The North Dakota Nurse - July 2022
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<strong>The</strong> <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong><br />
NORTH DAKOTA NURSES ASSOCIATION<br />
THE OFFICIAL PUBLICATION OF THE NORTH DAKOTA NURSES ASSOCIATION<br />
Sent to all <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong>s courtesy of the <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong>s Association (NDNA). Receiving this newsletter<br />
does not mean that you are a member of NDNA. To join please go to www.ndna.org and click on “Join.”<br />
Quarterly publication distributed to approximately 20,000 RNs and LPNs in <strong>North</strong> <strong>Dakota</strong><br />
Vol. 91 • Number 3 <strong>July</strong>, August, September <strong>2022</strong><br />
INDEX<br />
Message from the President<br />
Every Voice Matters<br />
Page 3<br />
August is National<br />
Breastfeeding Month<br />
Page 8<br />
NDNA Attends ANA Hill Day and<br />
Membership Assembly <strong>2022</strong><br />
Page 12<br />
Greetings <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong>s! We are<br />
advocates in so many ways. We know advocacy<br />
is defined as the act of pleading for or actively<br />
supporting a cause or proposal, but what we<br />
need to think about is what does that mean to<br />
us as nurses and more importantly to our patients<br />
we serve. According to Zolnierek, (2012) “<strong>The</strong><br />
American <strong>Nurse</strong>s Association’s Code of Ethics<br />
for <strong>Nurse</strong>s and Scope and Standards of Nursing<br />
Practice clearly identifies nurses’ ethical and<br />
professional responsibility for protecting the safety<br />
and rights of their patients; State nursing practice<br />
acts may establish a legal duty for patient<br />
advocacy as well” (p.1). We all need to consider if<br />
we are doing our part on a state level to fulfill that<br />
professional responsibility that we carry.<br />
Advocacy can mean many things in many<br />
different ways. Advocacy means using one’s<br />
position to support, protect, or speak out for the<br />
rights and interests of another. <strong>Nurse</strong>s have long<br />
claimed patient advocacy as fundamental<br />
to their practice. Since we have made this<br />
commitment to advocacy, others care what we<br />
have to say and that is why we need to speak<br />
to be heard. I am happy to report that just last<br />
week NDNA was able to meet with Congressmen<br />
in Washington to be advocates for some of the<br />
current most important health care issues.<br />
<strong>The</strong>re are many ways that we can speak<br />
to be heard. One of those ways is to start on a<br />
local level. <strong>The</strong>re are so many things we can<br />
do here in our home state in order to be heard.<br />
One of those ways is by joining NDNA/ANA and<br />
getting involved. Luckily NDNA has a voice<br />
at the table with the legislators in our state. By<br />
becoming a member of your local professional<br />
organization, you can have the opportunity<br />
to be heard and support our local platform<br />
of many nursing issues that arise. We are the<br />
experts and our legislators want to hear what<br />
we have to say. Of course,<br />
we all know that being<br />
an advocate isn’t always<br />
easy. It takes dedication,<br />
passion and love for our<br />
profession to continue to<br />
push forward.<br />
One misconception of<br />
nurses who do direct patient<br />
care is that they don’t have<br />
a voice; this couldn’t be<br />
more wrong. Direct-care<br />
Tessa Johnson<br />
MSN, BSN, RN,<br />
CDP, NDNA<br />
President<br />
nurses are poised especially well to identify and<br />
speak up about conditions that may result in near<br />
misses or actual adverse events. Cultures of safety<br />
promote and encourage staff to raise issues,<br />
yet most workplace cultures are imperfect, and<br />
nurses may face challenges in their advocacy<br />
efforts (Zolnierek, P. 1). This is when we find an<br />
internal struggle about what has been normal to<br />
us in some environment and when we know we<br />
need to speak up and make a change.<br />
One of the benefits of being involved in a<br />
group such as a professional association is<br />
you have support and a unified voice. We all<br />
know that nurses may fear retaliation and lack<br />
knowledge about established processes and<br />
protections for patient advocacy activities.<br />
Raising a concern disrupts the status quo<br />
and challenges the organization to confront<br />
problems. This, my friends, is EXACTLY what we<br />
need; we must challenge and disrupt the status<br />
quo to ensure we are always advocating for<br />
the best possible care for the patients we serve.<br />
I encourage you all to find a way that works for<br />
you to get involved. Be well, we need all of you!!!<br />
Zolnierek, C. (2012). Speak to be Heard. American<br />
<strong>Nurse</strong> Today, 7(10), 1-3. Retrieved June 13, 2018,<br />
from https://www.americannursetoday.com/<br />
speak-to-be-heard-effective-nurse-advocacy/.<br />
current resident or<br />
Presort Standard<br />
US Postage<br />
PAID<br />
Permit #14<br />
Princeton, MN<br />
55371
Page 2 <strong>The</strong> <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong> <strong>July</strong>, August, September <strong>2022</strong><br />
How to submit an article for<br />
<strong>The</strong> <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong>!<br />
<strong>Nurse</strong>s are strongly encouraged to contribute to the profession<br />
by publishing evidence-based articles; however, anyone is<br />
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Deadline for submission for the next issue is 9/6/<strong>2022</strong>.<br />
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<strong>The</strong> <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong><br />
Official Publication of:<br />
<strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong>s Association<br />
General Contact Information:<br />
701-335-6376 (NDRN)<br />
director@ndna.org<br />
Board of Directors and Staff<br />
President<br />
Tessa Johnson, MSN, BSN, RN, CDP<br />
President-Elect<br />
Mylynn Tufte, MBA, MSIM, RN<br />
Vice President of Finance<br />
Richelle Johnson, MSN, RN<br />
Director of Membership<br />
Kami Schauer, MSN, RN, CGMT-BC<br />
Director of Education and Practice<br />
Beth Sanford, MSN, RN, ACN, CLC<br />
Director of Advocacy<br />
Penny Briese, PhD, RN<br />
Director at Large<br />
VACANT<br />
Affiliate Member Representative (LPN)<br />
Catherine Sime, LPN<br />
Staff: Executive Director<br />
Sherri Miller, BS, BSN, RN<br />
Please go to our website to learn more about the<br />
board and their roles: www.ndna.org<br />
Published quarterly: January, April, <strong>July</strong>, and October<br />
for the <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong>s Association, a constituent<br />
member of the American <strong>Nurse</strong>s Association, 1515 Burnt<br />
Boat Dr. Suite C #325, Bismarck, ND 58503. Copy due<br />
four weeks prior to month of publication. For advertising<br />
rates and information, please contact Arthur L. Davis<br />
Publishing Agency, Inc., PO Box 216, Cedar Falls, Iowa<br />
50613, (800) 626-4081, sales@aldpub.com. NDNA and the<br />
Arthur L. Davis Publishing Agency, Inc. reserve the right<br />
to reject any advertisement. Responsibility for errors in<br />
advertising is limited to corrections in the next issue or<br />
refund of price of advertisement.<br />
Acceptance of advertising does not imply endorsement<br />
or approval by the <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong>s Association<br />
of products advertised, the advertisers, or the claims<br />
made. Rejection of an advertisement does not imply a<br />
product offered for advertising is without merit, or that<br />
the manufacturer lacks integrity, or that this association<br />
disapproves of the product or its use. NDNA and the Arthur<br />
L. Davis Publishing Agency, Inc. shall not be held liable for<br />
any consequences resulting from purchase or use of an<br />
advertiser’s product. Articles appearing in this publication<br />
express the opinions of the authors; they do not necessarily<br />
reflect views of the staff, board, or membership of NDNA or<br />
those of the national or local associations.<br />
Want to Make Your Nursing Voice<br />
Heard…Get Published in the<br />
<strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong>!<br />
<strong>The</strong> <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong> quarterly publication accepts<br />
content on a variety of topics related to nursing. <strong>Nurse</strong>s<br />
are strongly encouraged to contribute to the profession<br />
by publishing evidence-based articles, but we welcome<br />
anyone to submit for publication. If you have an idea,<br />
but don’t know how or where to start, contact one of<br />
the NDNA Board Members.<br />
Please note:<br />
*Send articles to director@ndna.org<br />
*Articles should be in Microsoft Word and be double<br />
spaced.<br />
*All articles should have a title.<br />
*Articles sent should have the words “<strong>North</strong> <strong>Dakota</strong><br />
<strong>Nurse</strong> Article” in the email subject line, along with the<br />
specific title.<br />
*Deadline for submission of material for upcoming<br />
<strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong> is 9/6/<strong>2022</strong>!<br />
<strong>The</strong> Vision and Mission of the<br />
<strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong>s Association<br />
Vision: <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong>s Association, a<br />
professional organization for <strong>Nurse</strong>s, is the voice of<br />
Nursing in <strong>North</strong> <strong>Dakota</strong>.<br />
Mission: <strong>The</strong> <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong>s Association (NDNA)<br />
is the only professional organization representing all nurses<br />
in <strong>North</strong> <strong>Dakota</strong>. <strong>The</strong> mission of NDNA is to advance the<br />
nursing profession by promoting professional development<br />
of nurses, fostering high standards of nursing practice,<br />
promoting the safety and well-being of nurses in the<br />
workplace, and by advocating on health care issues<br />
affecting nurses and the public.
<strong>July</strong>, August, September <strong>2022</strong> <strong>The</strong> <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong> Page 3<br />
Instilling Hope<br />
Sheri Gunderson, MS, RN, CNE,<br />
Assistant Professor of Nursing,<br />
University of Jamestown<br />
As a nurse you have seen the dejected look, heard the discouraging<br />
story, and tasted the bitterness of unfairness. In your heart you felt the<br />
person’s sadness and mirrored it in your face. Your empathetic and<br />
supportive touch have been the unspoken words of empathy and<br />
presence. Depression, grief, or fresh disability put a person’s focus on<br />
present circumstances and not the future, or if the person considers the<br />
future it seems bleak without colors of quality and not what the person<br />
wants to happen.<br />
Hope is defined as a verb, “to desire with expectation of obtainment<br />
or fulfillment,” and as a noun, “desire accompanied by expectation of or<br />
belief in fulfillment” per Merriam-Webster. You may experience a patient<br />
who either does not have hope, or is not hoping for a future. But to be<br />
mentally healthy a person needs to stretch their thoughts to hope, so<br />
here are a few steps to accomplish this:<br />
1. Provide an environment of openness: don’t deny the person’s<br />
feelings of sadness, anger, frustration, or grief, but instead encourage<br />
the person to express those emotions. “<strong>The</strong> outward expression of<br />
positive emotion has been repeatedly associated with better health<br />
outcomes,” (Tuck, Adams, & Consedine, 2017, p. 503) When you hear<br />
and see emotion your nursing active listening response should be to<br />
name the emotion(s) and include the story content. If the person denies<br />
your interpretation, this is beneficial because further clarification and<br />
explanation will occur. Through these interactions the person will often<br />
feel validated and more open to continue discussion. For Christians you<br />
could encourage reading the Psalms which include many emotions<br />
which the person may relate to while also gaining strength from the<br />
author’s faith. “Why, my soul, are you downcast? Why so disturbed within<br />
me? Put your hope in God,“ Psalm 42:11a. Situations may leave your<br />
patient reeling on a roller coaster of emotions and they need to realize<br />
this is normal.<br />
2. Find capabilities and strengths: listen for past interests and look for<br />
remaining abilities so you can assist the person with imagining a future<br />
worth living. Hope is found in discussion of plans for the future. Often<br />
your experience with other patients will assist you in reflecting possibilities<br />
available. It is important to hear the person’s interests and passions so<br />
you can help envision use of these, even if in a modified way related to<br />
disability or loss. When I was a hospice nurse I found that patients would<br />
sometimes paint an unrealistic future based on prognosis, but instead of<br />
challenging these plans I would try to ensure that some shorter term or<br />
modified goals were met. For those with longer futures the realization of<br />
small goals helps with stretching out the horizons of the mind. Children<br />
with disabilities and nursing home residents have taught me that new<br />
accomplishments are to be celebrated no matter the age or speed of<br />
attainment.<br />
3. Offer resources: Usually the person without hope feels alone or that<br />
others don’t understand. “Numerous studies have supported the finding<br />
that being socially excluded is psychologically and physically aversive,”<br />
(Hitlan, 2020, p. 309). While no one can feel exactly what the person is<br />
feeling, often an in-person group or online organization related to the<br />
diagnosis or loss will provide support and ability to talk/chat/blog on<br />
frustrations and adaptations. Comradery may be found by chance<br />
while in the waiting room for medical appointments, but the nurse can<br />
facilitate friendships with like people by making referrals or providing<br />
websites. Beyond emotional support, financial and educational supports<br />
can open doors for using capabilities. You may feel overwhelmed by a<br />
patient’s dreams combined with limitation, but your communication<br />
with the healthcare team may start the ball rolling. Social workers and<br />
physical/occupational therapists have a wealth of knowledge to assist<br />
with finding resources. One resource example is Make-a-wish that<br />
you may think of as just one-time trip givers, but some children receive<br />
adapted equipment to improve quality of life.<br />
4. Support faith: Hope may not be in earthly things, but in a heavenly<br />
future where there won’t be tears or fears. Offering prayer can help a<br />
person see that God is in control and planning for the future. As a<br />
hospice nurse I often saw that despite my best efforts during a visit, it was<br />
not until I offered prayer that I truly saw the person become peaceful as<br />
if a heavy weight was lifted from their shoulders. Allow and encourage<br />
chaplain, pastor, priest, or spiritual faith leader visits as an important<br />
part of holistic health care. Some people will find that an encouraging<br />
phrase, or motto, becomes the spark for glimmers of hope. If the person<br />
is Christian, then Bible verses can be a foundation for building hope: “But<br />
those who hope in the LORD will renew their strength,” Isaiah 40:31a, NIV;<br />
“For I know the plans I have for you declares the Lord, plans to prosper<br />
you and not to harm you, plans to give you hope and a future, Jeremiah<br />
29:11, NIV; “For with God nothing shall be impossible,” Luke 1:37, KJV; and<br />
“May the God of hope fill you with all joy and peace as you trust in him,<br />
so that you may overflow with hope by the power of the Holy Spirit,”<br />
Romans 15:13.<br />
Whether this article made you think of a patient, colleague, nursing<br />
student, or acquaintance, I encourage you to be a Hope Builder!<br />
Hitlan, R. (2020). Social exclusion and health: <strong>The</strong> buffering effects of perceived<br />
social support. <strong>North</strong> American Journal of Psychology, 22(3), 309-330.<br />
Tuck, N., Adams, K., & Consedine, N. (2017). Does the ability to express different<br />
emotions predict different indices of physical heath? A skill-based study<br />
of physical symptoms and health rate variability. British Journal of Health<br />
Psychology, 22(3), 502-523.
Page 4 <strong>The</strong> <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong> <strong>July</strong>, August, September <strong>2022</strong><br />
Palliative Care Awareness and Education in <strong>North</strong> <strong>Dakota</strong><br />
Nancy E. Joyner, MS, CNS-BC, APRN, ACHPN®<br />
National Palliative Care Definition<br />
A definition of palliative case was identified<br />
by the Center to Advance Palliative Care (n.d.)<br />
as follows:<br />
Palliative care is specialized medical care<br />
for people living with a serious illness.<br />
This type of care is focused on providing<br />
relief from the symptoms and stress of<br />
the illness. <strong>The</strong> goal is to improve quality<br />
of life for both the patient and the family.<br />
Palliative care is provided by a specially<br />
trained team of doctors, nurses and other<br />
specialists who work together with a<br />
patient’s other doctors to provide an extra<br />
layer of support. Palliative care is based<br />
on the needs of the patient, not on the<br />
patient’s prognosis. It is appropriate at any<br />
age and at any stage in a serious illness,<br />
and it can be provided along with curative<br />
treatment. (para. 2)<br />
Background of Palliative Care Awareness in<br />
<strong>North</strong> <strong>Dakota</strong><br />
On May 19, 2015, “Quality Care with Palliative<br />
Care in Cancer” was presented at the <strong>North</strong><br />
<strong>Dakota</strong> Cancer Coalition annual meeting<br />
in Bismarck. <strong>The</strong>re was discussion on how<br />
palliative care could be added to the qualityof-life<br />
aspect of the ND Cancer Control Plan.<br />
In October 2015, American Cancer Society/<br />
Cancer Action Network’s (ACS/CAN) <strong>North</strong><br />
<strong>Dakota</strong> Cancer Summit focused on palliative<br />
care.<br />
During the 2016 ND Cancer Coalition annual<br />
meeting, a dedicated breakout time was<br />
palliative care. Most attendees did not know<br />
exactly what palliative care is, where palliative<br />
care services were being provided across the<br />
state, and what services were provided. To<br />
understand the status of palliative care in <strong>North</strong><br />
<strong>Dakota</strong>, it was decided by those attending the<br />
breakout session to conduct a statewide survey<br />
of health care facilities and programs to include<br />
any diseases that could benefit from palliative<br />
care. To begin the process, a small group of<br />
individuals convened to develop and deploy<br />
this survey. Members of this survey workgroup,<br />
representing state programs, included:<br />
• Lynette Dickson (ND Center for Rural<br />
Health)<br />
• Sally May (Quality Health Associates &<br />
Honoring Choices® <strong>North</strong> <strong>Dakota</strong>)<br />
• Nancy Joyner (Nancy Joyner Consulting)<br />
• Sara McGaurvran and Deb Knuth (ACS/<br />
CAN)<br />
• Joyce Sayler (ND Dept. of Health)<br />
Goals of the survey were to:<br />
• increase awareness of and access to<br />
palliative care in <strong>North</strong> <strong>Dakota</strong> where<br />
current gaps exist and<br />
• develop a baseline for ND palliative care<br />
services.<br />
<strong>The</strong> survey demonstrated more awareness<br />
and education was needed throughout <strong>North</strong><br />
<strong>Dakota</strong>. ACS Cancer Action Network sought<br />
support from the legislature to assemble an<br />
advisory committee, focused on palliative<br />
care needs in the state. In 2017, Senator Judy<br />
Lee reached out to Tracee Capron (Hospice<br />
of the Red River Valley) and Patricia Moulton<br />
(ND Center for Nursing) to assist with the<br />
2017 Resolution 4010. <strong>The</strong> formation of state<br />
palliative care legislation would maximize the<br />
effectiveness of palliative care initiatives in the<br />
state by:<br />
• providing substantial cost reduction and<br />
• improving awareness, education, and<br />
workforce about palliative care<br />
<strong>The</strong> goal of this work was to adapt the<br />
taskforce into action-oriented workgroups of<br />
statewide partners, addressing the palliative<br />
care needs in ND.<br />
On June 27, 2017, a face-to-face meeting was<br />
held in Fargo at Hospice of the Red River Valley.<br />
Presenters were:<br />
• Nancy Joyner – Palliative Care Survey<br />
results and finds<br />
• Donelle Richmond – ANA palliative Care<br />
paper<br />
• Deb Knuth – SCR 4010<br />
• Lynette Dickson – Community needs<br />
assessment<br />
• Judy Beck – ND statistics<br />
<strong>North</strong> <strong>Dakota</strong> Palliative Care Taskforce<br />
<strong>The</strong> <strong>North</strong> <strong>Dakota</strong> Palliative Care Taskforce<br />
(NDPCTF) (<strong>2022</strong>) assembled workgroups,<br />
focused on palliative care access, awareness,<br />
and needs in the state:<br />
• Provider Education<br />
• Access and Reimbursement<br />
• Definition and Community Awareness<br />
Provider Education Workgroup Members<br />
Name<br />
Donelle Richmond<br />
Doris Vigen<br />
Discipline, Representing/<br />
Organization<br />
APRN, Fargo, Sanford<br />
RN, Mayville, ND Center<br />
for Nursing/Sanford<br />
Mayville<br />
Judy Beck<br />
Karen Semmens<br />
Kris Hendrickx<br />
Nancy Joyner<br />
Tracee Capron<br />
Liz Sterling- chair<br />
Phyllis Heyne-<br />
Lindholm<br />
Jesse Tran<br />
Sara Anderson<br />
Minot, Quality<br />
Improvement Program<br />
Manager<br />
APRN, Grand Forks, UND<br />
APRN, Grand Forks, UND<br />
APRN, Grand Forks,<br />
Nancy Joyner Consulting<br />
RN, MAOL, Fargo,<br />
Hospice of the Red River<br />
Valley<br />
RN, Fargo, Hospice of the<br />
Red River Valley<br />
PT, DPT, Bismarck, St.<br />
Alexius<br />
PhD, Bismarck, NDDOH<br />
Comprehensive Cancer<br />
Control Program Director<br />
ASC Cancer Action<br />
Network ND<br />
<strong>The</strong> Provider Education Work Group’s task<br />
was to make recommendations to improve<br />
access to information that will enhance the<br />
understanding of palliative care by providers<br />
in all areas of <strong>North</strong> <strong>Dakota</strong>. <strong>The</strong> group also<br />
hoped to increase opportunities for members<br />
of academia to disseminate information to<br />
professionals in the state. <strong>The</strong> work group<br />
members met over the past year and would like<br />
to make the following recommendations to the<br />
task force.<br />
Key Topics:<br />
• Access to educational information: RHIHub,<br />
Center for Rural Health, was deemed<br />
necessary.<br />
• <strong>The</strong> platform will provide information<br />
that is current by designating a plan or<br />
organization to check the site at least<br />
annually.<br />
• <strong>The</strong>re is a responsible group to update the<br />
information–consider the <strong>North</strong> <strong>Dakota</strong><br />
Hospice Association.<br />
• <strong>The</strong> platform has flexibility to house<br />
relevant education and training<br />
opportunities<br />
• Interface with academia needed to be<br />
considered.<br />
• UND College of Nursing in this workgroup<br />
will consider:<br />
• Develop programming for students<br />
• Program information in the form of<br />
posters or other presentations, and<br />
• Shared at state conferences or<br />
professional meetings.
