the infection are classically defined by three elements: 1) Proper handwashing technique, before discard sample. After the blood sample is 1) isolation of the same microorganisms from and after patient and/or catheter contact obtained, turbulently flush the catheter with the catheter and from at least two concurrent is essential in the prevention of catheter 10 to 20 ml of 0.9 normal saline. blood cultures from a peripheral vein; related infections. 6) Test for blood return every time the PICC 2) clinical and microbiological investigation 2) Maintain a dry, intact, clean, and is used. Lack of blood return may be due does not reveal an alternative source for the adherent dressing. Change a transparent to patient positioning, malposition of the bloodstream infection, and semipermeable membrane dressing and catheter or thrombus formation. 3) a negative culture of the infusate. Cultures catheter securement device once a week 7) Measure and document arm circumference of the infusate are rarely obtained in using sterile technique. Dressings are to be every shift, the measurement should be clinical practice, since the infusate is rarely changed any time they become wet, soiled taken half way between the PICC insertion responsible for bloodstream infections. or non-adherent. If a gauze dressing is used site and shoulder. The arm should also Suppurative thrombophlebitis is defined as or gauze is used under the transparent be assessed at least once a shift for pain, infection of the thrombus surrounding the dressing, the dressing should be changed erythema, edema or drainage. Increases in intravascular device with extension and every 48 hours. The insertion site should arm circumference or the development of invasion of the cannulated vein. be cleaned thoroughly with chlorhexidine pain, erythema, edema or drainage should Signs and symptoms of a systemic infection with each dressing change; allowing the be reported immediately. include: fever, chills, tachycardia, fatigue, chlorhexidine to dry completely before 8) Blood pressure cuffs or tourniquets should muscle aches, weakness, hypotension, and replacing the dressing. Most facility policies not be applied over the PICC, but may be an elevated white blood count. Bloodstream include wearing facemasks during PICC and placed distal to the catheter’s location. infections, suppurative thrombophlebitis and CVC dressing changes. Taking a blood pressure over the PICC distant complications can be life threatening. 3) Infusion caps should be cleaned vigorously insertion site can cause bleeding at the Early diagnosis and treatment is imperative. The with chlorhexidine or alcohol before insertion site, increase the risk of thrombus PICC should be immediately removed when a accessing the line. Positive or neutral end formation, and cause retrograde blood flow, systemic catheter-related blood stream infection is caps can be used. Caps should be changed raising the risk of catheter occlusion. confirmed. once a week and any time they become 9) Continue patient education on the care and 2) Thrombus Formation: Thrombus formation soiled. Open-ended PICCs need to be maintenance of their PICC, especially those is the most common complication reported in clamped before removing the infusion cap to patients being discharged to home with the relationship to PICCs. The incidence of upper prevent an air embolism. PICC intact. extremity deep vein thrombosis is increasing 4) To maintain catheter patency, flush catheter at the same time the rate of PICC insertion is on lumens every 12 to 24 hours when not in Complications: the rise. Any device inserted into the vascular use and before and after any infusions. The PICCs have a relatively low complication rate, system increases the risk of thrombus formation; Infusion Nurses Society (2006) standards but there are potentially serious problems related either in the vessel or in the catheter. The three recommend that the minimal flush volume to their use. Complications of PICCs include: primary causes of thrombus formation in a vessel be at least twice the volume capacity of the 1) Infection: Studies have shown that PICCs have are known as the Triad of Virchow. The first catheter and any add-on devices (extension a lower incidence of infection than traditional cause is an alteration in the vein wall caused tubing and stopcocks). To prevent catheter CVCs (PICC: 0.75 per 1,000 catheter days; by injury, irritation, or disease process. Vein damage, use the syringe size recommended CVC 2.51 per 1,000 catheter days). Catheter irritation can occur during the insertion of a PICC by the PICC manufacturer. As a general related infections are divided into two main or when the vessel is too small to accommodate rule, all flushing should be done with a 10 categories: local infections and systemic the diameter of the PICC. A catheter that is too ml or larger syringe to prevent excessive infections. Local infections occur at the PICC large will rub against the intima of