<strong>July</strong>, August, September <strong>2022</strong> <strong>The</strong> <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong> Page 5<br />
<strong>The</strong> following items also need to be<br />
considered:<br />
• Professional training opportunities for<br />
healthcare<br />
• End of Life Nursing Education Consortium<br />
training modules<br />
• Clinical specialties–individual training<br />
requirements<br />
• Directed by national professional<br />
organizations<br />
• Center for Rural Health Project ECHO<br />
• Implement standard education for<br />
providers<br />
Access and Reimbursement Workgroup<br />
Members<br />
Name<br />
Tracy Freidt<br />
Deb Knuth<br />
Shannon Bacon<br />
Nick Hillman<br />
Nancy Joyner<br />
Tim Blasl<br />
Jean Roland<br />
Courtney Vroman<br />
Tracee Capron<br />
Sue Heitkampchair<br />
Lynette Dickson<br />
Courtney Koebele<br />
Discipline, Representing/<br />
Organization<br />
RN, Bismarck, Sanford<br />
ACS Cancer Action<br />
Network ND<br />
ACS Cancer Action<br />
Network ND<br />
RN, Bismarck, Sanford<br />
APRN, Grand Forks,<br />
Nancy Joyner Consulting<br />
President, Bismarck,<br />
NDHA<br />
Minot, Quality<br />
Improvement Program<br />
Manager<br />
Fargo, Hospice of the Red<br />
River Valley<br />
RN, MAOL, Fargo, Hospice<br />
of the Red River Valley<br />
RN, CHI, Fargo<br />
MS, RD, LRD, Associate<br />
Director, State Office of<br />
Rural Health, CRH, GF<br />
JD, ND Medical<br />
Association- Bismarck<br />
Types of Palliative Care to Access<br />
• Community-based care includes a variety<br />
of models of care designed to meet the<br />
needs of seriously ill individuals and their<br />
families, outside of the hospital setting:<br />
• Independent entity<br />
• Affiliated with health system or hospital<br />
• Separate Business Line of Hospice or<br />
Home Health agency<br />
• Affiliated with physician practice.<br />
• Hospital-based:<br />
• Consult services<br />
• In-patient<br />
Increase Access (community/providers), using<br />
GetPalliativeCare.org provider directory tool.<br />
• <strong>The</strong> Community HealthCare Association<br />
of the <strong>Dakota</strong>s (CHAD) will share where<br />
current palliative care is offered.<br />
Reimbursement<br />
• Many private insurance companies and<br />
health maintenance organizations (HMOs)<br />
have some benefit, mostly fee for service<br />
for providers.<br />
• In 2017, extra Medicare plan (Part B)<br />
offered some palliative care benefits.<br />
• Medicaid coverage of hospice and<br />
palliative care for people of limited<br />
incomes varies by state<br />
• Fee for service, shared savings, or<br />
capitated payment model<br />
• Endowments, grants, or fundraising<br />
• Financial contributions<br />
• Risk Sharing arrangements<br />
• Single-Payer<br />
• Accountable Care Organizations (ACO)<br />
Definition and Community Awareness<br />
Workgroup Members<br />
Name<br />
Caleb Christiansen<br />
Trina Kaiser<br />
Discipline, Representing/<br />
Organization<br />
Hospice of the Red River<br />
Valley, Fargo<br />
MD, Bismarck, Primecare<br />
Rochelle Schaffer<br />
Shannon Feistchair<br />
Katie Ambuehl<br />
Kristi McCarty<br />
Mary Sahl<br />
Nancy Joyner<br />
Tammy <strong>The</strong>urer<br />
<strong>The</strong>resa Behrens<br />
Joyce Sayler<br />
Tracee Capron<br />
RN, Bismarck, Hospice<br />
Sanford<br />
APRN, Bismarck, Sanford<br />
LSW, Fargo, Essentia<br />
-Memory Care of the RR<br />
Valley<br />
DON, Jamestown,<br />
Sisters of Mary of the<br />
Presentation Health<br />
System<br />
<strong>Nurse</strong> Educator,<br />
Harwood, Sanford<br />
APRN, Grand Forks,<br />
Nancy Joyner Consulting<br />
Director, Bismarck, CHI<br />
RN, Fargo, Sanford<br />
Hospice<br />
ND DOH, Bismarck<br />
RN, MAOL, Fargo, Hospice<br />
of the Red River Valley<br />
• Standard definitions to define palliative<br />
care and hospice (Created by the NDPCTF<br />
Definition Workgroup, posted on the<br />
Center for Rural Health website, 2020)<br />
• Comparison table to show the similarities/<br />
distinctions<br />
• Diagram to show the progression of care<br />
over time<br />
• A wider range of learning styles<br />
• Some type of logo for the NDPCTF<br />
Palliative Care Education in <strong>North</strong> <strong>Dakota</strong><br />
In 2017, Stratis Health Project (2017-2020),<br />
originally the <strong>North</strong> <strong>Dakota</strong> Rural Community-<br />
Based Palliative Care project, was chosen<br />
by Stratis Health for a multi-state effort to<br />
increase access to palliative care services in<br />
rural communities. <strong>North</strong> <strong>Dakota</strong>, Wisconsin,<br />
Minnesota, and Washington collaborated in<br />
this multi-faceted project to increase access to<br />
palliative care services in rural communities and<br />
improve quality of life and quality of care for<br />
those with advanced illness and complex care<br />
needs.<br />
• <strong>North</strong> <strong>Dakota</strong> Rural Community-Based<br />
Palliative Care project was chosen by<br />
Stratis Health (<strong>2022</strong>) for a multi-state effort<br />
• Tiered approach: Washington, <strong>North</strong><br />
<strong>Dakota</strong> and Wisconsin<br />
• Based on Rural Community-based<br />
Palliative Care Toolkit being developed<br />
<strong>The</strong> following goals were developed:<br />
• Increase access to palliative care services<br />
in rural communities<br />
• Improve quality of life and quality of<br />
care for those with advanced illness and<br />
complex care needs.<br />
In 2018, a new serious illness definition<br />
emerged with new messaging, which reads,<br />
“A health condition that carries a high risk<br />
of mortality and either negatively impacts<br />
a person’s daily function or quality of life or<br />
excessively strains their caregiver” (Kelley &<br />
Bollens-Lund, 2018, para. 7). This is the definition<br />
of ‘Serious Illness’ that is used in the 4th edition<br />
of the National Consensus Project Guidelines<br />
for Quality Palliative Care (NCP) was critical in<br />
removing prognosis and lessening end-of-life/<br />
hospice mindset to defining palliative care.<br />
During this time, the Center for Rural Health’s<br />
Flex Program appropriated grant funds through<br />
August <strong>2022</strong> to promote statewide palliative<br />
care by:<br />
Full or Part Time RN or LPN<br />
Wages depend on experience<br />
Starting LPN $24.85/hr • RN $31.81/hr<br />
For More Information Contact<br />
Kasey Brandenburger, RN DON<br />
kasey.brandenburger@stgerards.org<br />
701-242-7891<br />
St. Gerard’s Community of Care • Hankinson, ND<br />
Stgerards.org<br />
• Offering ND POLST CME on demand online,<br />
• Offering monthly ND POLST CE live virtually,<br />
• Providing ongoing Project ECHO sessions:<br />
Organizing Palliative Care for Rural<br />
Populations TeleECHO, and<br />
• Expanding rural community-based<br />
palliative care throughout ND.<br />
When the COVID pandemic emerged<br />
in 2020, the NDPCTF efforts were paused.<br />
However, in November 2021, a renewed<br />
interest in ND’s Palliative care awareness and<br />
education emerged. <strong>North</strong> <strong>Dakota</strong>’s state<br />
senator Judy Lee and State Health Officer Dr.<br />
Nizar Wehbi have joined forces to assist in the<br />
National Academy for State Health Policy’s<br />
efforts to build and support Palliative Care.<br />
Call to Action<br />
Your help is needed. Please unite the efforts<br />
in advancing palliative care awareness,<br />
education, and implementation by joining the<br />
ND Palliative Care Taskforce and share with<br />
others.<br />
Reference<br />
Kelley, A. S., & Bollens-Lund, E. (2018). Identifying the<br />
population with serious illness: <strong>The</strong> "denominator"<br />
challenge. Journal of Palliative Medicine, 21(S2),<br />
S7–S16. https://doi.org/10.1089/jpm.2017.0548<br />
Resource Links<br />
Center to Advance Palliative Care (CAPC):<br />
https://www.capc.org/<br />
Center for Rural Health: https://ruralhealth.<br />
und.edu/assets/746-17373/palliative-hospicecare-flyer.pdf<br />
Get Palliative Care.org: https://<br />
getpalliativecare.org/<br />
National Academy for State Health Policy/<br />
Palliative Care: https://www.nashp.org/<br />
palliative-care/<br />
<strong>North</strong> <strong>Dakota</strong> Palliative Care Taskforce:<br />
https://www.qualityhealthnd.org/contracts/<br />
palliative-care-task-force/<br />
Palliative Care or Hospice Care Flyer<br />
(Created by the NDPCTF): https://ruralhealth.<br />
und.edu/assets/746-17373/palliative-hospicecare-flyer.pdf<br />
<strong>North</strong> <strong>Dakota</strong> POLST Awareness, Education,<br />
and Implementation CE: https://www.<br />
honoringchoicesnd.org/event/polst-awarenesseducation-and-implementation-10/<br />
Rural Health Information Hub (RHIHub)/<br />
palliative care: https://www.ruralhealthinfo.org/<br />
search?q=palliative+care<br />
UND’s Project ECHO/ Palliative Care: https://<br />
ruralhealtAwh.und.edu/projects/project-echo/<br />
topics/palliative-care
Page 6 <strong>The</strong> <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong> <strong>July</strong>, August, September <strong>2022</strong><br />
Telehealth Interventions in the Management of Diabetes<br />
Appraised by:<br />
Amanda Papke SN Alyssa Dailey SN, Tayla Gange SN, Tierrany Trudell<br />
SN, , Wallen Masiasa SN, Jonathan Gallagher SN<br />
Allison Sadowsky MSN RN Assistant Professor of Practice (Faculty)<br />
(NDSU School of Nursing at Sanford Health Bismarck)<br />
Clinical Question:<br />
In diabetic patients, what is the effect of telehealth interventions on<br />
patient health outcomes?<br />
Sources of Evidence:<br />
Anderson, A., O’Connell, S.S., Thomas, C., & Chimmanamada, R. (2021).<br />
Telehealth Interventions to Improve Diabetes Management Among Black<br />
and Hispanic Patients: A Systematic Review and Meta-Analysis. Journal of<br />
Racial and Ethnic Health Disparities (<strong>2022</strong>). https://doi.org/10.1007/s40615-<br />
021-01174-6<br />
Baron, J. S., Hirani, S., & Newman, S. P. (2016). A randomized, controlled<br />
trial of the effects of a mobile telehealth intervention on clinical and<br />
patient-reported outcomes in people with poorly controlled diabetes.<br />
Journal of Telemedicine and Telecare, 23(2), 207–216. https://doi.<br />
org/10.1177/1357633x16631628<br />
Eberle, C., & Stichling, S. (2021). Clinical Improvements by Telemedicine<br />
Interventions Managing Type 1 and Type 2 Diabetes: Systematic Metareview.<br />
Journal of medical Internet research, 23(2), 23244. https://doi.<br />
org/10.2196/23244<br />
Wild, S. H., Hanley, J., Lewis, S. C., McKnight, J. A., McCloughan, L. B., Padfield, P.<br />
L., Parker, R. A., Paterson, M., Pinnock, H., Sheikh, A., & McKinstry, B. (2016).<br />
Correction: Supported telemonitoring and glycemic control in people with<br />
type 2 diabetes: <strong>The</strong> Telescot diabetes pragmatic multicenter randomized<br />
controlled trial. PLOS Medicine, 13(10). https://doi.org/10.1371/journal.<br />
pmed.1002163<br />
Wong, V. W., Wang, A., & Manoharan, M. (2021). Utilization of telehealth for<br />
outpatient diabetes management during COVID-19 pandemic: How did<br />
the patients fare? Internal Medicine Journal, 51(12), 2021–2026. https://doi.<br />
org/10.1111/imj.15441<br />
Zhai, Y. K., Zhu, W. J., Cai, Y. L., Sun, D. X., & Zhao, J. (2014). Clinical- and costeffectiveness<br />
of telemedicine in type 2 diabetes mellitus: a systematic<br />
review and meta-analysis. Medicine, 93(28), e312. https://doi.org/10.1097/<br />
MD.0000000000000312<br />
Synthesis of Evidence:<br />
Six articles were reviewed as evidence in this report. <strong>The</strong> articles<br />
included three systematic reviews, a quasi-experimental, and two<br />
single randomized controlled trials. In patients with chronic conditions,<br />
there are various barriers that inhibit management of their disease.<br />
Determining these barriers and researching alternative interventions is<br />
necessary in improving clinical and patient-reported outcomes.<br />
Baron and Newman (2016) conducted a randomized controlled trial<br />
to examine the effects of mobile telehealth on a range of clinical and<br />
patient reported outcomes. <strong>The</strong> study included 81 participants who<br />
were patients diagnosed with type 1 or type 2 diabetes. <strong>The</strong> participants<br />
exchanged medical information daily, including blood glucose and<br />
blood pressure, with the telehealth nurse using a mobile device that<br />
transmitted the data to a web server where it was accessed and<br />
reviewed by the telehealth nurse. Feedback was provided to the patient<br />
based on the transmitted data. Variables such as hemoglobin A1c,<br />
blood pressure, daily insulin doses, and patient-reported outcomes were<br />
studied. <strong>The</strong> results conclude that participants who received access to<br />
the mobile telehealth intervention reported a significant increase in<br />
quality of life, improvement in hemoglobin A1c and a decrease in both<br />
systolic and diastolic blood pressures. Hemoglobin A1c decreased in the<br />
intervention group from an average of 9.07 at baseline to 8.56 at nine<br />
months. Average hemoglobin A1c increased in the control group from<br />
8.88 at baseline to 8.93 at nine months.<br />
Eberle and Stichling (2021) conducted a systematic meta-review of<br />
31 studies. Including 21 SR & MA, 8 RCT, 1 non-RCT, and one qualitative<br />
study. <strong>The</strong>se studies used the intervention of telehealth in various ways<br />
such as text messaging, telephone calls, video conferences, to email.<br />
Patients with type 1 and type 2 diabetes were studied with these clinical<br />
outcomes in mind: HbA1C, FBG (fasting blood glucose), BP, body weight,<br />
BMI, health-related quality of life (HRQoL), diabetes-related quality of<br />
life (DRQoL), cost effectiveness, and time saving. <strong>The</strong> results concluded<br />
a significant improvement in HbA1C. <strong>The</strong>re were also noted positive<br />
effects on BP, FBG, body weight, BMI, DRQoL, HRQoL, time saving, and<br />
cost effectiveness using an intervention of telemedicine to find these<br />
outcomes.<br />
Wild & Hanley (2016) conducted a randomized, parallel, investigatorblind<br />
controlled trial with centralized randomization of 321 people<br />
diagnosed with type 2 diabetes and glycated hemoglobin (HbA1c)<br />
greater than 58 mmol/mol. Patients self-monitored and transmitted their<br />
blood sugar levels to a secure website twice weekly during the morning<br />
and evening. Individuals in the intervention group had a decrease in<br />
HbA1c and Blood Pressure compared to the control group. <strong>The</strong> results<br />
showed that the monitored group HbA1c decreased by 5.60 mmol/mol /<br />
0.51% lower compared with the control group. <strong>The</strong> systolic BP decreased<br />
by 3.06 mmHg & diastolic BP decreased by 2.17 mmHg in the<br />
interventional group compared to the control group. This study showed<br />
that telemonitoring and supported self-management of blood glucose<br />
can result in clinically meaningful improvements in blood glucose among<br />
people with poorly controlled type 2 diabetes.<br />
Anderson, O’Connell, Thomas, and Chimmanamada (2021)<br />
conducted a systematic review and meta-analysis of randomized<br />
controlled trials including nine studies. <strong>The</strong> review and analysis of the<br />
nine studies were used to evaluate the effectiveness of telehealth<br />
interventions aimed at improving HbA1c values among Black and<br />
Hispanic patients with type 2 diabetes connected to primary care.<br />
Telehealth interventions were health care, health education, and health<br />
information services by remote technologies. <strong>The</strong> clinical effectiveness<br />
was aimed at evaluating the hemoglobin A1c pre- and post-telehealth<br />
intervention. <strong>The</strong> major findings indicated a net change decreased by<br />
-0.47%, this is a significant change in this case. <strong>The</strong>se findings suggest<br />
telehealth interventions can be effective at improving glycemic control<br />
among Black and Hispanic diabetes patients.<br />
Zhai, Zhu, Cai, Sun, & Zhao (2014) conducted a systemic Review and<br />
Meta-analysis of 35 randomized controlled studies tied to patients with<br />
type 2 diabetes who were 18 years or older and receiving insulin or oral<br />
diabetic drugs. <strong>The</strong> sample size ranged from 13-844 individuals from<br />
various health care settings. <strong>The</strong> purpose of the study was to evaluate<br />
the clinical effectiveness and cost effectiveness of telemedicine<br />
approaches on glycemic control in patients with type 2 diabetes mellitus.<br />
After implementing the telehealth interventions which included virtual<br />
visits, telephone calls, and website check ins, A1C improved from 6.4-<br />
11.2 to 6.4-8.7. <strong>The</strong> intervention also revealed institute for clinical and<br />
economic review (ICER) of $491 and $29,869 per capita for each unit<br />
reduction in HbA1c, for the telephone and internet base interventions.<br />
Wong, Wang, and Manoharan (2021) conducted a quasiexperimental,<br />
retrospective review of electronic medical records (EMRs)<br />
of 629 outpatient diabetic patients from two major hospitals in Sydney,<br />
Australia for a five-month period. Years reviewed were 2019 and 2020.<br />
Methods used for telehealth consultations consisted of voice calls,<br />
video calls, and sending blood glucose level results electronically. <strong>The</strong><br />
review found that the attendance rate improved from 85.2% to 88.9%,<br />
HbA1c improved from 8.2 to 7.8. <strong>The</strong>re was no statistical significance in<br />
unplanned admissions from 75 readmissions to 58 admissions after the<br />
telehealth interventions were implemented, albeit it improved. HbA1c<br />
was collected one year prior to 2019, one visit prior to the COVID-19<br />
pandemic, and one visit a year after their pre-virtual management<br />
period.<br />
Conclusion:<br />
All six articles supported the use of mobile telehealth interventions in the<br />
care management of patients with diabetes. Five of the six articles showed<br />
clinically significant changes in the hemoglobin A1c (HbA1c), while one<br />
article showed a marginal change in the HbA1c. Across the studies, the<br />
most commonly used modes of telehealth include video conferencing,<br />
telephone calls, texting, and internet programs. <strong>The</strong> evidence suggests<br />
these interventions lead to effective management of diabetes.<br />
Implications for Nursing Practice:<br />
Diabetes is a chronic condition that can have long-lasting effects<br />
on patients. <strong>The</strong> effects the interventions have on diabetic patients<br />
would be beneficial in effectively improving hemoglobin A1c. Care<br />
surrounding the management of diabetes should aim to implement<br />
mobile telehealth interventions as adjunct means to managing diabetes.<br />
Patients should also be encouraged to follow-up with their diabetes<br />
providers for optimal outcomes.
<strong>July</strong>, August, September <strong>2022</strong> <strong>The</strong> <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong> Page 7<br />
Staffing Effect on Hospital Acquired Infections<br />
Appraised by:<br />
Kiana Schatz SN, Chelsie Shook SN, Dominic<br />
Sieve SN, Jada Kjonaas SN, Kathryn Dragseth SN,<br />
Kylee Utter SN<br />
Allison Sadowsky MSN RN Assistant Professor<br />
of Practice (Faculty) (NDSU School of Nursing at<br />
Sanford Bismarck)<br />
Clinical Question:<br />
In hospitalized patients, does staffing on the<br />
unit affect hospital acquired infections?<br />
Sources of Evidence:<br />
Daud-Gallotti, R. M., Costa, S. F., Guimarães, T., Padilha,<br />
K. G., Inoue, E. N., Vasconcelos, T. N., da Silva<br />
Cunha Rodrigues, F., Barbosa, E. V., Figueiredo, W.<br />
B., & Levin, A. S. (2012). Nursing workload as a risk<br />
factor for healthcare associated infections in ICU:<br />
A prospective study. PLoS ONE, 7(12). https://doi.<br />
org/10.1371/journal.pone.0052342<br />
Kaier, K., Mutters, N. T., & Frank, U. (2014, December<br />
13). Bed occupancy rates and hospital-acquired<br />
infections-should beds be kept empty? Clinical<br />
Microbiology and Infection. Retrieved March<br />
20, <strong>2022</strong>, from https://www.sciencedirect.com/<br />
science/article/pii/S1198743X14610909<br />
Kouatly, I. A., Nassar, N., Nizam, M., & Badr, L. K. (2018).<br />
Evidence on <strong>Nurse</strong> Staffing Ratios and Patient<br />
Outcomes in a Low-Income Country: Implications<br />
for Future Research and Practice. Worldviews on<br />
Evidence-Based Nursing, 353-360.<br />
Mitchell, B. G., Gardner, A., Stone, P. W., Hall, L., &<br />
Pogorzelska-Maziarz, M. (2018). Hospital staffing<br />
and health care–associated infections: A<br />
systematic review of the literature. <strong>The</strong> Joint<br />
Commission Journal on Quality and Patient<br />
Safety, 44(10), 613–622. https://doi.org/10.1016/j.<br />
jcjq.2018.02.002<br />
Shang, J., Needleman, J., Liu, J., Larson, E., & Stone,<br />
P. W. (2019). <strong>Nurse</strong> Staffing and Healthcare-<br />
Associated Infection, Unit-Level Analysis. <strong>The</strong><br />
Journal of nursing administration, 49(5), 260–265.<br />
https://doi.org/10.1097/NNA.0000000000000748<br />
Tawfik, D., Profit, J., Lake, E., Liu, J., Sanders, L., & Phibbs,<br />
C. (2020). Development and use of an adjusted<br />
nurse staffing metric in the neonatal intensive care<br />
unit. Health Services Research, 190-200.<br />
Synthesis of Evidence:<br />
Six articles were reviewed as evidence in this<br />
report including a prospective cross-sectional<br />
study, a prospective cohort study, a repeated<br />
measures observational study, two systematic<br />
reviews, and a quantitative study with cross<br />
sectional data analysis. <strong>The</strong> articles are reviews of<br />
studies conducted to determine the relationship<br />
between the occurrence of hospital acquired<br />
infections or patient outcomes, and how they are<br />
related to nurse workload and staffing ratios.<br />
<strong>The</strong> first article by Kouatly, Nassar, Nizam, &<br />
Badr (2018) was a prospective cross-sectional<br />
study. This study was conducted to describe<br />
the relationship between nurse staffing and<br />
nurse sensitive outcomes (NSOs) at a Magnet<br />
designated university hospital in a low-income<br />
country. This study included 68,000 patients<br />
who had a fall, an injury fall, hospital-acquired<br />
pressure injury (HAPI), catheter-associated urinary<br />
tract infection (CAUTI), central line bloodstream<br />
infection (CLABSI), and ventilator-associated<br />
pneumonia (VAP) after admission during <strong>July</strong><br />
2011 to June 2013. <strong>The</strong> results concluded that in<br />
the critical care unit (CCU), high nurse hours per<br />
patient days (NHPPD) compared to low NHPPD<br />
it reduced total patient falls by 79%, injury falls<br />
by 77%, HAPIs by 74%, CAUTIs by 23%, CLABSIs by<br />
62%, and VAP by 38%. In the medical-surgical<br />
unit, the results concluded that when there was<br />
high NHPPD compared to low NHPPD it reduced<br />
falls by 84%, injury falls by 75%, HAPI by 74%, CAUTIs<br />
by 39%, CLABSIs by 79%, and VAP by 20%. <strong>The</strong>se<br />
results imply that when more nurses are available,<br />
the likelihood of adverse NSOs decreases.<br />
<strong>The</strong> second article by Daud-Gallotti, Costa,<br />
Guimarães, Padilha, Inoue, Vasconcelos, da Silva<br />
Cunha Rodrigues, Barbosa, Figueiredo, & Levin<br />
(2012) was a prospective cohort study. <strong>The</strong> aim<br />
of the study was to evaluate the role of nursing<br />
workload in the occurrence of HAIs (hospital<br />
acquired infection) in medical ICUs (intensive care<br />
unit) using a nursing activities score (NAS). <strong>The</strong><br />
study included 195 patient’s ages 12+ who were<br />
admitted to three medical ICUs and a step-down<br />
unit. <strong>The</strong> results concluded that out of the 195<br />
patients’ being evaluated, 43 of them developed<br />
HAI and data analysis showed that excessive<br />
nursing workload was found to be the biggest<br />
contributing factor to these HAI. It was also found<br />
that of the 195 patients, 79 of them suffered from<br />
adverse effects during their stay in the ICU.<br />
<strong>The</strong> third article by Tawfik, Profit, Lake, Liu,<br />
Sanders, & Phibbs (2020) was a repeated<br />
measures observational study. <strong>The</strong> purpose of<br />
the study was to determine whether adjusted<br />
nurse staffing in hospitals contributed to patient<br />
outcomes. <strong>The</strong> study took place in 99 California<br />
neonatal intensive care units (NICUs) where they<br />
studied 276,054 infants born between January<br />
2008-May 2016. <strong>The</strong> study aimed to evaluate<br />
staffing effects on HAIs, infant mortality, and<br />
length of stay (LOS). <strong>The</strong> results concluded that<br />
increased nurse staffing may result in reductions<br />
of patient-related events. Although the results<br />
showed there was no impact on staffing related<br />
to infant mortality and LOS, there was great<br />
evidence regarding staffing impacts on lower<br />
odds of HAIs. <strong>The</strong>re was a total of 25,744 infants<br />
that fell into the California Perinatal Quality Care<br />
Collaborative (CPQCC) test cohort and of those<br />
infants, 52% fell into the low birth weight and 7.2%<br />
experienced a HAI. <strong>The</strong>se numbers corresponded<br />
to lower odds of HAI with each additional nursing<br />
hours per patient-day (NHPPD). <strong>The</strong> results<br />
supported the idea that staffing on a hospital unit<br />
does indeed affect the rates of hospital acquired<br />
infections.<br />
<strong>The</strong> fourth article by Kaier, Mutters, and<br />
Frank (2014) was a systematic review. <strong>The</strong> study<br />
was conducted to look at the correlation<br />
of bed occupancy rates and the effects of<br />
overcrowding and understaffing on hospitalacquired<br />
infections. <strong>The</strong> study included 12 studies<br />
that were reviewed for analysis. <strong>The</strong>se studies<br />
included various hospital settings which were<br />
composed of general wards, surgical wards,<br />
ICU’s, and NICU’s. <strong>The</strong> results concluded that high<br />
bed occupancy rates and understaffing directly<br />
impacted the incidence and spread of hospitalacquired<br />
infections. This was evidenced by nine<br />
of the twelve studies finding a positive correlation,<br />
whereas three of the studies found no correlation<br />
or a negative correlation. <strong>The</strong>refore, hospitalacquired<br />
infections are at risk of increasing if<br />
overcrowding of beds and understaffing continue<br />
to be issues within the hospital setting.<br />
<strong>The</strong> fifth article by Mitchell, Gardner, Stone,<br />
Hall, Pogozelska-Maziarz (2018) conducted a<br />
systematic review. <strong>The</strong> systematic review included<br />
Appraised by:<br />
Leah Nelson, RN, Danica Calderon, RN, Vanessa<br />
Poitra, RN, and Mikayla Kitsch, RN: students at<br />
Mayville State University RN-to-BSN Program<br />
Clinical Question:<br />
Within staff in a medical-surgical unit, does<br />
bedside hand-off report compared to traditional<br />
report impact the number of errors made on a<br />
given shift?<br />
Articles:<br />
Becker, Sherry, MSN-Ed, RN-BC, Hagle, Mary, PhD,<br />
RN-BC, Amrhein, Andra, BSN, RN, et al. (2021).<br />
Implementing and sustaining bedside shift<br />
report for quality patient-centered care. Journal<br />
of Nursing Care Quality, 36, 125-131.<br />
Gettis, M. A., Dye, B., Williams, C., Frankish, B., &<br />
Alvarez, B. (2019). Bedside report: Nursing<br />
handoffs impact outcomes for caregivers,<br />
healthcare providers, and organizations.<br />
Worldviews on Evidence-Based Nursing, 16(6),<br />
495–497. https://doi.org/10.1111/wvn.12404<br />
McAllen, E., Stephens, K., Swanson-Biearman, B., Kerr,<br />
K., & Whiteman, K. (2018). Moving shift report<br />
to the bedside: An evidence-based quality<br />
improvement project. OJIN: <strong>The</strong> Online Journal<br />
of Issues in Nursing, 23(2). https://doi.org/10.3912/<br />
ojin.vol23no02ppt22<br />
Small, D. and Fitzpatrick, J. (2017). <strong>Nurse</strong> perceptions<br />
of traditional and bedside shift report. Nursing<br />
Management, 48, 44-49.<br />
Synthesis of Evidence:<br />
This synthesis includes four studies that provide<br />
evidence supported to the research question. <strong>The</strong><br />
Bedside Reporting<br />
54 studies. Study designs included cohort, case<br />
control, cross-sectional, randomized controlled or<br />
case reports. <strong>The</strong> aim of the study was to examine<br />
the association between hospital staffing and<br />
patients’ risk of developing HAIs in hospital<br />
settings. <strong>The</strong> studies were further categorized<br />
into studies examining nurse staffing and single<br />
site-specific infection; studies examining nurse<br />
staffing and multiple HAI’s; studies examining<br />
nurse staffing and organism-specific HAI’s; studies<br />
examining nurse staffing and HAI’s (unspecified<br />
infection type; and lastly, studies examining nonnurse<br />
staffing and HAI’s. Major findings of this<br />
systematic review find that 42/54 of the studies,<br />
suggest that staffing levels are associated with<br />
HAI’s. Increased levels of staffing seem to be<br />
connected to a decrease in the risk of patients<br />
acquiring HAI’s.<br />
<strong>The</strong> sixth article by Shang, Needleman, Liu,<br />
Larson, and Stone (2019) was a quantitative study<br />
with cross sectional data analysis. <strong>The</strong> study was<br />
done between 2007-2012 to examine whether<br />
healthcare associated infections (HAIs) and nurse<br />
staffing are associated using unit-level staffing<br />
data. It included 100,264 patients in the ICU,<br />
medical, med/surg, and step-down units in three<br />
hospitals in a large metropolitan area. <strong>The</strong> results<br />
concluded the hazard rate of HAIs in patients on<br />
units with nursing staff (NS) understaffing on both<br />
shifts two days before infection onset were 11%<br />
higher than for those staying in units with both day<br />
and night shifts adequately staffed with NS.<br />
Conclusion:<br />
All six articles indicated that staffing on a<br />
nursing unit plays a role in the prevalence of<br />
hospital acquired infections. <strong>The</strong>se articles<br />
support the same idea that either increasing staff<br />
on a hospital unit contributes to a decreased<br />
rate of infection, or in the same way, that by<br />
decreasing staff on a hospital unit it contributes to<br />
an increased rate of infection.<br />
Implications for Nursing Practice:<br />
Findings suggest that staffing is directly related<br />
to the rate of hospital acquired infections. By<br />
increasing nurse staffing, increasing nurse hours<br />
per patient day, eliminating excessive nurse<br />
workloads, and eliminating overcrowding, it leads<br />
to a decreased rate of adverse effects, with the<br />
main one being HAIs. Staffing nurses properly will<br />
allow for more compliance to care plans and<br />
adherence to infection control prevention.<br />
first study completed by S. Becker et al., (2021),<br />
identified the lack of bedside report increased<br />
the number of errors from miscommunication.<br />
<strong>The</strong> second study by Gettis et al., (2019),<br />
using the situation, background, assessment,<br />
recommendation (SBAR) method was used less<br />
inconsistent when report is given at the bedside.<br />
<strong>The</strong> third study by McAllen et al., (2018), identified<br />
less falls and improved satisfaction from the<br />
nurse and patient. <strong>The</strong> fourth study by Small<br />
and Fitzpatrick (2017), found that bedside report<br />
improves nurse accountability, decrease patient<br />
errors, and increase patient involvement.<br />
Bottom Line:<br />
Based on current research, there is evidence<br />
to show improvement in patient safety outcomes<br />
when using bedside report to help reduce the<br />
number of errors on shift. Bedside report can<br />
reduce errors by making sure drips, lines, and<br />
wounds are in order before the off-going nurse<br />
leaves. This bedside report helps reduce the<br />
patient’s hospital anxiety by providing them a<br />
better understanding of their plan of care and<br />
allow them to participate in the decision-making<br />
process. Bedside report can also reduce the risk of<br />
out of bed falls by making sure the patient is safe<br />
with visual observation until the new nurse comes in<br />
to complete the new shift assessment.<br />
Bedside Reporting continued on page 9
Page 8 <strong>The</strong> <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong> <strong>July</strong>, August, September <strong>2022</strong><br />
August is National<br />
Breastfeeding Month<br />
Richelle Johnson, MSN, RN, NDNA VP of Finance<br />
Nursing Needs a Mental<br />
Health Makeover<br />
Easy access to resources and erasing stigma are key.<br />
Since 2011, the United States Breastfeeding Committee (USBC) has<br />
claimed August as National Breastfeeding Month. Breastfeeding, more<br />
commonly known as nursing, is a means to feed a child human breast<br />
milk. It has been proven to be an excellent prevention strategy that<br />
ultimately builds a foundation for health and wellness in infants and<br />
parents (USBC, n.d.).<br />
<strong>The</strong> American Academy of Pediatrics recommends that infants be<br />
exclusively breastfed for the first six months of life and then continue to<br />
be breastfed up until twelve months or older while solid foods are being<br />
introduced.<br />
Current research still supports the many health benefits for both<br />
mother and baby as well as potential environmental and economic<br />
benefits for communities. According to the Centers for Disease Control<br />
and Prevention ([CDC], 2021), these benefits include but are not limited<br />
to:<br />
1) Breast milk is the best source of nutrition for most babies.<br />
2) Breastfeeding can help protect babies against some short- and<br />
long-term illnesses and diseases.<br />
3) Breast milk shares antibodies from the mother with her baby that<br />
formula cannot provide.<br />
4) Mothers can breastfeed anytime and anywhere.<br />
5) Breastfeeding can reduce the mother’s risk of breast and ovarian<br />
cancer, type 2 diabetes, and high blood pressure.<br />
As natural as the breastfeeding process may seem, problems can<br />
occasionally arise. When problems arise, they may interfere with the<br />
mother's milk production and the baby's ability to get the nutrients they<br />
need. For this reason, it is imperative that mothers seek help if they have<br />
trouble with breastfeeding or observe a change in their baby's behavior<br />
such as short (or long) nursing sessions, baby seeming hungry after<br />
feedings, baby not gaining weight, breast engorgement, etc.<br />
Lastly, breastfeeding may not be possible for all women and for many,<br />
the decision is solely based on their comfort level, lifestyle, and even<br />
certain medical situations. For mothers who decide not to or cannot<br />
breastfeed, infant formula is a healthy alternative as it does provide<br />
babies with the proper nutrients to thrive and grow.<br />
<strong>The</strong> decision to breastfeed is a very personal one. Encourage mothers<br />
to weigh the pros and cons of breastfeeding as well as talk to their<br />
doctor and/or a lactation consultant. <strong>The</strong>se health care providers can<br />
give mothers more information about their options and help them make<br />
the best decision for their family.<br />
References<br />
Centers for Disease Control and Prevention. (2021). Breastfeeding benefits<br />
both baby and mom. Retrieved May 9, <strong>2022</strong> from https://www.<br />
cdc.gov/nccdphp/dnpao/features/breastfeeding-benefits/index.<br />
html#:~:text=Breastfeeding%20can%20help%20protect%20babies,ear%20<br />
infections%20and%20stomach%20bugs.<br />
U.S. Breastfeeding Committee (USBC). (n.d.). State and territory breastfeeding<br />
reports. Retrieved May 9, <strong>2022</strong> from http://www.usbreastfeeding.org/p/cm/<br />
ld/fid=257<br />
Belcourt, ND<br />
Multiple Nursing Opportunities<br />
in OB, Clinic, Med/Surg & ER<br />
<strong>The</strong> Quentin N. Burdick Memorial Health Care Facility is an Indian<br />
Health Service unit located on the Turtle Mountain Reservation<br />
in Belcourt, ND. <strong>The</strong> Facility provides comprehensive primary<br />
care and preventive care and hosts a medical clinic, dental clinic,<br />
optometry clinic, pharmacy, radiology services, mental<br />
health services, outpatient surgical services, labor<br />
and delivery services, emergency room and inpatient/<br />
acute care unit.<br />
<strong>The</strong> site qualifies as a student loan payback site and offers benefits including annual<br />
and sick leave, health/dental/vision benefits, life insurance, and retirement.<br />
For more information, please visit www.usajobs.gov<br />
or call Lynelle Hunt, DON (701) 477-6111 ext. 8260.<br />
All RNs encouraged to apply or call for more information.<br />
Holly Carpenter, BSN, RN; Dawn Webb, MSN, RN, PMH-BC; and<br />
Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC<br />
For too long, nurses have struggled quietly with mental health issues,<br />
fearing stigma or negative consequences associated with getting<br />
help. Even before the COVID-19 pandemic, nurses had higher rates of<br />
depression and suicide than the general population. Suffering in silence<br />
can’t be a part of our profession.<br />
Survey results from Healthy <strong>Nurse</strong>, Healthy Nation (HNHN), the<br />
American <strong>Nurse</strong>s Association nurse wellness community, show that<br />
nurses’ mental well-being has worsened during the pandemic. <strong>The</strong><br />
Healthy <strong>Nurse</strong>® Survey found that, during the pandemic, respondents<br />
had statistically higher instances of anxiety and depression disorders<br />
than before. In addition, 34% of nurses reported feeling sad, down,<br />
or depressed for two weeks or more over the past 30 days during the<br />
pandemic, compared to 29% pre-pandemic.<br />
Mood and anxiety disorders commonly coexist with substance use<br />
disorders (SUD). Increases in substance use and drug overdoses in the<br />
United States during the pandemic, along with higher rates of depression<br />
and suicide among nurses, make it clear that nurses are at high risk<br />
for SUD and mental health conditions due to the stressors of simply<br />
being a nurse. <strong>Nurse</strong>s have worked on self-care and resilience building<br />
interventions. Now, we need healthcare employers, nursing associations,<br />
schools of nursing, legislators, and other interested parties to invest in<br />
nurses’ mental health.<br />
Recently, HNHN expanded its focus by adding mental health to its<br />
existing domains of rest, physical activity, nutrition, quality of life, and<br />
safety. HNHN’s Advisory Committee endorsed this change and formed a<br />
subcommittee to address nurses’ mental health, specifically confronting<br />
mental health stigma, identifying nursing leadership and employer<br />
responsibilities and planning strategies for improved mental health. For<br />
more information, visit www.hnhn.org.<br />
Many mental health and well-being resources support nurses.<br />
Several—such as HNHN—are free of charge and readily accessible:<br />
• <strong>2022</strong> Healthcare Workforce Rescue Package. A one-pager from the<br />
National Academy of Medicine’s Action Collaborative on Clinician<br />
Well-Being and Resilience. (bit.ly/35FyQKG)<br />
• <strong>Nurse</strong> Suicide Prevention/Resilience. ANA site dedicated to<br />
promoting mental health and suicide prevention. (bit.ly/3jeLcg1)<br />
• Substance Use Disorder in Nursing. Substance use disorder<br />
resources from the National Council of State Boards of Nursing. (bit.<br />
ly/3NHQPS5)<br />
• <strong>The</strong> Well-Being Initiative. Launched by the American <strong>Nurse</strong>s<br />
Foundation, this site offers free tools and apps to support nurses’<br />
mental health and well-being. (bit.ly/3jcBb2T)<br />
Many employers offer support through employee assistance programs,<br />
peer support, mental health screenings and services, healthcare<br />
insurance, and wellness officers. Helpful resources are accessible,<br />
anonymous, and affordable or free. Every organization must instill an “It’s<br />
ok not to be ok” culture.<br />
<strong>The</strong> Dr. Lorna Breen Health Care Provider Protection Act (S. 610/H.R.<br />
1667) will supply millions in funding to train healthcare professionals<br />
about suicide prevention, burnout, and SUD. An awareness campaign for<br />
healthcare professionals will promote assistance with mental health and<br />
substance use issues and resiliency.<br />
<strong>Nurse</strong>s need to be the CEOs of their own mental health. Please don’t<br />
wait until you are in crisis. All nurses should advocate and educate for the<br />
underserved—in this case, ourselves.<br />
Holly Carpenter is a senior policy advisor at ANA. Dawn Webb is<br />
director of nursing practice at Texas <strong>Nurse</strong>s Association. Katie Boston-<br />
Leary is director of nursing programs at ANA.<br />
JOIN US AT UMC<br />
Unity Medical Center, located in Grafton is<br />
recruiting for Med Surg/ER <strong>Nurse</strong>s to work<br />
in our new addition that consists of 11 new<br />
patient rooms and a new ED department.<br />
12 hour shifts rotating days and nights every<br />
3rd weekend and rotating Holidays.<br />
Please contact Jenny, CNO at 701-379-3002 or<br />
apply online at www.unitymedcenter.com.