the vein into flushing force that can damage the catheter. insertion site. Signs and symptoms of an which it has been inserted. The second cause A turbulent stop and go method of flushing infected insertion site include: purulent or of thrombus is stasis, obstruction, or change in is also recommended. The flush solution bloody drainage, erythema, edema, pain, fever, blood flow due to the catheter’s presence. For this (0.9 normal saline and/or heparin) and and/or tenderness. A culture of the insertion reason, it is important that the vein size and the amount used depends on facility Policy, site may be obtained to verify infection versus catheter size allow sufficient blood flow around the PICC. Thirdly, platelet aggregation due to hypercoagulability can also cause thrombus. Patients with hypercoagulability disorders who need central venous access may require a daily low dose of warfarin to help prevent thrombus formation. Two forms of thrombi may occur: intraluminal and mural thrombus. An intraluminal thrombus forms inside the catheter and can result in partial or complete occlusion. Partial or complete occlusions caused by intraluminal thrombus can often be dissolved with a small dose of a fibrinolytic agent that is instilled for 30-120 minutes and then withdrawn from the catheter. If catheter patency is not restored by the use of a fibrinolytic agent, the catheter should be discontinued. Follow manufacture’s recommendations and facility’s policy for the use of a fibrinolytic to de-clot a PICC. A mural thrombus forms between the catheter and the vein wall. Mural thrombi can also be partial or complete. Symptoms of a mural thrombus that significantly restricts blood flow around the catheter may include: swelling near and distal to the point of occlusion, peripheral collateral venous distension, periorbital edema, and/or tearing on the affected side, or discomfort/ pain in the arm, shoulder or jaw on the affected side. The arm may also become reddened and warm. In addition, difficulty flushing and infusing may be experienced. When a mural thrombus is suspected, measure upper arm circumference half way between the PICC insertion site and shoulder. Compare with

continued on page 19 December 2008 MAssachusetts Report on Nursing • Page 19 • Peripherally Inserted Central Venous Catheters phlebitis scale. For Phlebitis Grade 0, 1, 2: elevate Table 3. Potential PICC Complications continued from page 18 the extremity and apply warm moist heat for 20-30 minutes, four times a day. A Phlebitis Grade of 3 Complication Signs and Symptoms the arm circumference documented at the time or 4 is an indication for PICC removal, followed by of placement. If the change in circumference is continuous warm, moist heat application. Air embolus Hypotension, lightheadedness, less than three centimeters, with mild signs and (rare) confusion, tachycardia, anxiety, symptoms; the PICC may be used, but continued Table 2. Phlebitis Scale chest pain, shortness of breath. assessment is warranted. If the circumference change is greater than or equal to three Grade Clinical Criteria Catheter Shortness of breath, confusion, centimeters and the patient is symptomatic, notify embolus pallor, lightheadedness, tachypnea, the physician. Treatment usually involves removal 0 No symptoms (rare) hypotension, anxiety, of the PICC, elevation of the arm, and warm moist unresponsiveness, shorter catheter heat applied 20-30 minutes four times a day. 1 Erythema at site with or without measurement on removal than Anticoagulation therapy may also be ordered. The pain insertion. incidence of mural thrombus is approximately 2.5% in patients with a PICC. Approximately one 2 Pain at site with erythema and/or Catheter Hears gurgling sound during per 1,000 patients who develop a mural thrombus edema malposition flushing of catheter (internal will experience a pulmonary embolus. (can occur jugular tip malposition), arm 3) Nonthrombotic Catheter Occlusions: 3 Grade 2 plus streak formation, during or or shoulder pain, headache, Drug precipitations, lipid deposits, mechanical palpable venous cord after swelling in neck, dyspnea, occlusions, and fibrin formations at the tip insertion) absence of blood return, leaking at can also cause catheter occlusions. Medication 4 Grade 3 plus purulent drainage, insertion site, arm swelling, back crystallization and precipitations may occur cord > 1 inch in length discomfort, chest pain or if the pH of a solution varies too much from the tenderness, arrhythmias (right drug’s normal stability range. Adding a solution atrium catheter malposition). that returns the pH back to the normal range may 5) Catheter Malposition: Malposition can occur liquefy the drug and dissolve the precipitate. For during PICC insertion or later; due to changes Infection Fever, chills, tachycardia, fatigue, crystallized medications with a normally high pH, in intrathoracic pressure or catheter migration. muscle aches, weakness, such as phenytoin sodium, sodium bicarbonate It is crucial that determination of the distal tip hypotension, erythema, swelling can be infused to increase the pH in the hopes placement be confirmed by chest radiographic at insertion site, induration, the medication will return to its liquid state. With immediately after insertion and prior to PICC use. purulent drainage at site, elevated naturally low pH solutions such as vancomycin, Malposition can lead to serious complications. white blood count. hydrochloric acid may be used to lower the pH and Catheter tip placement in the right atrium or right dissolve the occlusion. Lipid occlusions are more ventricle can lead to arrhythmia; while placement Phlebitis Erythema, pain at insertion site, prevalent with silicone catheters. Lipid emulsions proximal to the superior vena cava increases the streak formation, palpable venous tend to adhere to silicone. Seventy percent ethyl risk for phlebitis and thrombus formation. cord. alcohol is the drug of choice used to dissolve lipid Spontaneous migration of the catheter tip occlusions. may result from forceful flushing or changes in Thrombus Arm swelling above and below Mechanical occlusions can also obstruct intrathoracic pressure associated with coughing/ formation insertion site, erythema, peripheral flow through a PICC and can lead to other sneezing, Valsalva maneuvers during vomiting, collateral venous distension, complications. Mechanical occlusions include: and heavy lifting. Migration can also occur as periorbital edema, and/or tearing crimping of the catheter and tip malposition the result of disease processes such as Congestive on the affected side, discomfort/ against a vessel wall. Tip malposition against a Heart Failure, tumors or venous thrombosis. pain in the arm, shoulder or jaw, vessel is more common with tip positioning high in Proper PICC securement is vital to help prevent inability to obtain blood return, the superior vena cava and is more prevalent with catheter dislodgement or migration. Tape should difficulty flushing or inability to left sided insertion. Another type of mechanical not be placed over the body of the catheter; flush. occlusion is catheter pinch-off syndrome. Catheter adhesives may cause damage to the catheter. pinch-off syndrome is compression of the catheter Research has shown securement devices are safer PICC Line Removal: between the first rib and clavicle. An intermittent and more effective than suturing the PICC at the While the removal of a PICC is usually a simple positional PICC may indicate catheter pinch- insertion site. The use of sutures increases the procedure, problems can occur. The patient off syndrome. A hallmark sign of this syndrome risk of infection; both at the insertion site and should be lying down, with the head of the bed is noted when the patient changes positions by in the blood stream. Sterile securement devices slightly elevated while the PICC is being removed. rolling the shoulder backward or raising their arm are available in a wide range of designs to fit the Apply slow, smooth, gentle pressure to remove and the position change results in return patency variety of PICCs currently marketed. the catheter; without applying direct pressure of the catheter. Signs and symptoms of catheter malposition on the insertion site. The patient should also be Fibrin begins to build up on the catheter almost include: inability to flush, infuse, or aspirate, instructed to perform the Valsalva maneuver as the immediately after insertion; sometimes developing arrhythmias, “ear gurgling” sound, headache catheter exits. Lastly, the nurse should maintain into a sheath that may completely encase the and pain, and swelling, redness, or discomfort in the patient’s arm below the level of the heart catheter. In this incidence, infusions may still be the shoulder, arm or neck. If catheter migration during PICC removal. The catheter should come possible, but the sheath will occlude the distal or dislodgement is suspected, stop all infusions out easily. If resistance is felt, stop. Resistance is opening during aspiration and prevent withdrawal and flushes and notify the physician. A chest usually caused by venospasm within the vein. of blood from the catheter. This is known as radiograph should be done to verify tip placement. Venospasms usually resolve with time. Apply persistent withdrawal occlusion. Fibrin may also Based on the tip placement, the catheter may slight tension to the line by taping it down, cover build up on a PICC without completely enclosing be pulled back a few centimeters or used as the exposed catheter with a dressing and allow it. In this case, a small piece of fibrin hangs off the a peripheral IV. Due to the increased risk of time for the venospasm to resolve. Application catheter tip; known as a fibrin tail. Fibrin tails also infection PICCs are rarely re-advanced when they of a warm, moist compress may help ease the represent a persistent withdrawal occlusion. Fibrin become dislodged or pulled