<strong>July</strong>, August, September <strong>2022</strong> <strong>The</strong> <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong> Page 9<br />
Violence in the Healthcare Industry:<br />
What is Being Done to Protect Healthcare Workers?<br />
Penny Briese, PhD (c), RN, <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong>s<br />
Association, Director of Advocacy<br />
On Wednesday, June 1, <strong>2022</strong>, a man walked<br />
into <strong>The</strong> Warren Clinic, a specialty care office<br />
within Saint Francis Hospital in Tulsa, Oklahoma,<br />
with a gun he had purchased that very day<br />
and opened fire. Michael Louis murdered<br />
four people; a receptionist, a patient, and<br />
two doctors including Dr. Preston Phillips, an<br />
orthopedic surgeon who had recently operated<br />
on Mr. Louis’ back. According to sources, Mr.<br />
Louis was dissatisfied with the level of pain<br />
following his surgery. He had sought medical<br />
help several times in the days leading up to<br />
the shooting and blamed Dr. Phillips for not<br />
receiving adequate pain relief. Mr. Louis took<br />
his own life at the scene; a letter found on his<br />
body confirmed his intent and motive (Hanna &<br />
Watts, <strong>2022</strong>, June 3).<br />
Workplace violence is not uncommon,<br />
however it is five times more prevalent in<br />
the healthcare industry. “According to the<br />
American College of Emergency Physicians<br />
and the Emergency <strong>Nurse</strong>s Association, almost<br />
half of emergency physicians and 70% of<br />
emergency nurses reported being physically<br />
assaulted on the job” (Skog, <strong>2022</strong>, para. 1). In a<br />
recent <strong>2022</strong> survey of 2,500 hospital nurses, 48%<br />
reported having experienced violence in the<br />
workplace, a 31% increase since just last year.<br />
According to testimony given on Capitol Hill<br />
by Todd Haines, a member of the Emergency<br />
<strong>Nurse</strong>s Association, nurses have been “bitten,<br />
punched, knocked unconscious and strangled<br />
with stethoscopes, all while just trying to provide<br />
basic care to patients” (Mensik, <strong>2022</strong>, May 5,<br />
para. 1).<br />
So what is being done?<br />
Legal protections for healthcare workers are<br />
already in place in many states. According<br />
to the Emergency <strong>Nurse</strong>s Association, 31 out<br />
of 50 states have made it a felony to assault a<br />
healthcare worker and they are lobbying for<br />
it to become a felony nationwide. Wisconsin<br />
state law already makes battery against a<br />
healthcare worker a felony, however in March<br />
<strong>2022</strong> they passed a law making it a felony to<br />
even threaten a healthcare worker. In May of<br />
2020, Oklahoma Governor Kevin Stitt signed <strong>The</strong><br />
Medical Care Provider Protection Act (Senate<br />
Bill 1290) increasing penalties from one year to<br />
a mandatory two to five year sentence and<br />
requiring that assaults on healthcare workers<br />
be reported to the state health department.<br />
(Rowland, 2020, May 20).<br />
At the federal level, <strong>The</strong> Workplace Violence<br />
Prevention for Health Care and Social Service<br />
Workers Act (H.R. 1195) was introduced in<br />
February, 2021 with strong bipartisan support.<br />
<strong>The</strong> bill was passed in the US House of<br />
Representatives in April of 2021 and sponsors<br />
of the bill are pushing to have it brought to<br />
the forefront in the US Senate. This bill would<br />
require that healthcare facilities receiving<br />
Medicare funds “develop and implement<br />
a comprehensive workplace violence<br />
prevention plan and carry out other activities or<br />
requirements…to protect health care workers,<br />
social service workers, and other personnel<br />
from workplace violence” (Congress.gov, <strong>2022</strong>,<br />
p. 10). <strong>The</strong> bill has met with some opposition<br />
with regard to cost to healthcare facilities and<br />
questions as to the actual outcome of such<br />
programs.<br />
And here in <strong>North</strong> <strong>Dakota</strong>?<br />
In 2015, legislation was introduced in <strong>North</strong><br />
<strong>Dakota</strong> that would make it a felony to assault<br />
a healthcare worker, including by putting<br />
excrement or bodily fluids on them. It did not<br />
pass. In 2017, legislators in <strong>North</strong> <strong>Dakota</strong> tried<br />
again, introducing Senate Bill 2216 which<br />
called for an amendment and reenactment of<br />
sections 12.1-17-01.1 (Assault), and subsection<br />
1 of section 12.1-17-11 (Contact by bodily fluids<br />
or excrement) of the <strong>North</strong> <strong>Dakota</strong> Century<br />
Code. This Bill discussed assault of health care<br />
facility providers, specifically via contact by<br />
bodily fluids or excrement. Peace officers<br />
and correctional institution officers working at<br />
the <strong>North</strong> <strong>Dakota</strong> state hospital were already<br />
covered under this section and it was, and<br />
remains, a Class C felony to assault them while<br />
they are acting in the course and scope of<br />
their employment. Senate Bill 2216 called for<br />
intentionally making contact of bodily fluids<br />
(blood, emesis, excrement, mucus, saliva,<br />
semen, vaginal fluid or urine) with a healthcare<br />
provider a Class A misdemeanor “…if the victim<br />
is employed or contracted by a health care<br />
facility, which the actor knows to be a fact, and<br />
the assault occurs on the health care facility<br />
property” (Dever et al., 2017). This time, the bill<br />
was successfully passed.<br />
In 2021, S.B. 2268 was introduced to once<br />
again try to amend and reenact section 12.1<br />
17 01 of the <strong>North</strong> <strong>Dakota</strong> Century Code,<br />
making it a felony to assault a healthcare<br />
Face Shields and Face Coverings<br />
worker in <strong>North</strong> <strong>Dakota</strong> (Roers et al., 2021).<br />
Despite strong support from the <strong>North</strong> <strong>Dakota</strong><br />
Medical Association, this bill failed to pass. But<br />
healthcare provider advocates and supporters<br />
are not giving up just yet. <strong>The</strong> 68th legislative<br />
session is due to begin in January, 2023 so don’t<br />
be surprised if this issue is once again brought<br />
forward. As a healthcare provider, you can be a<br />
part of the action by lending your voice. Like so<br />
many doctors and nurses in other states across<br />
the nation, healthcare workers in <strong>North</strong> <strong>Dakota</strong><br />
deserve to be protected.<br />
References<br />
Congress.gov. (<strong>2022</strong>). H. report 117-14-workplace<br />
violence prevention for health care and social<br />
services workers act. Retrieved from https://<br />
www.congress.gov/congressional-report/117thcongress/house-report/14/1?overview=closed<br />
Dever, D., Burkhard, R., Nelson, C., Karls, J., Nelson,<br />
M., & Westlind, G. (2017). Senate bill no. 2216.<br />
Retrieved from https://trackbill.com/bill/northdakota-senate-bill-2216-an-act-to-create-andenact-a-new-subsection-to-section-12-1-17-11-ofthe-north-dakota-century-code-relating-to-thedefinition-of-a-health-care-facility-to-amendand-reenact-subsection-1-of-section-12-1-17-11-<br />
of-the-north-dakota-century-code-relating-tocontact-by-bodily-fluids-or-excrement-and-toprovide-a-penalty/1339077/<br />
Hanna, J. & Watts, A. (<strong>2022</strong>, June 2). Gunman<br />
who killed at Oklahoma medical building<br />
had been a patient of a victim, police chief<br />
says. CNN. Retrieved from https://amp.cnn.<br />
com/<strong>2022</strong>/06/02/us/tulsa-hospital-shotingthursday/index.html<br />
Mensik, H. (<strong>2022</strong>, May 5). ER providers push for federal<br />
protection against rising health worker violence.<br />
HEALTHCAREDIVE. Retrieved from https://<br />
www.healthcaredive.com/news/workplaceviolence-prevention-healthcare-workers-billpandemic/623244/<br />
Roers, K., Dever, D., Heinert, J., Nelson, M., & Westlind,<br />
G. (2021). Senate bill no. 2268. Retrieved from<br />
https://www.ndlegis.gov/assembly/67-2021/<br />
documents/21-0918-02000.pdf<br />
Rowland, R. (2020, May 20). Okla. Governor signs law<br />
to protect EMS, hospital personnel from violence.<br />
EMS1 by Lexipol. Retrieved from https://www.<br />
ems1.com/ems-assaults/articles/okla-governorsigns-law-to-protect-EMS-hospital-personnelfrom-violence-6OB6YzG6rspiLISv/<br />
Skog, A. (<strong>2022</strong>, March 3). Other views: HB 4142<br />
could reduce assaults on health care workers.<br />
Retrieved from https://www.lagrandeobserver.<br />
com/opinion/columns/other-views-hb-4142-<br />
could-reduce-assaults-on-health-care-workers/<br />
article_2205d5ea-98e1-11ec-959c-3bb7762060c7.<br />
html<br />
Appraised by:<br />
Natalie Hadrava, Rachel Hill<br />
Clinical Question:<br />
Are face shields more effective than face<br />
coverings and between the two options, which<br />
face protection had a higher success rate in<br />
preventing the spread of Covid-19?<br />
Articles References:<br />
Coclite, D., Napoletano, A., Gianola, S., Del Monaco,<br />
A., D'Angelo, D., Fauci, A., & Iannone, P. (2021).<br />
Face mask use in the community for reducing<br />
the spread of COVID-19: a systematic review.<br />
Frontiers in medicine, 1060.<br />
Lindsley, W. G., Blachere, F. M., Law, B. F., Beezhold,<br />
D. H., & Noti, J. D. (2021). Efficacy of face masks,<br />
neck gaiters, and face shields for reducing<br />
the expulsion of simulated cough-generated<br />
aerosols. Aerosol Science and Technology, 55(4),<br />
449-457.<br />
Pooja, A., Kabir, S., & Surabhi, S. (<strong>2022</strong>, December).<br />
Real-world assessment, relevance, and<br />
problems in the use of personal protective<br />
equipment in a clinical dermatology practice<br />
in a COVID referral tertiary hospital. EBSCOhost.<br />
Retrieved April 13, <strong>2022</strong>.<br />
Wendling, J.-M., Fabacher, T., Pébaÿ, P.-P., Cosperec,<br />
I., & Rochoy, M. (2021, February 17). Experimental<br />
efficacy of the face shield and the mask against<br />
emitted and potentially received particles.<br />
International journal of environmental research<br />
and public health. Retrieved April 12, <strong>2022</strong>.<br />
Synthesis of Evidence:<br />
In the review of literature, we used keywords<br />
such as “face mask,” “face covering,” “face<br />
shields,” and “Covid-19 prevention” in our<br />
search engines (google scholar, Mayville State<br />
University online library databases). To narrow<br />
the search even further, we looked at articles<br />
and studies that have only been conducted<br />
in the last five years, as well as only looking at<br />
scientific articles and studies from reputable<br />
sources. We, as partners, chose the best articles<br />
that we both found and used them to create an<br />
answer to our question.<br />
Bottom Line:<br />
<strong>The</strong> evidence found that face coverings<br />
are better for the prevention of the spread of<br />
Covid-19. In all four articles, face coverings<br />
were found to be more effective than face<br />
shields. <strong>The</strong> best face covering to prevent the<br />
spread of Covid-19 is the N95 respirator mask,<br />
and face shields were ineffective when used by<br />
themselves to prevent the spread of Covid-19.<br />
<strong>The</strong> studies that were used had different ways<br />
of showing how face coverings were effective,<br />
different experiments to show the efficacy of<br />
face coverings vs. face shields, and flaws of<br />
wearing a face covering and a face shield.<br />
Implications for Nursing:<br />
Knowing this information, all healthcare<br />
facilities should be using face coverings rather<br />
than face shields within their facilities. If some<br />
facilities prefer to do both, that will also work<br />
because the face shield could stop a few<br />
particles before they reach the face covering.<br />
However, face shields should not be used on<br />
their own because of their ineffectiveness. <strong>The</strong><br />
N95 respirator mask would be the most ideal<br />
face covering to have due to the mask’s ability<br />
to stop the greatest number of particles.<br />
Bedside Reporting continued from page 7<br />
Implications for Nursing Practice:<br />
Implications for nursing practice include to use<br />
bedside report rather than traditional report to<br />
help reduce the number of errors on a shift (Small<br />
& Fitzpatrick, 2017). Using the SBAR method will<br />
help make sure all information is provided about<br />
the patient (Becker et. al, 2021). During bedside<br />
report the nurses can observe the lines, drips,<br />
and wounds in the patient room and note if any<br />
changes. <strong>The</strong> research including the patient in<br />
bedside report is an effective nursing intervention<br />
that provides better shift outcomes for patients,<br />
allowing the patient to be a part of their care and<br />
ask questions if needed.
Page 10 <strong>The</strong> <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong> <strong>July</strong>, August, September <strong>2022</strong><br />
Acute Hepatitis in Children: Where are We Now<br />
Joylyn Anderson, APRN, MSN, RN<br />
In the last few months, there has been<br />
worldwide concern regarding an increase in<br />
the number of cases of acute hepatitis among<br />
children. According to the World Health<br />
Organization (WHO), 650 children in 33 countries<br />
have been diagnosed with acute hepatitis<br />
between April 5 and May 28 (WHO, <strong>2022</strong>). Of<br />
these 650 cases, approximately 38 children (6%)<br />
have required liver transplants, and nine deaths<br />
have been reported (WHO, <strong>2022</strong>). Europe has<br />
had the most significant impact, with 305 cases<br />
reported since April of this year (ECDC, <strong>2022</strong>).<br />
Since April, the United States has reported 216<br />
acute hepatitis in children (WHO, <strong>2022</strong>).<br />
A particular increase in acute hepatitis<br />
in children was noted earlier this year in<br />
Alabama between October 2021 and<br />
February <strong>2022</strong>, according to the Morbidity<br />
and Mortality Weekly Report (Baker et al.,<br />
<strong>2022</strong>). Nine pediatric patients were found to<br />
have adenovirus and concomitant acute<br />
hepatitis (Baker et al., p.638). <strong>The</strong> World Health<br />
Organization was alerted of concerns of an<br />
increase in pediatric hepatitis cases when<br />
169 confirmed cases of acute hepatitis were<br />
noted in the United Kingdom by April of<br />
this year. Researcher Robert de Kleine and<br />
colleagues evaluated the number of pediatric<br />
hepatitis cases across the United Kingdom<br />
by sending a web-based public survey to<br />
pediatric healthcare centers in the United<br />
Kingdom addressing pediatric diagnoses of<br />
acute hepatitis over the preceding year. Of<br />
the 34 participating centers, there were 64<br />
children diagnosed with severe hepatitis (p.<br />
2). A previously known cause was noted in 16<br />
of the 64 children. Thirteen of these children<br />
were diagnosed with virus-like symptoms,<br />
with adenovirus being diagnosed in four<br />
patients. Five of the sixty-four children have<br />
been previously vaccinated for COVID-19. Four<br />
children received liver transplants due to severe<br />
infection (p. 2).<br />
According to the European Center for<br />
Disease Prevention and Control (May 31, <strong>2022</strong>),<br />
the following data is the most recent reported<br />
findings regarding acute pediatric hepatitis<br />
diagnosis:<br />
• 76.1% of acute hepatitis cases are five years<br />
or younger<br />
• Of the 305 probable cases, 180 have<br />
recovered while 31 remain under medical<br />
care<br />
• 13.6% of patients were admitted to ICU<br />
• 10.7% received liver transplants<br />
• One death has been reported<br />
• Of the 199 tested for adenovirus, 118 (59.3%)<br />
tested positive<br />
• Of 204 PCR tested for SARS-C-V-2, 24 (11.8%)<br />
tested positive. Serology results for SARS-<br />
C-V-2 were only available for 34 cases, with<br />
23 (67.6%) testing positive.<br />
• Of the 72 cases with data on<br />
COVID-19 vaccination, 61 (84.7%) were<br />
unvaccinated.<br />
(European Centre for Disease Prevention and<br />
Control. May 31, <strong>2022</strong>)<br />
<strong>The</strong> World Health Organization and Centers<br />
for Disease Control continue to work together<br />
to identify the cause of this increase in acute<br />
hepatitis in pediatric clients. Adenovirus has<br />
been noted in several cases of severe acute<br />
hepatitis in both Europe and the U.S. (ECDC,<br />
<strong>2022</strong>; CDC, <strong>2022</strong>); however, further surveillance<br />
is necessary to determine the cause correctly.<br />
New Series!<br />
<strong>The</strong> Future of Nursing<br />
A cause must be identified before proper<br />
management, care, and preventative measures<br />
can begin. Continue to follow the Center for<br />
Disease Control and World Health Organization<br />
for updates.<br />
References:<br />
Baker, J.M., Buchfellner, M., Britt, W., (<strong>2022</strong>).<br />
Morbidity and Mortality Weekly Report. Acute<br />
hepatitis and adenovirus infection among<br />
children—Alabama, October 21- February<br />
<strong>2022</strong>. 71(18), 638-640. MMWR, Acute Hepatitis,<br />
and Adenovirus Infection Among Children —<br />
Alabama, October 2021–February <strong>2022</strong> (cdc.<br />
gov)<br />
Center for Disease Control and Prevention. (<strong>2022</strong>).<br />
CDC alerts providers to hepatitis cases of<br />
unknown origin. https://www.cdc.gov/media/<br />
releases/<strong>2022</strong>/s0421-hepatitis-alert.html<br />
De Kleine, R.H., Lexmond, W.S., Buescher, G., Sturm,<br />
E., Kelly, D., Lohse, A.W., Lenz, D. & Jorgensen,<br />
M.H. (<strong>2022</strong>). Severe acute hepatitis and acute<br />
liver failure of unknown origin in children: a<br />
questionnaire-based study within 34 pediatric<br />
liver centers in 22 European countries and<br />
Israel, April <strong>2022</strong>. Eurosurveillance, 27(19).<br />
Eurosurveillance | Severe acute hepatitis and<br />
acute liver failure of unknown origin in children:<br />
a questionnaire-based study within 34 pediatric<br />
liver centres in 22 European countries and Israel,<br />
April <strong>2022</strong><br />
European Center for Disease Prevention and Control<br />
(ECDC). (<strong>2022</strong>). Joint ECDC-WHO Regional<br />
Office for Europe Hepatitis of Unknown Origin in<br />
Children Surveillance Bulletin. Stockholm: ECDC;<br />
May 31, <strong>2022</strong>. https://www.ecdc.europa.eu/en/<br />
hepatitis/joint-weekly-hepatitis-unknown-originchildren-surveillance-bulletin<br />
World Health Organization (WHO). (<strong>2022</strong>). Acute<br />
hepatitis of unknown aetiology in children- Multicountry<br />
WHO; May 27, <strong>2022</strong>. https://www.who.<br />
int/emergencies/disease-outbreak-news/item/<br />
DON-389<br />
Bottineau, ND<br />
Full-Time RN/LPN<br />
Also hiring CNAs and<br />
CS/ER Technicians<br />
NEW competitive salary &<br />
excellent benefit package<br />
ND licensure/certification required.<br />
SIGN-ON<br />
BONUS<br />
For more information or an application, please contact<br />
Human Resources at 228-9314 or visit our website at<br />
www.smphealth.org/standrews<br />
Nevaeh Schmieg<br />
My name is Nevaeh<br />
Schmieg. I’m currently<br />
pursuing my BSN at the<br />
University of <strong>North</strong> <strong>Dakota</strong>.<br />
After graduation, I plan<br />
to stay in <strong>North</strong> <strong>Dakota</strong><br />
and work as a registered<br />
nurse in family medicine<br />
or pediatrics. In the future,<br />
I hope to continue my<br />
education to become a<br />
nurse practitioner.<br />
Natalie Buck<br />
My name is Natalie Buck.<br />
I am from Grand Forks, ND<br />
and am currently a senior<br />
at the University of <strong>North</strong><br />
<strong>Dakota</strong> majoring in nursing.<br />
Upon graduation I hope<br />
to work in a burn unit or<br />
the ICU as a bedside nurse<br />
and then continue my<br />
education to become a<br />
nurse practitioner. I have<br />
enjoyed getting involved at UND by also being<br />
a part of my sorority, Kappa Alpha <strong>The</strong>ta, and<br />
volunteering at UND’s Food for Thought Food<br />
Pantry. I enjoy spending my free time at the<br />
lake, playing golf, and reading.<br />
Greta Mclagan<br />
My name is Greta<br />
Mclagan and I’m from<br />
Fargo <strong>North</strong> <strong>Dakota</strong>. I am<br />
studying nursing, and I run<br />
track and cross country for<br />
UND. My interest in nursing<br />
started in high school when<br />
I took a health career class<br />
from my favorite teacher<br />
Mrs. Aho. After graduation,<br />
I plan on continuing to<br />
advance my nursing skills and become a<br />
pediatric or labor and delivery nurse.<br />
Ashley Davis<br />
My name is Ashley Davis,<br />
and I am from Belcourt,<br />
<strong>North</strong> <strong>Dakota</strong>. I currently<br />
am a nursing student at<br />
the University of <strong>North</strong><br />
<strong>Dakota</strong> where I am a part<br />
of the RAIN Program, which<br />
focuses on the recruitment<br />
and retention of Native<br />
Americans into the nursing<br />
field. I am a board member<br />
of the UND Nursing Student<br />
Association. I also work as a 911 Dispatcher here<br />
in Grand Forks, ND and am a medication aide<br />
at Valley Senior Living as well. After graduation<br />
I would ideally like to work with, or alongside,<br />
the RAIN program. Native American students<br />
often face culture shock or other barriers when<br />
pursuing higher education and I would like to<br />
use my education and experience to assist<br />
them through this process in any way that I<br />
can. I would also like to work alongside Indian<br />
Health Services. I feel this will positively impact<br />
the Native American community greatly as I will<br />
be providing a familiar face and understanding<br />
when administering care. Providing better<br />
access to healthcare and education on the<br />
reservations has become a recent focus of mine<br />
and I want to do everything I can to help make<br />
that happen.<br />
NDNA member Susan Indvik and her<br />
husband are sponsoring these students for<br />
Student Subscriber memberships! Click here<br />
or go to the ANA website and hover over the<br />
Membership tab. Click on “Student <strong>Nurse</strong>s” to<br />
read more! To sponsor a student, please email<br />
director@ndna.org.<br />
If you would If you are a nursing instructor<br />
and would like some of your students to be<br />
featured here or if you are a student, we would<br />
love to hear from you! Email director@ndna.org.