out. venospasm. It is important not to continue to pull sheaths can often be resolved with an infusion of 6) Catheter Damage: Catheter damage can on the catheter if resistance occurs. Continuing low dose fibrinolytic agent over two to four hours. occur with any PICC; sometimes due to defective to pull against resistance will aggravate the Infusion of a fibrinolytic is not always successful products. More often than not, catheter damage is venospasm. In addition, pulling against resistance and the fibrin tail may develop again. caused by lack of attention to or knowledge of the could cause the PICC to break, possibly leading to 4) Phlebitis: There are usually two causes of care and maintenance of PICCS. The damage can a life threatening catheter embolus. If resistance phlebitis at the PICC insertion site: mechanical result from improper securement or inadvertently is met on the second attempt to remove the and chemical. Mechanical phlebitis is caused applying excessive pressure when flushing the catheter, stop and notify the physician for further by irritation of the venous endothelium by the PICC. Use of a syringe with a barrel smaller than instructions. catheter. This occurs more frequently when a 10 ml causes increased intraluminal pressure. Once the catheter has been successfully PICC is inserted in the antecubital fossa versus This can cause catheter rupture. Other causes of removed, apply manual pressure to the site for the upper arm. The main causes of mechanical damage include: contact with sharp objects and one to two minutes, or until all evidence of phlebitis are: small veins at the point of insertion, applying luer-locking devices too tightly (which bleeding is gone. Cover the insertion site with a and catheter movement with the bending and can cause the catheter hub to crack). Catheter sterile occlusive dressing. The dressing can be straightening the arm. damage can also result from entanglement removed after 24 hours. The entire catheter should Chemical phlebitis rarely occurs with solutions in bed linens, patient clothing or equipment. be inspected and catheter length measured; infused through a PICC, because the infusate Once a catheter has been damaged, it should be comparing the length of the catheter to the exits the catheter at a point with adequate considered contaminated. documented insertion length. This safety measure hemodilution. However, damage to the catheter Sometimes damaged catheters can be verifies that the entire catheter was removed. If body can lead to chemical phlebitis if the infusate repaired. However, repair increases the risk of any part of the catheter appears to have broken off, leaks through the damaged area into surrounding complications. Only an experienced clinician, apply a tourniquet to the upper arm at the axilla tissue. Occasionally, a fibrin sheath develops using only the repair kit provided by the (to prevent catheter embolus). Notify the physician over the catheter that allows retrograde flow of PICC manufacturer, should attempt to repair immediately and monitor the patient for signs of the infusate along the catheter. At the end of the the catheter. Catheter repair is a short-term distress. fibrin sheath, the infusate can leak into the vein intervention only. A repaired PICC should not and cause chemical irritation. In some cases, the remain in place longer than necessary. Experts Midlines versus PICCs: fibrin sheath may even force the infusate to leak at now recommend PICC replacement versus repair. Many nurses use the terms Midline and PICC the insertion site. When this occurs, complications Often, a damaged catheter can be replaced with an interchangeably. It is important for nurses to know include both infiltration and chemical phlebitis. over-the-wire modified Seldinger procedure. and respect the difference between these catheters. To determine the grade of phlebitis use the continued on page 20 • Page 20 • MAssachusetts Report on Nursing December 2008 Peripherally Inserted Central Venous Catheters Table 4 Comparison of Midline and PICC References: continued from page 19 Band, J. (2007). Central venous catheter-related Comparison Criteria Midline PICC infections: types of devices and definitions. Retrieved 9/10/07 from the Up To Date website (Licensed to Fairfield Look-alike catheters, and similar insertion Medical Center). htpp://uptodateonline.com/utd/content/ technique cause part of the confusion. Midlines Placement of Axillary Superior topic.co?topicKey=hosp_inf/8074 are peripheral catheters that have a dwell time of catheter tip Vein Vena Cava Bowes-Geddes, L., Nichols H. (2007). An overview two to four weeks. Midlines are not recommended of Peripherally Inserted Central Catheters. Topics in for the infusion of vesicants or vasopressors. Appropriate for No Yes Advance Practice Nursing eJournal. Retrieved 10/5/07 PICCs are central venous catheters that have a vesicant, from the Medscape website. htpp;//www.medscape.com/ dwell time of up to one year. Table 4 highlights irritating, or viewarticle/508939 the major differences and uses between a Midline vasopressor Grove, J., Pevee, W. (2000). Venous thrombosis related to and PICC. The accompanying picture shows the infusates Peripherally Inserted Central Catheters. Journal of Vascular difference in catheter tip placement. The catheter and Interventional Radiology. 11(7), 837-840. Appropriate for Yes Yes Gutherie, D., Dreher, D. and Munson, M. (2007). I.V. hub and all documentation should clearly define Rounds: What you should know about PICCs, part 1. the catheter as a midline or PICC. Many facilities infusing blood Nursing 2007. 37(8), 18. do not require a physician order or patient consent Gutherie, D., Dreher, D. and Munson, M. (2007). I.V. form for Midline placement. Follow facility policy Appropriate for Yes Yes Rounds: What you should know about PICCs, part 2. regarding blood draws from Midline catheters. blood draws Nursing 2007. 37(9), 14-15. Intravenous Nurses Society (1997). Peripherally Inserted Appropriate for No Yes Central Catheter position paper. Journal of Intravenous the infusion TPN Nursing. 20(4), 172-174. Infusion Nursing Standards of Practice. (2006). Indwelling Time 2-4 weeks Up to 1 year Supplement to the Journal of Infusion Nursing. 29 (1S). Midline and PICC Picture. (2007). Retrieved 10/23/07 from the Carenotes (Licensed to Fairfield Medical Center). CXR Needed to No Yes htpp: www.thomsonhc.com/carenotes/librarian/ssl/true/ confirm placement PFPUI/7L16h6h239xDLY/ND_PG/CNot Moureau, N. (2006,). It’s all about PICCs; optimal Appropriate for No Yes catheter and vein selection prove vital to patient safety CVP readings initiatives. Nursing Management. May, 22-27. Ngo, A., and Murphy, S. (2005). A theory-based Conclusion: intervention to improve nurse’s knowledge, self-efficacy, Picture obtained from CarenotesTM Vascular access is the cornerstone in the provision and skills to reduce PICC occlusion. Journal of Infusion of care for any acute care setting. Greater than 90% Nursing. 28(3), 173-181 of patients cared for in hospitals will have some Phlebitis Scale. (2002). Retrieved 10/27/07 from the National Guidelines Clearing House website. htpp/www. type of IV access. Today, optimal catheter and vein guidelines.gov selection are considered vital to patient safety. PICC insertion and removal. (2007). Retrieved 9/23/07 PICCs are gaining popularity due to lower cost and from the Lippincott online Procedures Website (Licensed less severe complications. PICCs are recommended to Fairfield Medical Center). http://iis400/procedures3/ for therapies requiring infusions of vesicant and standard roceduresSelect.do;jsessionid=90EDA9DBA74428 irritating medications and/or solutions that require DB9601D long-term therapy. While not appropriate for every Young, M. (2007). Indications for and placement of patient, PICCs offer an excellent alternative to central venous catheters. Retrieved 9/10/07 from the Up frequent venipunctures and the routine use of other To Date website (Licensed to Fairfield Medical Center). higher-risk, short-term central catheters. When used http://www.uptodateonline.com/utd/content/topic. do?topicKey=cc/medi/12561 properly, PICCs are a reliable and safe vascular access device. December 2008 MAssachusetts Report on Nursing • Page 21 • An Introduction to Peripherally Inserted Central Venous Catheters Post Test and Evaluation Form ONF-07-44-I DIRECTIONS: Please complete the post-test and 8. The most common complication associated with True False 17. A peripheral IV has a dwell time evaluation form. There is only one answer per PICCs is: of 7-10 days. question. The evaluation questions must be complete a) infection and returned with the post-test to receive a b) catheter occlusions caused by drug True False 18. Vesicants cause a short-lived, certificate. precipitations usually limited, irritation when c) thrombus formation extravasation occurs. Name: ______d) catheter migration True False 19. The cephalic vein is usually the Final Score:______9. Which of the following is not an example of a last choice for PICC placement systemic catheter-related infection? because its anatomy increases Please circle the correct answer for each question. a) blood stream infections the risk of mechanical phlebitis. Please mark each question only once. b) cellulites at the PICC insertion site c) metastatic abscesses True False 20. The use of visualization 1. Nurses began inserting peripheral IV catheters in: d) suppurative thrombophelbitis technologies are recommended a) 1929 by the Infusion Nurses Society b) 1940’s 10. Suspect a mural thrombus in a patient with a PICC if for the insertion of PICC by c) Late 1970’s a) the patient complains of numbness of the nurses. d) Early 1980’s hands and fingers on the affected side b) if there is a change in the arm circumference True False 21. The inability to draw blood from 2. Benefits of a central venous catheter include: of the affected arm of 2 cm a PICC is always