<strong>July</strong>, August, September <strong>2022</strong> <strong>The</strong> <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong> Page 11<br />
Psych <strong>The</strong>rapies Compared<br />
to Medication<br />
Appraised by:<br />
Taylor Painter & Mackenzie Duval<br />
Clinical question: How do psychological<br />
therapies, such as animal therapy or cognitive<br />
therapy, compare to medication therapies in<br />
calming dementia patients?<br />
Articles:<br />
Carrion, C., Folkyord, F., Anastasiaduo, D., &<br />
Aymerich, M. (2018). Cognitive therapy for<br />
dementia patients: A systematic review.<br />
Dementia and Geriatric Cognitive Disorder, 46(1-<br />
2), 1-26. https://doi.org/10.1159/000490851<br />
Madhusoodanan, S. & Ting, M.B. (2014).<br />
Pharmacological management of behavioral<br />
symptoms associated with dementia. World<br />
Journal of Psychiatry, 4(4), 72-79. https://doi.<br />
org/10.5498/wjp.v4.i4.72<br />
Muller-Spahn, F. (2003). Behavioral disturbances in<br />
dementia. Dialogues in Clinical Neuroscience,<br />
5(1), 49-59. https://doi.org/10.31887/<br />
DCNS.2003.5.1/fmuellerspahn<br />
Sheikh, A.B., Javed, N., Leyba, K., Khair, A.H., Ijaz,<br />
Z., Dar, A.A., Hanif, H., Farooq, A., & Shekahr,<br />
R. (2021). Pet-assisted therapy for delirium<br />
and agitation in hospitalized patients with<br />
neurocognitive impairment: A review of<br />
literature. Geriatrics (Basel), 6(4). https://doi.<br />
org/10.3390/geriatrics6040096<br />
Synthesis of evidence:<br />
It is estimated that anywhere from 30 to 90<br />
percent of dementia patients experience some<br />
form of psychological or behavior symptoms<br />
(Muller-Spahn, <strong>2022</strong>). It is important to treat<br />
these symptoms in order to maintain the safety<br />
and quality of life of the patient and those<br />
around them. This review focuses specifically on<br />
symptoms and behaviors that impact patient<br />
calmness, such as anxiety, agitation, and<br />
aggression.<br />
<strong>The</strong>re are two forms of intervention that<br />
can be utilized: pharmaceutical and nonpharmaceutical.<br />
Pharmaceutical interventions<br />
use medications such as antidepressants,<br />
sedative hypnotics, cholinesterase inhibitors,<br />
mood stabilizers and antipsychotics. Because<br />
these medications can result in adverse<br />
effects, the possible risks and benefits must be<br />
weighed carefully. It is also recommended<br />
that pharmaceutical interventions are not<br />
used unless non-pharmaceutical therapies<br />
have failed or the patient’s symptoms require<br />
immediate treatment (Madhusoodanan &<br />
Ting, 2014). <strong>The</strong>re is a wide variety of nonpharmaceutical<br />
treatment options, but this<br />
review focuses on cognitive therapy and<br />
animal-assisted therapy. Cognitive therapy<br />
utilizes a combination of reality orientation and<br />
skills training in an attempt to reverse or slow the<br />
development of cognitive impairment (Carrion<br />
et al., 2018).<br />
Bottom line:<br />
Many existing studies have found the use of<br />
cognitive therapy to be beneficial to patients<br />
while others have found it to have no effect. <strong>The</strong><br />
same can be said for animal-assisted therapy,<br />
although some studies have found animal<br />
exposure can exacerbate symptoms in severe<br />
cases. Due to small sample sizes, inconsistent<br />
study designs, and lack of randomizedcontrolled<br />
trials, results are inconclusive at this<br />
time. It is currently unclear if psychological<br />
interventions are more effective at promoting<br />
patient calmness than pharmaceuticals,<br />
although they have proven to be less risky.<br />
Once the better intervention has been<br />
determined, more randomized-controlled<br />
trials are needed to determine the number<br />
of sessions, length of sessions, and duration of<br />
intervention that give the best results.<br />
Implication for nursing practice:<br />
Dementia can cause a wide variety of<br />
symptoms, some of which pose a threat<br />
to patients and those around them. It is<br />
important to try and combat these symptoms<br />
in a way that maintains quality of living for<br />
the patient, while also keeping everyone<br />
involved safe. Pharmaceutical intervention<br />
can be an effective treatment but can also<br />
cause other symptoms, decrease quality of<br />
life, and increase patient mortality. Cognitive<br />
and animal-assisted therapy have produced<br />
inconclusive results in terms of effectiveness but<br />
have not shown to have negative impacts on<br />
patients. When working with dementia patients,<br />
non-pharmaceutical interventions should be<br />
attempted first as they are less likely to cause<br />
harm to patients.<br />
NDNA’s Highlight a<br />
<strong>Nurse</strong>!<br />
Meet Megan Teske, BSN, RN<br />
Nursing Specialty: Family<br />
Practice Nursing<br />
By Joylyn Anderson, APRN, BSN<br />
What sparked your interest<br />
in nursing?<br />
As a freshman in high<br />
school, I had a family<br />
member suffer a medical<br />
illness that required<br />
hospitalization for several<br />
weeks. <strong>The</strong> nurses (in the<br />
same facility I now work<br />
in) showed so much love<br />
and compassion in the<br />
care they delivered that<br />
it created a drive in me to<br />
do the same for others.<br />
Although that experience<br />
wasn’t particularly a good<br />
one, I am so grateful for it for leading me into this<br />
profession of caring for others.<br />
What does a typical day look like for you?<br />
I work part-time in a rural health clinic<br />
specializing in allergy and family practice. It is a<br />
busy facility that provides care to people of all<br />
ages. Every day is different, which is one of the<br />
things I like most.<br />
What do you find challenging?<br />
Insurance companies. Seeing this side of<br />
nursing has shown me how difficult and frustrating<br />
it can be for patients to get the services they need<br />
in a timely manner.<br />
<strong>The</strong> past two years of the pandemic have been<br />
challenging for nurses. What self-care advice<br />
would you give to new graduate nurses?<br />
As a mom of three, self-care can be difficult<br />
to come by as is… but even more so as a nurse.<br />
Sleep is one of the most important things for my<br />
personal self-care at this stage of my life… it is<br />
hard to function and think critically without it.<br />
It is so important to make time for yourself & the<br />
activities you enjoy. It’s impossible to pour from an<br />
empty cup.<br />
<strong>The</strong> Quest for Excellence<br />
Karen L. Zimmerman, MSN, RN<br />
Have you ever found yourself in a position<br />
of asking if where you are is where you want<br />
to be? What are your aspirations and more<br />
importantly, how hard are you willing to work<br />
to get to where you want to be? As humans,<br />
we often unknowingly place a filtered lens<br />
(aka rose colored glasses) over our eyes that<br />
protects us in such a way, that we may be<br />
blinded by the reality of a situation. Humans<br />
were developed with that protection in part,<br />
to shield us from the impact of trauma. That<br />
becomes problematic when we are blinded to<br />
areas of opportunity. This filtered view may lead<br />
to complacency and/or blocking behaviors<br />
when changes are necessary. John Kotter<br />
(1996) author of Leading Change, states that<br />
“complacency, is supported by the very human<br />
tendency to deny that which we do not want to<br />
hear” (p. 43). This is especially problematic in a<br />
work environment when trying to drive change<br />
because “life is usually more pleasurable<br />
without problems” (Kotter, 1996, p. 43).<br />
If I were to ask you if you wanted to be known<br />
for excellence or mediocrity, you would likely<br />
look at me like I had two heads. Most of us do<br />
not desire to be average, yet there are times<br />
in our life, personally or professionally, that we<br />
find ourselves in that very place. Maybe fear is<br />
preventing us from challenging the status quo<br />
because we are afraid to confront someone or<br />
something that is blocking forward movement.<br />
Maybe we are too tired to expend the effort<br />
it will take to move from a place of comfort.<br />
Maybe we want to make changes or be part<br />
of the solution, but we do not know how and<br />
are afraid to show our vulnerability and ask for<br />
help due to fear of being judged or accused of<br />
being an imposter. Maybe we are afraid of our<br />
own judgment. Or just maybe doing the right<br />
thing is too difficult because of potential barriers<br />
or backlash.<br />
I issue the following challenge to each of us:<br />
1. Do not accept mediocrity.<br />
2. Strive for excellence wherever you are.<br />
3. Be part of the solution not the problem.<br />
4. Hold others accountable if you see<br />
deficiencies in their practice (i.e. seeing<br />
someone not performing hand hygiene).<br />
5. Join a committee or ask how you can<br />
contribute to an effort of change or<br />
improvement.<br />
6. Do not get defensive if someone coaches<br />
you.<br />
7. Do NOT be a blocker.<br />
Colin Powell once stated, “if you are going to<br />
achieve excellence in big things, you develop<br />
the habit in little matters. Excellence is not an<br />
exception; it is a prevailing attitude.” Rather<br />
than saying “no,” say “how” and make an effort<br />
to ensure your attitude is such that you support<br />
change and strive for excellence instead of<br />
accepting mediocrity.<br />
Kotter, J. (1996). Leading Change. Harvard Business<br />
Review Press.<br />
<strong>The</strong> <strong>North</strong> <strong>Dakota</strong> Department of Health has seen<br />
a decrease in the number of immunized children<br />
(regular immunization) as a result of not having<br />
access to care during the pandemic. Is this<br />
something that you are seeing in your rural area?<br />
We have definitely seen a decrease in our<br />
immunization rates due to the pandemic. Our<br />
rates are normally fairly high thanks to scheduled<br />
well child visits and our Public Health <strong>Nurse</strong><br />
offering immunizations to children in our school<br />
systems. However, people were not scheduling<br />
routine exams for their children during the height<br />
of the pandemic, nor was there much time for<br />
our Public Health <strong>Nurse</strong> to offer routine screenings<br />
and visits to the schools.<br />
If so, is there anything that you recommend doing<br />
to help promote timely immunizations?<br />
We have a traveling Pediatrician that visits our<br />
facility once a month. She has been seeing a<br />
significant increase in the number of patients she<br />
sees when she visits our facility. We advertise on<br />
Facebook & our weekly newspaper to alert the<br />
community of her scheduled visits and for routine<br />
vaccination.<br />
Nursing Faculty position<br />
Beginning August <strong>2022</strong><br />
Teaching Mental Health and<br />
Medical Surgical Nursing<br />
For more details,<br />
visit www.uj.edu/employment.
Page 12 <strong>The</strong> <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong> <strong>July</strong>, August, September <strong>2022</strong><br />
NDNA Attends ANA Hill Day and<br />
Membership Assembly <strong>2022</strong> in Washington, DC<br />
Sherri Miller, BS, BSN, RN,<br />
NDNA Executive Director<br />
NDNA was back in DC!<br />
NDNA President Tessa Johnson, elected<br />
NDNA Membership Assembly Representative<br />
Susan Indvik, and I attended the <strong>2022</strong> ANA Hill<br />
Day and Membership Assembly in Washington,<br />
DC June 9-11.<br />
If you do not know, ANA Hill Day is a unique<br />
opportunity for nurses across the county to<br />
meet with their members of Congress and to<br />
share their perspectives on the most pressing<br />
issues facing nurses across the nation.<br />
At Membership Assembly, the representatives<br />
vote on everything, from bylaws to position<br />
statements, that affect legislation and nursing<br />
practice. Candidates for elected positions<br />
share their stance and discuss viewpoints. This<br />
particular event has been the first in-person<br />
event for ANA in three years!<br />
We were very excited as meetings began<br />
early Thursday morning with a breakfast briefing<br />
that provided a federal legislative overview<br />
and key talking points for nurse representatives<br />
to share with their members of Congress during<br />
the day’s scheduled meetings.<br />
Dr. Ernest Grant began this day with an<br />
inspiring speech and a fun, surprise impromptu<br />
rendition of “Sweet Caroline” when he filled<br />
time in the program (after a dare!). Brian Davis,<br />
Grassroots Advocacy Coordinator for ANA’s<br />
Department of Policy and Government Affairs,<br />
provided logistics for Hill Day, and Samuel<br />
Hewitt and Kristina Weger from ANA’s Federal<br />
Government Affairs reviewed the issue briefs<br />
which included Workplace Violence and the<br />
Value of Nursing.<br />
ANA-California’s President, Dr. Anita Girard<br />
DNP, RN, CNL, CPHQ, NEA-BC, introduced<br />
U.S. Representative Lucille Roybal-Allard.<br />
Representative Roybal-Allard reminds nurses to<br />
take steps to get their elected officials to get<br />
to know them and their staff. She encouraged<br />
us to offer to help and stated that “the more<br />
you get to know them, the more they’ll want to<br />
help.” This inspired us to start our meetings!<br />
We had a remote visit with Senator John<br />
Hoeven’s Legislative Assistant, Ty Kennedy, on<br />
June 23.<br />
We discussed:<br />
• “Valuing the Nursing Workforce” in which<br />
we provided findings from the American<br />
<strong>Nurse</strong>s Foundation COVID-19 Two-Year<br />
Impact Assessment Survey. We noted that<br />
60% of acute care nurses report feeling<br />
burned out and 75% report feeling stressed,<br />
exhausted, and frustrated. Two out of three<br />
nurses under 35 reported feeling burned<br />
out. We asked them to cosponsor and<br />
pass the Workplace Violence Prevention<br />
for Health Care and Social Service Workers<br />
Act (S. 4182/H.R. 1195).<br />
• “Improving Seniors’ Timely Access to Care<br />
Act of 2021” with the goal of protecting<br />
patients from unnecessary delays in<br />
care by streamlining and standardizing<br />
prior authorization under the Medicare<br />
Advantage program.<br />
In discussing these bills and issues, we felt our<br />
meetings went very well and that we expressed<br />
our points clearly to the members of Congress<br />
who heard and received our message. We<br />
even felt that we had an emotional personal<br />
connection with them in telling our stories.<br />
We then went into ANA Membership<br />
Assembly on June 10th and 11th. Early morning<br />
on June 10th was an opportunity to meet the<br />
candidates and a Hearing on ANA Racial<br />
Reckoning Statement. President Ernest Grant<br />
gave a “Call to Order” and we began the<br />
order of business. His President’s Address<br />
was wonderful. He stated, “when nurses are<br />
protected, patients are as well.” He went on<br />
to say that we need to “push for changes to<br />
ensure that nurses have a professional home.”<br />
President Grant also shared a personal side as<br />
he gave an emotional thank you to the ANA<br />
Board of Directors, membership, and staff for his<br />
term in office which will be ending in December<br />
of <strong>2022</strong>. We are so pleased that President Grant<br />
will be the keynote speaker at the NDNA Fall<br />
Conference, “Celebrating the Art of Nursing”<br />
September 20, <strong>2022</strong> in Bismarck. During<br />
President Grant’s address, NDNA was one of the<br />
C/SNAs (Constituent/State <strong>Nurse</strong>s Associations)<br />
recognized for their years of existence – 110<br />
years for NDNA. (Watch for more upcoming<br />
celebration on that note!)<br />
In the afternoon on the first day, the Dialogue<br />
Forums were held on the below topics that had<br />
been submitted.<br />
• <strong>The</strong> Impact of Climate Change on Health<br />
• Advancing Solutions to Address Verbal<br />
Abuse and Workplace Violence Across<br />
the Continuum of Care where key points<br />
were brought out such as if someone on<br />
a flight assaulted a flight attendant, but<br />
not a nurse in a hospital! Verbal threats<br />
are violence as well and de-escalation<br />
techniques should be part of training/<br />
orientation for staff<br />
• <strong>Nurse</strong> Staffing where discussion focused<br />
on patient outcomes, school nursing/<br />
long term care (not just acute care) and<br />
referring to ratios as “standards.”<br />
Friday we also heard a very positive report<br />
from ANA’s Treasurer and some scheduling<br />
updates from the Vice President.<br />
On Saturday, the last day of Membership<br />
Assembly, we heard a moving Nightingale<br />
Tribute. We were then able to do some<br />
lunchtime networking and hear from the ANA<br />
Professional Policy Committee.<br />
For the elections, the Membership Assembly<br />
elected Jennifer Mensik Kennedy, PhD, MBA,<br />
RN, NEA-BC, FAAN, of the Oregon <strong>Nurse</strong>s<br />
Association as the association’s next president<br />
to represent the interests of the nation’s more<br />
than 4.3 million registered nurses. Mensik has<br />
more than 25 years of nursing experience in a<br />
variety of settings ranging from rural critical<br />
access hospitals and home health to hospital<br />
administration, and academia. She has served<br />
as President of the Arizona <strong>Nurse</strong>s Association<br />
and 2nd Vice President and Treasurer of ANA.<br />
<strong>The</strong> term of service for Dr. Mensik and all other<br />
newly elected leaders will begin January 1,<br />
2023.<br />
ANA’s Membership Assembly also elected<br />
four members to serve on the board of<br />
directors. <strong>The</strong> newly elected board members<br />
are: Secretary Amanda Oliver, BSN, RN, CCRN,<br />
of ANA–Illinois; Director-at-Large, Edward<br />
Briggs, DNP, MS, APRN, of the Florida <strong>Nurse</strong>s<br />
Association; Director-at-Large, Jennifer Gil, MSN,<br />
RN, of the New Jersey State <strong>Nurse</strong>s Association;<br />
and Director-at-Large, Staff <strong>Nurse</strong>, David<br />
Garcia, MSN, BSN, RN, PCCN, of the Washington<br />
State <strong>Nurse</strong>s Association.<br />
<strong>The</strong> following ANA board members will<br />
continue their terms: Susan Swart, EdD, MS,<br />
RN, CAE, of ANA-Illinois as Vice President;<br />
Joan Widmer, MS, MSBA, RN, CEN, of the New<br />
Hampshire <strong>Nurse</strong>s Association as Treasurer;<br />
Amy McCarthy, MSN, RNC-MNN, NE-BC, of<br />
the Texas <strong>Nurse</strong>s Association as Director-at-<br />
Large; and Marcus Henderson, MSN, RN, of<br />
the Pennsylvania State <strong>Nurse</strong>s Association as<br />
Director-at-Large, Recent Graduate.<br />
Elected to serve on the Nominations and<br />
Elections Committee are: MaryLee Pakieser,<br />
MSN, RN, FNP-BC, of ANA Michigan; Jennifer<br />
Tucker, MA, RN, of the Minnesota Organization<br />
of Registered <strong>Nurse</strong>s; and Kimberly Velez, MSN,<br />
RN, of ANA - New York.<br />
This event is an excellent opportunity to<br />
express our nursing voices and represent our<br />
state. It was my second time to be “in person”<br />
for Hill Day and Membership Assembly, and<br />
again I felt it was an extreme honor and<br />
privilege! We were treated with respect by<br />
our legislators and their staff who were all<br />
hospitable and provided us the opportunity<br />
to engage in meaningful and collaborative<br />
discussions. It’s truly an experience that<br />
connects <strong>North</strong> <strong>Dakota</strong> nurses to ANA’s mission<br />
of “nurses advancing our profession to improve<br />
health for all.”