due to catheter a) assessment of fluid status c) the patient has periorbital edema or tearing occlusions related to thrombus b) intensive cardiovascular monitoring on the affected side formation. c) increased viability of IV medications d) erythema is noted at the PICC insertion site d) all of the above True False 22. Patients with hypercoagulability 11. Causes of non-thrombi catheter occlusion include require daily doses of heparin 3. Which vein is not appropriate for PICC placement? all of the following except: to help prevent thrombus a) cephalic a) drug precipitations formation. b) basilic b) catheter pinch-off syndrome c) brachial c) lipid deposits True False 23. The incidence of PICC infections d) external jugular d) phlebitis is approximately 0.75 per 1,000 days. 4. Indications for PICC placement include: 12. When using the Phlebitis Scale, which is incorrect? a) vesicant IV medications a) 1 = no symptoms True False 24. Arm circumference for the b) IV fluids with a pH greater than 5 b) 2 = pain with redness and/or edema purpose of PICC assessment c) IV fluids with a osmolaity less than c) 3 = grade 2 + streak formation, palpable venous should be measured ½ between 600mOsml cord the antecubital fossa and d) Infusions of medications considered to be d) 4 = grade 3 + purulent drainage shoulder. vasodilators 13. Which statement is true regarding migration of tip True False 25. Directly after placement, a 5. Which of the following is a contraindication for placement? PICC may be used as long as the PICC placement? a) never occurs with proper use of a securement catheter flushes easily and there a) patients with chronic or end stage renal device is a blood return. failure b) can be caused by increased intrathoracic b) patients with chest injuries or burns pressure from vomiting or coughing True False 26. Chemical phlebitis rarely occurs c) patients with increased intracranial pressure c) if the catheter is partially pulled out, it may be with solutions infused through d) patients with cystic fibrosis advanced back into place a PICC because the infusions d) catheter migration does not affect the use of the exit the catheter at a point of 6. Maximal sterile barrier precautions include: PICC line high blood flow and adequate a) sterile gloves and gowns hemodilution. b) face masks and hair covers 14. Proper removal of a PICC includes: c) full body drapes a) having the patient in a high fowlers position True False 27. The most frequent cause of d) all of the above b) applying direct pressure to the insertion site damage to a PICC is caused by c) applying smooth, slow, gentle pressure when lack of attention to or knowledge 7. Which of the following is correct regarding care of pulling on the catheter related to care and maintenance a PICC? d) having the patient deep breath while the of the catheter. a) always flushing the catheter with heparin catheter is being pulled out after use True False 28. A Midline is considered a central b) using a 3ml to infuse medications or aspirate True False 15. Most Boards of Nursing consider line versus a peripheral IV site. blood central line placement, specific to c) re-infusing the discard sample after obtaining PICC placement, within the scope True False 29. If resistance is met on the first a blood sample of nursing practice. attempt at removing a PICC, d) reporting an increase in arm circumference of stop immediately and call the 3 cm or greater True False 16. A Midline catheter requires physician. radiographic verification of tip placement before use.

Evaluation: An Introduction to Peripherally Inserted Central Venous Catheters ONF-07-44-I 1. Were the following objectives met? INDEPENDENT STUDY Yes No Registration Form

a. Review the terminology associated with vascular access ❍ ❍ Name:______devices. (please print clearly)

b. Identify the indications and contraindications for ❍ ❍ Address: ______PICC placement. Day phone number: (_____) ______RN_____LPN_____ c. Describe appropriate care and maintenance for PICCs. ❍ ❍ MARN Member: ___Yes ___No ______MARN Member Number:______

d. Explain the complications associated with PICCs. ❍ ❍ MARN OFFICE USE ONLY

e. Discuss PICC removal. ❍ ❍ Date Received:______Amount:______Check No:______

2. Was this independent study an effective method of learning? ___Yes ___No Cost: $20 for MARN Members $35 for Non-MARN Members If no, please comment: I am paying by: _____Check _____Master Card _____ Visa ____ Discover ____ American Express

Credit Card #______Expiration Date______

3. How long did it take you to complete the study, the post-test, and the Signature ______evaluation form? Please return: TO: MARN – Completed Post-test P.O. Box 285 4. What other topics would you like to see addressed in an independent study? – Evaluation Form Milton, MA 02186 – Registration Form – Additional Amount Due: $______• Page 22 • MAssachusetts Report on Nursing December 2008 An Invitation for MARN Members! Become an active member—Join a MARN Committee today!