<strong>July</strong>, August, September <strong>2022</strong> <strong>The</strong> <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong> Page 13<br />
I would like to thank NDNA President Tessa<br />
Johnson and NDNA Membership Assembly<br />
Representative Susan Indvik for being excellent<br />
partners on this event. <strong>The</strong>y deserve extra kudos<br />
for some travel woes they encountered on the<br />
way home – forcing each of them to stay in a<br />
few other cities and extra days before finally<br />
making it home.<br />
<strong>North</strong> <strong>Dakota</strong> nurses, if you are interested in<br />
being involved in Hill Day/Membership Assembly<br />
or any ANA/NDNA activities, you are welcome<br />
to attend our open Board Meetings to become<br />
engaged or talk to anyone at NDNA!<br />
Photo credit: Jerry Frishman Photo credit: Jerry Frishman Photo credit: Jerry Frishman
Page 14 <strong>The</strong> <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong> <strong>July</strong>, August, September <strong>2022</strong><br />
CAUTI’s and External Catheterization<br />
Appraised by:<br />
Brenna Hoger SN, Patricia Shepard SN, Kaylie<br />
Wilson SN, Ashley Wanner SN, Emily Russell SN,<br />
Morgane Inangorore SN<br />
Allison Sadowsky MSN RN Assistant Professor<br />
of Practice (Faculty)<br />
(NDSU School of Nursing at Sanford Bismarck)<br />
Clinical Question:<br />
For women in need of urinary catheterization,<br />
does the use of external catheterization reduce<br />
the risk for urinary tract infections compared to<br />
indwelling foley catheters?<br />
List of Articles:<br />
Eckert, L., Mattia, L., Patel, S., Okumura, R., Reynolds,<br />
P., & Stuiver, I. (2020). Reducing the risk of<br />
indwelling catheter-associated urinary tract<br />
infection in female patients by implementing<br />
and alternative female external urinary<br />
collection device: A quality improvement<br />
project. Journal of wound, ostomy, and<br />
continence nursing: official publication of <strong>The</strong><br />
Wound, Ostomy, and Continence <strong>Nurse</strong>s Society,<br />
47(1), 50-53.<br />
Leontie, S.L., & Delawder, J.M. (2021). Utilizing a ‘Fight<br />
the Foley’ bundle to reduce device utilization<br />
rates and catheter-associated urinary tract<br />
infections. Urologic Nursing, 41 (4), 208-213.<br />
Rearigh, L., Gillett, G., Sy, A., Micheels, T., Evans, L.,<br />
Goetschkes, K., Van Schooneveld, T.C., Lyden, E.,<br />
& Rupp, M.E. (2021). Effect of an external urinary<br />
collection device for women on institutional<br />
catheter utilization and catheter-associated<br />
urinary tract infections. Infection control and<br />
hospital epidemiology, 42(5), 619-621. https://doi.<br />
org/10.1017/ice.2020.1259<br />
Van Decker SG., Bosch N., Murphy J. (2021). Catheter<br />
associated urinary tract infection reduction<br />
in critical care units: a bundled care model.<br />
BMJ Open Quality, 10(e001534) Doi: 10.1136/<br />
bmjoq-2021-001534<br />
Warren, C., Fosnacht, J. D., & Tremblay, E. E. (2021).<br />
Implementation of an external female urinary<br />
catheter as an alternative to an indwelling<br />
urinary catheter. American journal of infection<br />
control, 49(6), 764–768. https://doi.org/10.1016/j.<br />
ajic.2020.10.023<br />
Zavodnick, J., Harley, C., Zabriskie, K., & Brahmbhatt,<br />
Y. (2020). Effect of a female external urinary<br />
catheter on incidence of catheter-associated<br />
urinary tract infection. Cureus. https://doi.<br />
org/10.7759/cureus.11113<br />
Synthesis of Evidence:<br />
Six articles were reviewed as evidence<br />
in this report, including three retrospective<br />
observational studies and three quasiexperimental<br />
quality improvement project<br />
studies. Rearigh et al (2021) stated “catheterassociated<br />
urinary tract infections (CAUTIs) are<br />
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a common hospital-acquired infection resulting<br />
in excess morbidity, mortality, and cost.” Urine<br />
management, for women in particular, has<br />
been challenging due to the limited options<br />
for control of urinary incontinence and the<br />
anatomy of the female body. <strong>The</strong> external<br />
catheter allows for urine management in a<br />
manner that is still easily measurable and<br />
accurate and avoids an indwelling catheter.<br />
Eckert et al (2020) conducted a quasiexperimental<br />
“quality improvement project.”<br />
This project entailed the use of a “test run”<br />
in one unit utilizing a female external urinary<br />
collection device in an effort to reduce the<br />
number of CAUTI rates in female patients<br />
needing urinary management. <strong>The</strong> trial run<br />
included a 60-bed telemetry unit for 30 female<br />
patients requiring urinary management. At<br />
the end of the trial period, each nurse on the<br />
unit who used the female external urinary<br />
collection device was given a survey, and the<br />
nursing usage reports were positive. After the<br />
trial run and survey analysis, the experiment<br />
was expanded to other units in the hospital.<br />
<strong>The</strong> amount of CAUTI rates with the use of a<br />
foley catheter were compared to CAUTI rates<br />
with the use of the female external urinary<br />
collection (FEUC) device. Before implementing<br />
the use of a FEUC device, the female CAUTI<br />
rate were eight cases per 7,181 indwelling<br />
catheter device days, so approximately 0.11%.<br />
After implementation of the FEUC device,<br />
CAUTI rates were approximately 0% in 2016,<br />
and 0.09% in 2017. It was found that the use<br />
of a female urinary collection device may<br />
reduce both indwelling catheter utilization and<br />
CAUTI rates if a consistent, comprehensive, and<br />
interdisciplinary approach is used to assess<br />
CAUTI bundle compliance that included a FEUC<br />
device.<br />
Leontie and Delawder (2021) conducted<br />
a quasi-experimental “quality improvement<br />
project” (QI). This QI was conducted to<br />
determine if implementing a ‘fight the Foley’<br />
bundle would reduce the device utilization<br />
rates of indwelling catheters and reduce the<br />
rates of CAUTI. This study included anyone<br />
with an indwelling catheter on a critical care,<br />
intermediate care, or medical surgical unit in a<br />
238 bed Not-for-profit hospital. Pre-intervention<br />
data was collected from <strong>July</strong> 2017 to August<br />
2018 and post intervention data was collected<br />
from October 2018 to September 2019. <strong>The</strong><br />
intervention developed an implementation<br />
of a daily ‘Fight the Foley’ line huddle for unit<br />
leaders, developed and implemented a Foley<br />
stop huddle prior to insertion and increased<br />
available alternative devices (Pure Wick). <strong>The</strong><br />
major finding of this study found that there<br />
was a downward trend in CAUTIs, but no<br />
clinical significance was noted. <strong>The</strong>re were 16<br />
CAUTIs captured pre-intervention and eight<br />
in the post-intervention timeframe. <strong>The</strong>re was<br />
statistical significance in alternative device<br />
usage which increased with a 105% increase<br />
in condom catheter use, 16% with intermittent<br />
catheterization, and 409% increase in female<br />
urinary incontinence device usage such as Pure<br />
Wick.<br />
Rearigh et al (2021) conducted a<br />
retrospective quasi-experimental study to<br />
determine whether external urinary catheter<br />
devices, in comparison to indwelling catheters,<br />
decreased the amount of catheter usage days,<br />
catheter associated urinary tract infections in<br />
females, and adverse events associated with<br />
urinary catheterization. <strong>The</strong> study included<br />
2,347 adult inpatient women in need of urinary<br />
catheterization during the experimental period<br />
(14 months) and other female patients (number<br />
not stated) in the control comparison period<br />
(14 months). <strong>The</strong> intervention in this study was to<br />
initiate the external collection device, otherwise<br />
known as the “PureWick.” <strong>The</strong> study found that<br />
there was a significant decrease in catheter<br />
utilization (71.49 to 56.15), the rate of CAUTI<br />
decreased (0.15-0.09), and there were only five<br />
reported adverse events in the 14 months of the<br />
experimental period related to malposition of<br />
the “PureWick” and patient allergies.<br />
Van Decker SG., Bosch N., Murphy J. (2021)<br />
conducted a quasi-experimental quality<br />
improvement project utilizing the Plan/Do/<br />
Study/Act (PDSA) Framework at a Boston<br />
Medical Center (BMC) hospital in Boston,<br />
Massachusetts starting in Spring 2013 and<br />
spanning five years. <strong>The</strong> CAUTI taskforce<br />
implemented the PDSA cycle and used CAUTI<br />
rates per 1000 patient days as measurement,<br />
which aimed at testing the effect of Purewick<br />
external catheter use among female ICU<br />
patients and resulted in a significant downward<br />
shift from 5.86 to 1.62 mean CAUTI rate post<br />
intervention.<br />
Warren et al (2021) conducted a quasiexperimental<br />
retrospective study. <strong>The</strong> purpose<br />
of this study was to analyze “the impact of a<br />
hospital-wide implementation of an external<br />
female urinary catheter at a large academic<br />
medical center.” This study compared predevice<br />
implementation and post-device<br />
implementation to see if there was a reduction<br />
of CAUTIs. This study took place in a large<br />
academic center in Madison, WI. Data was<br />
collected from March 1, 2016, until May 31,<br />
2018. This study compared CAUTI rates per unit<br />
month, indwelling urinary catheter utilization<br />
rate, and external urinary catheter utilization<br />
rate in a retrospective chart review from EPIC.<br />
<strong>The</strong> major findings of this study were that the<br />
overall female CAUTI rate went from 5.5 to<br />
1.7, indwelling urinary catheter utilization ratio<br />
decreased from 0.46 to 0.35, and external<br />
female urinary catheter device utilization<br />
increased from 0 to 0.17.<br />
Zavodnick, Zabriskie, and Brahmbhatt (2020)<br />
conducted a retrospective observational study.<br />
This study was conducted to investigate the<br />
effect of female external urinary catheters<br />
(FEUCs) on indwelling catheter use and female<br />
CAUTIs. <strong>The</strong> study focused on female ICU<br />
patients at Thomas Jefferson University Hospital.<br />
<strong>The</strong> study included ICU patients during the<br />
preintervention time period of Jan 1, 2017 to<br />
December 31, 2017 and then the intervention<br />
period of Jan 1, 2018 to December 31, 2019<br />
when the FEUC became available. <strong>The</strong> major<br />
findings were that female CAUTI rates were<br />
3.14 per 1000 catheter days and 1.42 after the<br />
FEUC was introduced. CAUTI rates decreased<br />
by over 50% after the FEUC was introduced.<br />
Device-associated pressure injury (DAPI)<br />
increased after the FEUC was introduced. <strong>The</strong><br />
DAPI was 0.49% for preintervention and 0.61%<br />
during intervention. Overall, after the FEUC<br />
was introduced, CAUTI rates had a significant<br />
decrease.<br />
Conclusions: Brief Summary of the Evidence<br />
All six articles indicated a downward<br />
trend in catheter associated urinary tract<br />
infections after implementing an external<br />
catheter device in females in comparison to<br />
indwelling catheters. Also, all articles showed<br />
a decrease in overall catheter usage days<br />
after the implementation of the external<br />
female collection device. However, Zavodnick,<br />
Zabriskie, and Brahmbhatt (2020) found that<br />
there was an increase in adverse events after<br />
the implementation of the external device due<br />
to device associated pressure injuries.<br />
Implications for Nursing Practice:<br />
(Recommendations for Practice)<br />
According to this research, there is evidence<br />
to suggest that implementing an external<br />
urinary collection device will reduce catheter<br />
associated urinary infections and reduce the<br />
number of catheter usage days in female<br />
patients. Warren et al (2021) recommended<br />
that facilities first implement the device in<br />
the ICU as this level of care was where they<br />
observed the most significant impact, before<br />
facilities implement the device on every floor.<br />
This external female collection device provides<br />
a non-invasive method to manage female<br />
urinary incontinence, measure urinary output<br />
and reduce skin breakdown from urinary<br />
incontinence, which overall improves patient<br />
outcomes and associated costs.
<strong>July</strong>, August, September <strong>2022</strong> <strong>The</strong> <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong> Page 15<br />
Ozone Compared to 02<br />
Appraised By:<br />
Amanda Hanson, RN, Mayville State University<br />
RN-to-BSN Student; Ashley Locken, RN, Mayville<br />
State University RN-to-BSN Student; Brandon<br />
Ferguson, RN, Mayville State University RN-to-<br />
BSN Student.<br />
Clinical Question:<br />
In patients hospitalized for COVID-19, how<br />
does integrating ozone treatment compared to<br />
O2 alone affect prognosis?<br />
Articles:<br />
Hernández, A., Viñals, M., Pablos, A., Vilás, F.,<br />
Papadakos, P. J., Wijeysundera, D. N., Bergese,<br />
S. D., & Vives, M. (2020, December 5). Ozone<br />
therapy for patients with COVID-19 pneumonia:<br />
Preliminary report of a prospective case-control<br />
study. International immunopharmacology.<br />
Retrieved April 12, <strong>2022</strong>, from https://www.ncbi.<br />
nlm.nih.gov/pmc/articles/PMC7833586/<br />
Hernández, Viñals, M., Isidoro, T., & Vilás, F. (2020).<br />
Potential Role of Oxygen-Ozone <strong>The</strong>rapy<br />
in Treatment of COVID-19 Pneumonia. <strong>The</strong><br />
American Journal of Case Reports, 21, e925849–<br />
e925849–6. https://doi.org/10.12659/AJCR.925849<br />
Orscelik, A., Karaaslan, B., Agiragac, B., Solmaz,<br />
I., & Parpucu, M. (2020). Could the minor<br />
autohemotherapy be a complementary therapy<br />
for healthcare professionals to prevent COVID-19<br />
infection? Annals of Medical Research,<br />
28(10), 1863–1869. https://doi.org/10.5455/<br />
annalsmedres.2020.11.1133<br />
Synthesis of Evidence:<br />
Ozone therapy is considered a nonpharmacologic<br />
method which can be used<br />
as a complementary therapy when paired<br />
with pharmacologic interventions in the<br />
treatment of COVID-19. <strong>The</strong> treatment method<br />
depends on the severity of the infection and<br />
what stage of the infection the patient is<br />
currently experiencing. Ozone therapy is used<br />
in conjunction with standard treatment for<br />
COVID-19 to improve patient outcomes and<br />
provide for a better prognosis than using O2<br />
therapy alone. “Ozone therapy acts as an<br />
auto-vaccine which can induce the oxidation<br />
of the viral components” and is administered<br />
as a minor hemotherapy (Orscelik, et al, 2020,<br />
g 1863). <strong>The</strong> treatment method depends on<br />
the severity of the infection and what stage<br />
of the infection the patient is currently in. It<br />
also depends on if the patient is receiving<br />
pharmacological treatment for the infection.<br />
<strong>The</strong> research for this study was a random<br />
sample study that was obtained from a group<br />
of people that had tested positive for COVID-19<br />
and were symptomatic. <strong>The</strong> research that<br />
was conduced was used to determine the<br />
benefits of the use of ozone therapy for patients<br />
that tested positive for COVID-19 and were<br />
experiencing symptoms.<br />
A randomized controlled group that<br />
consists of three covid positive individuals<br />
that acquired covid induced pneumonia,<br />
gave informed consent to receive ozone<br />
oxygenated treatment. <strong>The</strong>se three individuals<br />
that presented with respiratory distress was<br />
a 49-year-old male, 61-year-old male, and<br />
64-year-old female. Each patient received four<br />
to six sessions of the ozone autohemotherapy.<br />
<strong>The</strong> outcomes were that each patient was<br />
able to discharge from the hospital on day two<br />
through four after ozone treatment. Laboratory<br />
tests and chest x-rays obtained before, during<br />
and after treatment and shown significant<br />
improvements throughout the study. None of<br />
these three patients needed invasive measures<br />
for breathing assistance, oxygenation, or<br />
mechanical ventilation. Each patient had an<br />
overall rapid clinical improvement after ozone<br />
therapy.<br />
Bottom Line:<br />
COVID-19 was a rapid outbreak that spread<br />
from person to person through airborne and<br />
droplets causing a global pandemic in March<br />
of 2020. This pandemic continued on through<br />
early <strong>2022</strong>. Guidelines were put in place that<br />
instructed people to isolate in their homes and<br />
wear masks when they were out in public to<br />
hopefully stop the spread of this new infection.<br />
Treatment options were limited due to the<br />
unknowns of the infection transmission, cause,<br />
and barriers. When the infection first surfaced<br />
in the United States, standard treatment was<br />
supplemental oxygen therapy and occasional<br />
antibiotic treatment. Through research and trial<br />
and error, new standards for infection treatment<br />
have surfaced.<br />
One of the new treatments was ozone<br />
therapy. Ozone treatment is an alternative<br />
medical therapy that introduces ozone to the<br />
body. For the treatment of COVID-19, ozone is<br />
mixed with a patient’s blood and reinjected<br />
into the patient’s body. This process is known<br />
as autohemotherapy. “Ozone therapy can<br />
be giving in multiple treatments; it improves<br />
oxygenation through attaching to the blood<br />
cells and it consider to be ‘10 times more soluble<br />
than oxygen’” (Hernadez et. al. 2020). This<br />
therapy is shown to improve the overall immune<br />
system response.<br />
Studies have shown that ozone therapy<br />
combined with supplemental oxygen have<br />
significantly decreased COVID-19 symptoms<br />
and prevented the need for mechanical<br />
ventilation or intubation. Ozone therapy was<br />
trialed in some areas and was found to be<br />
successful in COVID treatment, however, there<br />
is not enough studied evidence to consider it a<br />
true treatment for COVID-19 symptoms.<br />
Ozone therapy can be used in the<br />
treatment of COVID-19 infection in addition<br />
to traditional treatment of the infection. <strong>The</strong>re<br />
is not enough evidence to determine if using<br />
ozone therapy alone would provide better<br />
outcomes for the patient, so it is determined<br />
that using it in addition to oxygen therapy and<br />
pharmacologic treatment provides better<br />
outcomes for the patient. <strong>The</strong>re is still more<br />
research available, and all studies are shortterm<br />
with moderate-small sample sizes.<br />
Implications for Nursing Practice:<br />
Ozone therapy cannot be said to provide<br />
sufficient protection alone but can be used<br />
with other treatments to provide better results in<br />
protection and therapy for COVID-19 infection.<br />
Using ozone as an adjuvant therapy in the<br />
treatment of COVID-19 associated pneumonia<br />
is shown to be beneficial to the patient.<br />
Determining what patients can receive ozone<br />
therapy and which patients are candidate for<br />
other forms of therapy is imperative to ensure<br />
the patient is getting the highest quality of<br />
care/treatment for the best results. Early results<br />
show that ozone therapy does benefit patients<br />
affected by the COVID-19 virus.<br />
<strong>Nurse</strong>s should continue to educate<br />
themselves on potential treatment options for<br />
patients with COVID-19 infection. Many people<br />
are rather skeptical about the infection and<br />
the presented treatment options. Staying up to<br />
date by reading current studies can go a long<br />
way when talking to people about treatment<br />
options for COVID-19 infection, including Ozone<br />
therapy.