Mary A. Manning, MN.RN necessary to prepare for Annual Meeting. Members legislators. Meets monthly on the first Tuesday Executive Director expected to attend Annual Meeting held during evening of each month by teleconference (7- Massachusetts Association of Registered Nurses Spring Convention. For more information, please 8pm) and plans to meet quarterly in person. For PO Box 285 contact Cammie Townsend at CTownsend@mghihp. more information, please contact MARN: info@ Milton, Ma 02186 edu or 617-990-2856. MARNonline.org or 617-990-2856. 617-990-2856 MARN Continuing Education Committee: The MARN Membership Committee: Develops new Massachusetts Association of Registered Nurses, Inc. membership initiatives, reviews membership Are you a MARN member who is looking for a is accredited as an approver of continuing nursing statistics, and contacts new members to welcome them way to become more involved in the organization? education by the American Nurses Credentialing to the Association. Presents to schools and colleges Do you have a special talent or interest? Can you find Center’s Commission on Accreditation. This of nursing, attends other professional organizational the time to work on a one time only project? If you committee plans and executes an Annual Provider programs and meetings to promote MARN and are looking for the chance to become more active in Forum, writes quarterly newsletter articles, and the importance of professional organizational the organization, then we are looking for you! Listed functions as the MARN Approver Unit in reviewing membership. Meetings are monthly by teleconference below are the descriptions of the various active provider and activity applications for continuing (5:30-6:30pm) and quarterly in person. For more committees for the Massachusetts Association of education credit. Meets monthly in Milton, MA on the information, please contact chairperson, Cidalia Vital Registered Nurses. first Wednesday morning of each month (9am–12pm). at [email protected] or 617-990-2856.. MARN Awards Committee: Develops criteria For more information, please contact Chairperson MARN Newsletter Committee: Meets exclusively for and selects winners for three annual nursing Sandra MJ Reissour at [email protected] or 413- by email to review articles for publication, develop excellence awards, two scholarship awards and Living 794-3402. story lines, and create a quarterly newsletter circulated Legend awards. Meets quarterly by teleconference and MARN Fall Clinical Conference Planning to every RN licensed by the Commonwealth. ALL email and once/year in person to prepare for Awards Committee: Plans and executes Annual Fall MARN MEMBERS ARE INVITED TO SUBMIT Luncheon/Dinner. Members expected to attend Conference focused on topics of clinical relevance. ARTICLES OF INTEREST. For more information, Annual Meeting and Awards Luncheon/Dinner Responsibilities include site selection, speaker please contact Editor Myra Cacace at newsletter@ during the Spring Convention. For more information, selection, developing contact hour application, MARNonline.org or 978-433-6155. please contact MARN at [email protected] or assisting with marketing and on-site registration. MARN Spring Convention Planning Committee: 617-990-2856: Attention: Maura Fitzgerald, Chair. Meets monthly by teleconference and/or email to Plans and executes Annual Spring Convention MARN Bylaws Committee: Reviews MARN plan. For more information, please contact MARN at and Business Meeting. Responsibilities include Bylaws annually to create and propose changes and [email protected] or 617-990-2856. site selection, speaker selection, business meeting additions as suggested by the membership and/or MARN Health Policy Committee: Reviews execution, developing contact hour application, Board of Directors and to maintain compliance with proposed legislation and health policy issues assisting with marketing and on-site registration. ANA Bylaws. Meets in person as necessary (usually for recommendation to the Board of Directors. Meets monthly by teleconference and/or email to once per year) and by teleconference and email as Provides analysis to the Board and the membership plan. For more information, please contact MARN for recommendations; will also be meeting with at [email protected] or 617-990-2856: Attention Peggie Griffin Bretz. MARN Vision ANA Partners With 21 National Nursing Organizations To Statement Commission A Study Of Advanced Practice Registered VISION STATEMENT Nurses On Safety, Effectiveness And Quality Care MARN is committed to the advancement of nursing standards SILVER SPRING, MD—The American Nurse each aspect of the regulatory process for APRNs, and practice, and to continuing professional development of registered nurses across the Commonwealth who share the Association (ANA) is collaborating with nearly resulting in increased mobility, and will establish belief that greater achievement occurs in an environment that two dozen national nursing organizations to independent practice as the norm rather than the embraces mutual respect of diverse perspectives, a spirit of commission the first comprehensive study of its exception. This will support APRNs caring for