Page 16 <strong>The</strong> <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong> <strong>July</strong>, August, September <strong>2022</strong><br />
Progression of <strong>North</strong> <strong>Dakota</strong> POLST and Emergence of Honoring<br />
Choices® <strong>North</strong> <strong>Dakota</strong><br />
Nancy E. Joyner, MS, CNS-BC, APRN, ACHPN®<br />
Karli Olson, DNP, APRN, FNP-C, CCRN<br />
Inception of POLST<br />
In 2003, Altru Health System staff from Grand<br />
Forks, Nancy Joyner, MS, CNS-BC, APRN, ACHPN®<br />
and Gayla Drengson, MS, LICSW, attended<br />
Physician Orders for Life Sustaining Treatment<br />
(POLST) session at a national conference and<br />
brought the information back to administration.<br />
At that time, Altru Health System was evaluating<br />
the change the code level status from numbers<br />
(e.g., 1,2,3) to nationally recognized wording<br />
(e.g., Full Code, Do Not Resuscitate (DNR), Do Not<br />
Intubate (DNI), and Allow Natural Death (AND)<br />
as well as promote engagement in serious illness<br />
conversations.<br />
By 2007, Altru Health System developed a<br />
workgroup of physicians, nurses, social workers,<br />
chaplains, and other disciplines to study and<br />
plan for the implementation of the POLST form.<br />
Both a POLST policy and form were developed<br />
and adapted through Altru Health System. Altru<br />
worked with first responders and paramedics in<br />
hopes of implementing POLST in the communities<br />
surrounding Grand Forks. <strong>The</strong> local long term care<br />
facilities also became involved. <strong>The</strong>re was also<br />
interest, regarding the implementation of POLST,<br />
at the state level from the <strong>North</strong> <strong>Dakota</strong> Medical<br />
Association’s (NDMA) Ethics Committee at that<br />
time.<br />
In 2010, the <strong>North</strong> <strong>Dakota</strong> Medical Association’s<br />
House of Delegates adopted a resolution, urging<br />
<strong>North</strong> <strong>Dakota</strong> physicians and other healthcare<br />
professionals across all healthcare settings to<br />
consider POLST components in developing<br />
an initiative across the state. NDMA’s Ethics<br />
Committee reviewed the National Institutes of<br />
Health (NIH) support of POLST and analyzed<br />
studies published, regarding POLST, and<br />
concluded that engaging in POLST conversations<br />
have a significant advantage over traditional<br />
methods to communicate preferences about<br />
life-sustaining treatment. <strong>The</strong> Minnesota Medical<br />
Association Ethics Committee and Medical-Legal<br />
Affairs had also endorsed the POLST program in<br />
their state.<br />
In 2012, NDMA assigned the POLST project to<br />
the ND Healthcare Review in Minot (now formally<br />
known as Quality Health Associates of <strong>North</strong><br />
<strong>Dakota</strong>). <strong>The</strong> project and workgroup were led by<br />
Quality Improvement Specialist, Sally May, BSN,<br />
RN. May invited interested parties throughout the<br />
state to explore a statewide POLST initiative as well<br />
as advance care planning. <strong>The</strong> ND advance care<br />
planning coalition grew from 10 to 40 members.<br />
By 2013, an initial POLST workgroup was formed.<br />
<strong>The</strong> original POLST form, created in 2007 at the<br />
Altru Health System, was updated to reflect<br />
the efforts and recommendations of the POLST<br />
workgroup. In 2017, the statewide ND POLST form<br />
and ND POLST program were established and<br />
went live on <strong>July</strong> 1, 2017. Lastly, in 2018, the ND<br />
POLST form was updated to meet the national<br />
standards.<br />
Commencement of Honoring Choices® <strong>North</strong><br />
<strong>Dakota</strong><br />
As the statewide POLST project was evolving,<br />
Sally May, BSN, RN presented a webinar in<br />
2013 titled, Advance Care Planning: Beyond<br />
an Advance Medical Directive. <strong>North</strong> <strong>Dakota</strong><br />
Advance Care Planning Initiative face-to-face<br />
meeting. By December of 2013, members of the<br />
<strong>North</strong> <strong>Dakota</strong> Advance Care Planning Initiative<br />
had drafted a vision, goal, and objectives for a<br />
prospective organization with a focus to create<br />
a statewide initiative to improve advance care<br />
planning across the state.<br />
In 2014, several interested individuals<br />
participated in the Minnesota Network of Hospice<br />
and Palliative Care. At the conference, individuals<br />
learned about Respecting Choices®, an<br />
evidence-based practice program that focuses<br />
on person-centered decision-making to ensure<br />
individuals’ preferences and wishes, regarding<br />
their medical decisions, are known and respected<br />
as well as Honoring Choices® Minnesota (HCM),<br />
which was a public health initiative to help<br />
individuals make informed decisions about their<br />
future medical care. HCM recently dissolved in<br />
2021. At the time, HCM was creating a national<br />
network and with licensing through HCM/East<br />
Metro Medical Society Foundation, Honoring<br />
Choices® <strong>North</strong> <strong>Dakota</strong> (HCND) was formed.<br />
HCND created a steering committee and<br />
active workgroups, and by April of 2015, HCND<br />
was incorporated as a ND 501(c)3 nonprofit<br />
organization.<br />
<strong>The</strong> original vision of goal of HCND were as<br />
follows:<br />
Vision: To create a culture across ND where<br />
continuous (on-going) advance care planning<br />
is the standard of care, and every individual’s<br />
informed preferences for care are documented<br />
and upheld.<br />
Goal: To assist statewide community partners<br />
with the development and implementation of a<br />
comprehensive advance care planning program<br />
by December 2016<br />
In 2016, the efforts and aspirations of<br />
the <strong>North</strong> <strong>Dakota</strong> Advance Care Planning<br />
Initiative Committee and HCND came to<br />
light. In September of 2016, HCND held its first<br />
conference, Striving for Success: Challenges and<br />
Opportunities for Advance Care Planning. In<br />
November 2016, First Steps® ACP (Advance Care<br />
Planning) instructors were trained and prepared<br />
to educate ACP facilitators across the state. Lastly,<br />
in December of 2016, HCND was awarded a<br />
$10,000 grant from Consensus Council of Bismarck<br />
through its Community Innovation Grant Program,<br />
offered in partnership with the Bush Foundation,<br />
to assist with the statewide ACP facilitator<br />
training. <strong>The</strong> National Healthcare Decisions Day<br />
event on April 16th was recognized, and events<br />
were planned annually. ND POLST awareness,<br />
education, and implementation had gone<br />
statewide.<br />
In 2017, the HCND website was created and has<br />
been hosted by Quality Health Associates of ND.<br />
<strong>The</strong> HCND Board of Directors revised the previous<br />
vision and goals and composed the following:<br />
VISION: <strong>The</strong> health care choices a person<br />
makes become the health care the person<br />
receives.<br />
GOAL: To assist communities to develop a<br />
successful advance care planning process.<br />
OBJECTIVES:<br />
1: Promote advance care planning through<br />
community and professional outreach and<br />
education.<br />
2: Promote standardization of advance care<br />
planning.<br />
3: Establish base of financial support.<br />
In 2018, HCND held a second statewide<br />
presentation at a conference in Fargo titled,<br />
Improving Quality of Life—It Starts with<br />
Competent Caring Conversations. HCND<br />
continued offering the First Steps® ACP training<br />
opportunities. <strong>The</strong> HCND Board of Directors<br />
welcomed the first physician affiliate, Dr.<br />
Kristina Schlecht, MD, and Dr. Jonathon Berg,<br />
MD became the POLST medical director.<br />
Continuing medical education (CME) for POLST<br />
was endorsed nationally, and as previously<br />
mentioned, the statewide POLST policy went into<br />
effect.<br />
In 2019, HCND became affiliated with ND<br />
Palliative Care Taskforce and Center for Rural<br />
Health (CRH) with an emphasis on CRH’s Rural<br />
Community-Based Palliative Care program<br />
to promote all aspects of advance care<br />
planning (ACP) and POLST. With the support of<br />
CRH, HCND held educational POLST webinars<br />
throughout 2020 and 2021, which focus on<br />
increasing awareness and discuss key elements to<br />
implement the POLST process. <strong>The</strong> POLST webinars<br />
are available to multiple disciples, currently being<br />
offered, and are approved for 1.5 contact hours<br />
by the <strong>North</strong> <strong>Dakota</strong> Board of Nursing, <strong>North</strong><br />
<strong>Dakota</strong> Board of Social Work Examiners, <strong>North</strong><br />
<strong>Dakota</strong> Department of Health – EMS Division, and<br />
the Board of Chaplaincy Certification, Inc.<br />
In December 2021, HCND received a $10,000<br />
grant from the <strong>North</strong> <strong>Dakota</strong> Comprehensive<br />
Cancer Control Program to create, educate,<br />
and certify individuals who were interested in<br />
becoming ACP Facilitators. <strong>The</strong> ACP Facilitator<br />
training course utilized resources from <strong>The</strong><br />
Conversation Project and the Serious Illness<br />
Conversation Guide. In total, there were twentyseven<br />
individuals who completed the training, are<br />
newly designated ACP facilitators, and received<br />
four continuing education (CEs) credits through<br />
the <strong>North</strong> <strong>Dakota</strong> Board of Nursing.<br />
To promote HCND as well as the process of<br />
ACP and POLST, HCND began sending bimonthly<br />
newsletters to update communities, local health<br />
care organizations, and interested individuals<br />
with recent activities, upcoming educational<br />
offerings, and progress within HCND. As of March<br />
<strong>2022</strong>, Honoring Choices® <strong>North</strong> <strong>Dakota</strong> became<br />
a 501(c)3 public charitable organization. To<br />
date, the organization is all volunteer, and HCND<br />
continues to pursue funding for hiring staff and<br />
program development. Currently, HCND’s Board<br />
of Directors is comprised of individuals across<br />
the state of <strong>North</strong> <strong>Dakota</strong>, who represent various<br />
organizations and professions, with a focus to<br />
promote advance care planning and POLST.
<strong>July</strong>, August, September <strong>2022</strong> <strong>The</strong> <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong> Page 17<br />
Throughout the next year, HCND has aspiring plans to promote ACP<br />
and POLST through community engagement (i.e., bimonthly newsletters,<br />
Facebook), professional education (i.e., POLST webinars), and expanding<br />
partnerships and affiliations. Advance care planning, or lack thereof,<br />
has recently been identified as a public health issue due to the aging<br />
population and the significant implications that ACP possesses, including<br />
enhanced, individualized care at the end-of-life, reduction in patient<br />
and family emotional stress as well as minimization of associated costs,<br />
which may be incurred by unwanted medical treatments. <strong>The</strong>re are many<br />
components of ACP and POLST, but it all begins with a conversation.<br />
Call to Action:<br />
1. Please partner with us, join our email list, and stay abreast of upcoming<br />
activities, educational offerings, and opportunities to promote<br />
advance care planning and POLST within your local community and<br />
organization.<br />
2. Please do your part in promoting advance care planning and<br />
engaging in shared decision-making conversations, particularly with<br />
individuals who have a serious illness.<br />
3. Please reach out if you, your colleagues, or your local health care<br />
organization are interested in learning more about how ACP and<br />
POLST and how Honoring Choices® <strong>North</strong> <strong>Dakota</strong> can assist with<br />
individual and community outreach interventions.<br />
<strong>The</strong> name “Honoring Choices <strong>North</strong> <strong>Dakota</strong>” is used under license from East<br />
Metro Medical Society Foundation.<br />
https://www.honoringchoicesnd.org/<br />
<strong>Nurse</strong> License Protection Case Study:<br />
Administering medication without an order<br />
<strong>Nurse</strong>s and License Protection Case Study with<br />
Risk Management Strategies, Presented by NSO<br />
A State Board of Nursing (SBON) complaint<br />
may be filed against a nurse by a patient,<br />
colleague, employer, and/or other regulatory<br />
agency, such as the Department of Health.<br />
Complaints are subsequently investigated<br />
by the SBON in order to ensure that licensed<br />
nurses are practicing safely, professionally,<br />
and ethically. SBON investigations can lead to<br />
outcomes ranging from no action against the<br />
nurse to revocation of the nurse’s license to<br />
practice. This case study involves a registered<br />
nurse (RN) who was working as the clinical<br />
director of a small, rural emergency care<br />
center.<br />
Summary<br />
<strong>The</strong> insured RN was employed as the clinical<br />
director of a small, rural emergency care<br />
center when they responded to a Code Blue,<br />
arriving just as the patient was being intubated.<br />
<strong>The</strong> patient was fighting the intubation, so a<br />
physician gave a verbal order for propofol.<br />
<strong>The</strong> RN asked the pharmacy technician to<br />
withdraw a 100-cc bottle of propofol from the<br />
medication dispensing machine and asked<br />
another nurse to administer the medication to<br />
the patient. Shortly after the other nurse began<br />
administering the propofol, the patient’s blood<br />
pressure dropped, so the nurse was ordered to<br />
stop the propofol infusion.<br />
<strong>The</strong> patient continued to decompensate and<br />
suffered respiratory collapse/arrest. Following<br />
some delay, the patient was eventually<br />
intubated, then emergently transferred to a<br />
higher acuity hospital for further treatment.<br />
<strong>The</strong> patient ultimately suffered anoxic<br />
encephalopathy while he was in respiratory<br />
arrest.<br />
A recorder was present documenting<br />
the Code, and, afterwards, another nurse<br />
transcribed the recorder’s notes into the<br />
patient’s healthcare information record. <strong>The</strong><br />
recorder noted that it was the insured RN who<br />
advised the pharmacy technician to remove<br />
propofol from the medication dispensing<br />
machine and instructed a nurse to administer<br />
the medication. However, the recorder failed to<br />
note that the physician gave a verbal order for<br />
the propofol. <strong>The</strong> insured RN failed to review the<br />
notes that the recorder and nurse entered into<br />
the patient’s healthcare information record and<br />
failed to note this error. <strong>The</strong> physician who was<br />
present during the Code also failed to catch this<br />
error in the record.<br />
Approximately six months later, the patient’s<br />
family filed a lawsuit against the emergency<br />
care center. During a review of the Code record<br />
in response to the lawsuit, it was noted that,<br />
during the Code, the RN instructed another<br />
nurse to administer propofol. However, there<br />
wasn’t any indication in the record that a<br />
physician had ordered the medication. <strong>The</strong><br />
emergency care center dismissed the RN from<br />
employment and reported the incident to the<br />
SBON. <strong>The</strong> SBON opened its own investigation<br />
into the RN’s conduct.<br />
Resolution<br />
While the insured RN denied ordering another<br />
nurse to administer propofol without a verbal<br />
order from the physician, the RN could not deny<br />
failing to ensure that the propofol administration<br />
was documented in the patient's healthcare<br />
information record.<br />
<strong>The</strong> RN entered into a stipulation agreement<br />
with the SBON, under which:<br />
• the RN’s multi-state licensure privileges<br />
were revoked;<br />
• the RN was required to complete<br />
coursework on nursing jurisprudence<br />
and ethics, medication administration,<br />
documentation, and professional<br />
accountability; and<br />
• the RN was required to work under direct<br />
supervision for one year and submit<br />
quarterly nursing performance evaluations<br />
to the SBON.<br />
<strong>The</strong> total incurred expenses to defend the<br />
insured RN in this case exceeded $16,600.<br />
Risk Control Recommendations<br />
• Know the parameters of your state’s<br />
nursing scope of practice act, and your<br />
facility’s policies and procedures, related<br />
to medication administration.<br />
• Only accept verbal drug orders from<br />
practitioners during emergencies or<br />
sterile procedures. Before carrying out<br />
a verbal order, repeat it back to the<br />
prescriber. During a Code Blue, be sure to<br />
communicate all procedures, medications,<br />
treatments to the recorder.<br />
• Review Code Blue records for<br />
completeness and process of care<br />
after each Code. Report any concerns<br />
and provide feedback through proper<br />
channels to ensure that any errors in<br />
the record or areas of improvement are<br />
identified and addressed.<br />
• Document simultaneously with medication<br />
administration, whenever possible, in order<br />
to prevent critical gaps or oversights.<br />
Disclaimers<br />
<strong>The</strong>se are illustrations of actual claims that were<br />
managed by the CNA insurance companies.<br />
However, every claim arises out of its own unique<br />
set of facts which must be considered within the<br />
context of applicable state and federal laws and<br />
regulations, as well as the specific terms, conditions<br />
and exclusions of each insurance policy, their forms,<br />
and optional coverages. <strong>The</strong> information contained<br />
herein is not intended to establish any standard<br />
of care, serve as professional advice or address<br />
the circumstances of any specific entity. <strong>The</strong>se<br />
statements do not constitute a risk management<br />
directive from CNA. No organization or individual<br />
should act upon this information without appropriate<br />
professional advice, including advice of legal<br />
counsel, given after a thorough examination of<br />
the individual situation, encompassing a review of<br />
relevant facts, laws and regulations. CNA assumes<br />
no responsibility for the consequences of the use or<br />
nonuse of this information.<br />
This publication is intended to inform Affinity<br />
Insurance Services, Inc., customers of potential<br />
liability in their practice. This information is provided<br />
for general informational purposes only and is not<br />
intended to provide individualized guidance. All<br />
descriptions, summaries or highlights of coverage<br />
are for general informational purposes only and<br />
do not amend, alter or modify the actual terms<br />
or conditions of any insurance policy. Coverage<br />
is governed only by the terms and conditions of<br />
the relevant policy. Any references to non-Aon,<br />
AIS, NSO, NSO websites are provided solely for<br />
convenience, and Aon, AIS, NSO and NSO disclaims<br />
any responsibility with respect to such websites. This<br />
information is not intended to offer legal advice or<br />
to establish appropriate or acceptable standards of<br />
professional conduct. Readers should consult with a<br />
lawyer if they have specific concerns. Neither Affinity<br />
Insurance Services, Inc., NSO, nor CNA assumes any<br />
liability for how this information is applied in practice<br />
or for the accuracy of this information.<br />
<strong>Nurse</strong>s Service Organization is a registered trade<br />
name of Affinity Insurance Services, Inc., a licensed<br />
producer in all states (TX 13695); (AR 100106022);<br />
in CA, MN, AIS Affinity Insurance Agency, Inc. (CA<br />
0795465); in OK, AIS Affinity Insurance Services, Inc.;<br />
in CA, Aon Affinity Insurance Services, Inc., (CA<br />
0G94493), Aon Direct Insurance Administrators and<br />
Berkely Insurance Agency and in NY, AIS Affinity<br />
Insurance Agency.