collegiality, and the advocacy role of the nurse to individually kind in 20 years addressing the positive impact patients in a safe environment to the full potential and collectively shape quality health care. the 240,000 Advanced Practice Registered Nurses of their nursing knowledge and skill,” said ANA This contemporary organization provides a virtual home (APRNs) have on health care quality and patient President Rebecca M. Patton, MSN, RN, CNOR. for the nurturing and development of its membership. As a outcomes. Substantial challenges to educational constituent member of ANA, the membership proactively “An Assessment of the Safety, Quality, and expectations and certification requirements responds to regional and national issues in ways that produce Effectiveness of Care Provided by Advanced for APRNs, and the proliferation of nursing rippling outcomes in larger communities of professional nurses, health care decision makers, and citizens. Membership Practice Nurses,” for the first time, when specializations have sparked debates on initiatives serve to strengthen enduring partnerships with implemented by January 2009, will standardize appropriate credentials, scope of practice, and other stakeholders in health care. state-by-state regulation of nursing scope of practice. To that end, the consensus model for APRN regulation focuses on the regulation and credentialing of nurses. Though APRNs have been linked to improved access to health care services, enhanced patient safety, and cost-effective care, a contemporary systematic review is needed to gauge the overall impact these providers are having in today’s health care system. Researchers will examine research-based evidence connected to care provided by nurses in the four APRN roles—certified registered nurse anesthetist (CRNA), certified nurse- midwife (CNM), certified clinical nurse specialist (CNS), and certified nurse practitioner (CNP). Additionally, APRNs focus on at least one of six population foci: psych/mental health, women’s health, adult-gerontology, pediatrics, neonatal, or family. The American Nurses Association (ANA) has been an active participant in both the APRN Consensus Work Group and the subsequently formed Joint Dialogue Group. In addition to ANA, members of the Joint Dialogue Group are: the American Academy of Nurse Practitioners Certification Program, National Association of Clinical Nurse Specialists, American Association of Colleges of Nursing, American Association of Nurse Anesthetists, American College of Nurse- Midwives, American Organization of Nurse Executives, National Organization of Nurse Practitioner Faculties, National Council of State Boards of Nursing, National Council of State Boards of Nursing APRN Advisory Committee National League for Nursing Accrediting Commission and nursing compact administrators. December 2008 MAssachusetts Report on Nursing • Page 23 • MARN & ANA - A Partnership That Works For YOU! The American Nurses Association and MARN are an influential and effective network of registered nurses who support nursing. When you join MARN and ANA, you join with nurses around the country in speaking with one strong voice on behalf of your profession and health care. Together we can make a difference! As a full ANA/CMA member—you are a full voting member in the American Nurses Association and your state nurses association and entitled to valuable products and benefits that help you:

Be heard: advocating for nurses where it matters • Federal lobbying on issues important to nursing and health care—issues such as safe staffing, nursing workforce development, overtime pay and access to care. • State lobbying through our State Nurses Associations and nationwide state legislative agenda on issues vital to your scope of practice. • Representing nursing where it matters, including the Environmental Protection Agency, Department of Labor, the U.S. Department of Health and Human Services and many others, right up to the White House. • Speaking for nursing through the media including stories in the Wall Street Journal, Chicago Tribune, USA Today, 60 Minutes, NBC Nightly News, CNN, and NPR to name a few. • Speaking for U.S. nurses as the only U.S.A. member of the International Council of Nurses and attending meetings of the World Health Organization.

Guide the Profession: ensuring nursing quality and safety • Maintaining the Code of Ethics for Nurses which was first developed by ANA in 1926. • ANA develops and publishes the Scope and Standards of practice for nursing and many of its specialties. • Through the National Database on Nursing Quality Indicators, ANA is collecting data that link nurse staffing levels to quality nursing care. • Addressing workplace hazards such as back injuries, latex allergies, safe needles and workplace violence.

Influence Decisions: becoming involved • Join one of the many committees and boards at the national, state and local level that are shaping the direction of the association and the profession. • Participate in member surveys that let you influence the association’s agenda.

Save money: discounts and privileges for members. For more information, visit the ANA website http://www.nursingworld.org/member2.htm