Page 18 <strong>The</strong> <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong> <strong>July</strong>, August, September <strong>2022</strong><br />
Timed Repositioning Effect on Pressure Injury Incidence<br />
Appraised By:<br />
Kailey Fiske SN, Kylee Grabow SN, Courtney<br />
Hawkinson SN, Alexis Helm SN, Hailey Fried SN,<br />
Sarah Selle SN<br />
Allison Sadowsky MSN RN Assistant Professor of<br />
Practice (Faculty)<br />
(NDSU School of Nursing at Sanford Health)<br />
Clinical Question:<br />
For adult patients with decreased mobility,<br />
does the use of timed repositioning reduce the risk<br />
for pressure injuries?<br />
Sources of Evidence:<br />
Chew, H.S., Thiara, E., Lopez, V., & Shorey, S. (2018).<br />
Turning frequency in adult bedridden patients<br />
to prevent hospital-acquired pressure ulcer: A<br />
scoping review. International Wound Journal, 15(2),<br />
225–236. https://doi.org/10.1111/iwj.12855<br />
Cyriacks, B. (2019). Reducing HAPI by Cultivating Team<br />
Ownership of Prevention with Budget-Neutral Turn<br />
Teams. MEDSURG Nursing, 28(1), 48–52.<br />
Darvall, J. N., Mesfin, L., & Gorelik, A. (2018). Increasing<br />
frequency of critically ill patient turns is associated<br />
with a reduction in pressure injuries. Critical Care<br />
and Resuscitation, 20(3), 217-222.<br />
De Meyer, D., Van Hecke, A., Verhaeghe, S., &<br />
Beeckman, D. (2019). PROTECT – Trial: A cluster RCT<br />
to study the effectiveness of a repositioning aid<br />
and tailored repositioning to increase repositioning<br />
compliance. Journal Of Advanced Nursing, 75(5),<br />
1085-1098. doi: 10.1111/jan.13932<br />
Harmon, L. C., Grobbel, C., & Palleschi, M. (2016).<br />
Reducing Pressure Injury Incidence Using a<br />
Turn Team Assignment: Analysis of a Quality<br />
Improvement Project. Journal of wound, ostomy,<br />
and continence nursing : official publication<br />
of <strong>The</strong> Wound, Ostomy and Continence <strong>Nurse</strong>s<br />
Society, 43(5), 477–482. https://doi-org.ezproxy.lib.<br />
ndsu.nodak.edu/10.1097/WON.0000000000000258<br />
Kahn, M., & Jonusas, E. (2019). Turn Teams: How Do You<br />
Prevent Pressure Injuries? MedSurg Nursing, 257–<br />
261.<br />
Synthesis of Evidence:<br />
Six articles were reviewed as evidenced in<br />
this report. A systematic review, three quasiexperimental,<br />
a descriptive correlational study,<br />
and a randomized control trial. Pressure ulcers are<br />
a result of decreased mobility due to increased<br />
pressure on body prominences and decreased<br />
blood flow to the tissue. This is important because<br />
pressure injuries are associated with increased<br />
mortality rate and cost of treatment (Kahn &<br />
Jonusas, 2019). This report will assess the effect of<br />
timed repositioning on the incidence of pressure<br />
injuries.<br />
Chew, Thiara, Lopez and Shorey (2018)<br />
conducted a systematic review which included<br />
five randomized control studies, one prospective<br />
cohort study and one literature review. <strong>The</strong>se<br />
studies took place in various hospital and longterm<br />
care facilities and included immobile,<br />
elderly, hospitalized or nursing home residents<br />
with a focus on pressure ulcer prevention<br />
interventions. In total, the sample size ranged<br />
from 63-335 patients. <strong>The</strong> interventions included:<br />
pressure ulcer incidences with foam mattresses,<br />
incidence of pressure ulcer development using<br />
various repositioning schedules, stages of pressure<br />
ulcers related to differing turning schedules<br />
and lastly degree of blanchable erythema.<br />
<strong>The</strong> findings did not statistically differ from one<br />
intervention to another. <strong>The</strong> evidence was not<br />
statistically significant, however, repositioning<br />
every two hours had a pressure ulcer rate of<br />
10.3% while repositioning every four hours had a<br />
13.4%. This systematic review brings forward the<br />
idea of implementing facility-wide pressure redistributing<br />
air-mattresses in hospitals and nursing<br />
homes to prevent pressure ulcer development<br />
while reducing manpower needed to reposition<br />
patients.<br />
Cyriacks (2019) conducted an evidencebased<br />
quality improvement project with a<br />
quasi-experimental design. <strong>The</strong> purpose of<br />
this study was to empower nurses with direct<br />
responsibility for HAPI prevention, ensure patients<br />
were repositioned every two hours, and remove<br />
barriers to allow staff to reach this expectation.<br />
<strong>The</strong> study took place in a 36-bed medical<br />
surgical pulmonary unit in an academic medical<br />
center. <strong>The</strong> population included 36 adults that<br />
were at higher acuity with multiple risk factors<br />
for occurrence of pressure injury. <strong>The</strong> study<br />
implemented turn teams who turned the patients<br />
every two hours and found that the reduction of<br />
hospital acquired pressure injury decreased by<br />
75%, no new pressure injuries occurred on the<br />
coccyx, sacrum, heel, or ischium for any patients,<br />
and staff benefitted in that they were engaged,<br />
teamwork was enhanced, and time saving was<br />
notable.<br />
Daravall, Mesfin, and Gorelik (2018) conducted<br />
a quasi-experimental prospective intervention<br />
evaluation study. <strong>The</strong> study was conducted at<br />
Royal Melbourne Hospital ICU and included<br />
adult critically ill patients that were admitted to<br />
the ICU; the sample included a pre-intervention<br />
group, with 1094 patients, and a post-intervention<br />
group, with 1165 patients. <strong>The</strong> total sample size<br />
was 2259 patients. <strong>The</strong> studied interventions were<br />
a five-hourly turn schedule, the pre-intervention<br />
group, and a three-hourly turn schedule, the<br />
post-intervention group, and the interventions<br />
effect on pressure injury and decubitus injury<br />
incidence. <strong>The</strong> results concluded that there was<br />
a 49% reduction in the risk of pressure injuries and<br />
the rate of decubitus pressure injury fell from 62.5%<br />
to 25.0% when the turning schedule was changed<br />
from five-hourly to three-hourly.<br />
De Meyer, Van Hecke, Verhaeghe, &<br />
Beeckman (2019) conducted a three-arm,<br />
randomized, controlled pragmatic trial. This<br />
study was conducted to see the outcomes of<br />
repositioning with the Turn and Position System<br />
on patients and what that does for nurse<br />
compliance, the incidence of pressure ulcers,<br />
patient comfort, and budget. This study included<br />
226 patients, all patients who are 18 years and<br />
older that are at risk for pressure ulcers. <strong>The</strong><br />
intervention included repositioning that varied<br />
every one to four hours using devices such as<br />
the Prevalon Turn and Position System. <strong>The</strong> results<br />
concluded that the nurses’ compliance to<br />
repositioning was increased significantly. Few<br />
pressure ulcers and incontinence-associated<br />
dermatitis incidents occurred, 2.22% of patients<br />
compared to the mean prevalence of 20.9%<br />
before the trial. Patients reported their comfort as<br />
a 6.1/10. <strong>The</strong> cost of materials to prevent pressure<br />
ulcers increased to $15.40 per day, but the cost<br />
of treating pressure ulcers ($2.52-$83.43 per day)<br />
went down through prevention.<br />
Harmon, Grobbel, and Palleschi (2016)<br />
conducted a descriptive correlational study. <strong>The</strong><br />
purpose of this study was to analyze outcomes<br />
of a quality improvement project that evaluated<br />
a Turn Team intervention for prevention of facilityacquired<br />
pressure injuries. <strong>The</strong> study took place in<br />
a Midwest teaching hospital with twelve surgical<br />
intensive care units. <strong>The</strong> findings were that unit<br />
acquired pressure injury occurrence declined<br />
from 24.9% to 16.8% following implementation<br />
of the intervention; evaluation of verbal cueing<br />
intervention to increase compliance with regular<br />
patient repositioning and achieved a 77.8%<br />
compliance rate; and half the participants<br />
indicated that the turn team provided adequate<br />
two-hour reminders needed for turning.<br />
Kahn & Jonusas (2019) conducted a quasiexperimental<br />
quality improvement project that<br />
looked at the effectiveness of "turn teams" in a<br />
51-bed medical-surgical unit in the southeastern<br />
United States. <strong>The</strong> population consisted of all<br />
adult patients at risk for developing pressure<br />
injuries which was evidenced by a Braden Scale<br />
score of 18 or below and the inability to turn<br />
independently in bed. Turn Teams were used to<br />
turn these at-risk patients every two hours. Unitacquired<br />
pressure injury data was assessed 12<br />
months before implementation of Turn Teams<br />
and 12 months after implementation. Weekly<br />
skin assessment audits were also performed for<br />
a 12-month period after implementation. <strong>The</strong><br />
results included that the number of unit-acquired<br />
pressure injuries over a 12-month period was<br />
reduced by 54 percent.<br />
Conclusion:<br />
Five out of the six studies found a statistically<br />
significant decrease in the incidence of pressure<br />
injuries with the implementation of regular<br />
repositioning schedule. However, the study by<br />
Chew, Thiara, Lopez, and Shorey showed that<br />
having widespread pressure redistributing airmattresses<br />
in hospitals and nursing homes can<br />
be used to prevent pressure ulcer development,<br />
while reducing the need to reposition patients.<br />
Implications of Nursing Practice:<br />
Preventing pressure injuries is important<br />
because they are associated with increased<br />
mortality and cost of care. <strong>The</strong> evidence showed<br />
that the implementation of turn teams utilizing a<br />
regular timed repositioning schedule is beneficial<br />
to reduce the incidence of pressure injuries<br />
in patients with decreased mobility. Pressure<br />
relieving hospital beds can also be implemented<br />
to reduce the incidence of pressure injuries.<br />
Healthcare facilities need to implement a variety<br />
of pressure prevention interventions to prevent<br />
healthcare related pressure injuries.<br />
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<strong>July</strong>, August, September <strong>2022</strong> <strong>The</strong> <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong> Page 19<br />
Play <strong>The</strong>rapy in Autistic Children<br />
Appraised By:<br />
McKenna Johnson SN,Jessica Hansen SN, Ryley Gunderson SN, Kimberly<br />
San Juan SN, Rachel Leblanc SN<br />
Allison Sadowsky MSN RN Assistant Professor of Practice (Faculty)<br />
(NDSU School of Nursing at Sanford)<br />
Clinical Question:<br />
In autistic children, what is the effect of play therapy on behavior?<br />
List of Articles:<br />
Baranek, G.T., Boyd, B.A., Crais, E.R., Dykstra, J.R., Watson, L.R. (2012). <strong>The</strong> impact<br />
of the Advancing Social-communication And Play (ASAP) intervention on<br />
preschoolers with autism spectrum disorder. Sage Pub, 16 (1), 27-44.<br />
Hillman, H. (2018). Child-centered play therapy as an intervention for children with<br />
autism: A literature review. International Journal of Play <strong>The</strong>rapy, 27(4), 198-204.<br />
https://doi.org/10.1037/pla0000083<br />
Schottelkorb, A. A., Swan, K. L., & Ogawa, Y. (2020). Intensive Child-Centered<br />
Play <strong>The</strong>rapy for Children on the Autism Spectrum: A Pilot Study. Journal of<br />
Counseling & Development, 98(1), 63–73. https://doi-org.ezproxy.lib.ndsu.nodak.<br />
edu/10.1002/jcad.12300<br />
Tilmont Pittala, E., Saint-Georges-Chaumet, Y., Favrot, C., Tanet, A., Cohen, D.,<br />
& Saint-Georges, C. (2018). Clinical outcomes of interactive, intensive and<br />
individual (3i) play therapy for children with ASD: a two-year follow-up study.<br />
BMC pediatrics, 18(1), 165. https://doi-org<br />
Tseng, K. C., Tseng, S. H., & Cheng, H. Y. (2016). Design, development, and clinical<br />
validation of therapeutic toys for autistic children. Journal of physical therapy<br />
science, 28(7), 1972–1980. https://doi.org/10.1589/jpts.28.1972<br />
Synthesis of Evidence:<br />
Autism spectrum disorder (ASD) is the fastest growing<br />
neurodevelopmental disorder in the U.S. <strong>The</strong> prevalence of ASD calls for<br />
study on symptoms of autism, etiology, and treatments. Symptoms of ASD<br />
include communication and language deficits, social impairment, and<br />
restricted and repetitive behaviors. ADHS, oppositional defiant disorder<br />
(ODD), obsessive-compulsive disorder (OCD), and generalized anxiety<br />
disorder (GAD) are common in children on the autism spectrum. <strong>The</strong>se<br />
children are at risk for emotional and behavioral problems. Children<br />
diagnosed with ASD may have decreased quality of life, adaptive<br />
functioning, and educational achievement. As stated above, further study<br />
is needed on treatments/management for autism (Schottelkorb, 2020). Five<br />
articles including a single case study, a systemic review of four case studies,<br />
a randomized control trial, quasi-experimental and quantitative exploratory<br />
studies were reviewed as evidence in this report.<br />
Baranek (2012) conducted a single case study to examine the effect of<br />
the Advancing Social-communication And Play (ASAP) intervention on<br />
preschoolers with autism in public school classrooms. <strong>The</strong> study addressed<br />
if the implementation improved social-communication and play skills in<br />
these children and if the implementation of ASAP in both a group setting<br />
and one-to-one setting resulted in further improvements. <strong>The</strong> design utilized<br />
three phases for each participant. In Phase A, pre-data was collected as<br />
children received their typical instruction in the classroom. In Phase B,<br />
teachers and/or teaching assistants were trained and began implementing<br />
the ASAP interventions during already occurring group activities in the<br />
classroom. In Phase C, the speech-language pathologist was trained<br />
and began to implement ASAP, making social-communication and play<br />
intervention a part of both one-to-one and group settings. <strong>The</strong> study results<br />
showed at least some improvement in social communication and play skills.<br />
All participants showed either increases in frequency or more stability in<br />
targeted behaviors such as initiating social interactions.<br />
Hillman (2018) conducted a systematic review of four studies. <strong>The</strong><br />
systematic review had two case studies and two single case designs. <strong>The</strong>y<br />
threw out one of the studies so I will only talk about three of them. <strong>The</strong><br />
studies included nine children ages 4-11 that had autism and were receiving<br />
play therapy, seven boys and two girls in all the studies. <strong>The</strong> intervention they<br />
used was child centered play therapy, which is when the children, instead<br />
of the therapist, control the pace, direction, and content of the therapeutic<br />
journey. <strong>The</strong> findings overall showed an increase in social and emotional<br />
behaviors, and a reduction in ritualistic behaviors from the use of playtherapy.<br />
Schottelkorb, A. A., Swan, K. L., & Ogawa, Y. (2020) conducted a<br />
randomized control trial that aimed to test the efficacy of Child-Centered<br />
Play <strong>The</strong>rapy (CCPT) using validated rating scales to measure core autism<br />
symptoms, attention problems, aggression problems, and externalizing<br />
problems. Participants were recruited from five elementary schools in the<br />
<strong>North</strong>western United States. Play therapy rooms were established at each<br />
participant’s school. <strong>The</strong> participants consisted of 23 children aged 4-10 (19<br />
male, four female) who displayed moderate to severe symptoms on the SRS-<br />
2 scale. <strong>The</strong> items of the SRS-2 were used on a likert scale to measure the<br />
symptoms of social impairment. Additionally, the items of the Child Behavior<br />
Checklist were used on a likert scale to examine emotional and behavioral<br />
problems as well as adaptive functioning. <strong>The</strong> children in the CCPT group<br />
showed a decrease of eight points on the SRS-2, while the control group’s<br />
score increased by four. In addition, the children in the CCPT group showed<br />
an eight-point decrease in attention problems, a six-point decrease in<br />
aggressive problems, and a five-point decrease in externalizing problems,<br />
while the children in the control group showed a two-point increase in<br />
attention and externalizing problems (aggressive behavior remained the<br />
same).<br />
Tilmont Pittala, Saint-Georges-Chaumet, Favrot, Tanet, Cohen, and<br />
Saint-Georges (2018) conducted a quantitative prospective exploratory<br />
study. <strong>The</strong> study aimed to “assess the outcome of 20 Autism spectrum<br />
disorder (ASD) subjects who followed the 3i method for 24 months.”<br />
Using appropriate scales, they estimated the course of developmental<br />
and behavioral skills and autism severity. <strong>The</strong> 3i method was used as the<br />
intervention in this study which included the study occurring in a specific<br />
room for one on one interaction and designed to reduce unwanted<br />
sensorial stimuli, focuses on sensory specificities of the child, provides<br />
participants with developmental roadmap that improves understanding<br />
of the present abilities and difficulties on their developmental path and<br />
it distinguished three developmental age stages in their corresponding<br />
agenda (0-18 months, 18-36 months, and older than 36 months). <strong>The</strong> study<br />
found an increase by 83% in the socialization and an increase by 34% in<br />
communication. <strong>The</strong>re was an increase in imitation scores by 53%. CARS<br />
(Chilhood Autism Rating Score) scores dropped significantly since the<br />
beginning of the study where 94% of the patients were considered severely<br />
autistic and 6% were moderately autistic and at the end only 21% remained<br />
severely autistic and 53% progressed to moderate autistic and 26% could be<br />
considered to no longer have autism.<br />
Tseng (2016) conducted a quasi-experimental study aimed at helping<br />
autistic children to “experience healthy growth and development and<br />
improve their language ability, behavior, and social interaction.” <strong>The</strong><br />
study had four stages, all except one took place in a playroom at Taiwan<br />
university hospital. This playroom used direct observation with hidden<br />
cameras and microphones and measured the interaction using the Penn<br />
Interactive Peer Play Scale (PIPPS). <strong>The</strong> first stage included two autistic boys<br />
and results showed mainly passive behavior; the second stage included<br />
13 boys and showed the interaction increased significantly between<br />
neurotypical child; the 3rd stage included just the psychiatrists and<br />
they discussed the effectiveness of the toys from their point of view and<br />
concluded that the play needed fixed rules and progressive variations;<br />
the last stage only discussed types of toys and beneficial features. Overall<br />
test results showed after the introduction of the cooperative play toy into<br />
the autism play therapy, the interaction between the children increased<br />
significantly; 2.1419 whereas it was 2.8571.<br />
Conclusions:<br />
<strong>The</strong> studies conducted in the articles included: a systematic review, a<br />
single case study, a randomized control trial, a quasi-experimental study<br />
and a quantitative prospective exploratory study with 3-23 participants<br />
in each study. Each study implemented some sort of play therapy such as<br />
the use of blocks, sensory play or pretend play. <strong>The</strong> results of all five articles<br />
indicated an improvement in social interaction with the implementation<br />
of play therapy in children with ASD. Implementing play therapy improves<br />
social and emotional behaviors and reduces negative behaviors.<br />
Implications for Nursing Practice:<br />
<strong>The</strong>re is evidence to suggest implementing play therapy into interactions<br />
with children who have ASD improves social interaction and decreases<br />
negative behavior (ex. aggression). <strong>The</strong> evidence supports improvement<br />
in both group settings and one-on-one settings. <strong>The</strong> effects of this<br />
implementation will be beneficial to children with ASD and to healthcare<br />
team members when working with this specific pediatric population in all<br />
healthcare settings. Collaborating with Child Life Specialists to implement<br />
the delivery of developmentally appropriate play activities within the<br />
healthcare settings, whether it be in the patient’s room or in the play room,<br />
will promote positive behavior and social communication. <strong>The</strong> goal of<br />
implementing play therapy is to promote healthy growth, development,<br />
and improve their language ability, behavior, and social interaction. Using<br />
cooperative play to create a bridge between staff and the child with<br />
autism to overall improve the delivery of care.
Page 20 <strong>The</strong> <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong> <strong>July</strong>, August, September <strong>2022</strong><br />
Answering Your Questions on Vaccines<br />
MMR Vaccination: Protecting the Public<br />
and <strong>Nurse</strong>s Against Measles<br />
Jessica Allen, Immunization Health Educator,<br />
<strong>North</strong> <strong>Dakota</strong> Department of Health<br />
Did you know, two doses of the MMR<br />
(measles, mumps, and rubella) vaccine is<br />
97% effective at preventing measles? MMR<br />
vaccination plays an important part in keeping<br />
you and your community safe from measles.<br />
Here’s what you need to know about measles<br />
and the MMR vaccine!<br />
In April of <strong>2022</strong>, the World Health<br />
Organization (WHO) and the United Nations<br />
International Children’s Emergency Fund<br />
(UNICEF) announced that in the first two months<br />
of <strong>2022</strong>, global cases of measles had increased<br />
by 79% when compared to that same time<br />
period last year. <strong>The</strong>se agencies and public<br />
health officials across the planet are concerned<br />
that this could trigger larger measles outbreaks<br />
that may impact millions of children in <strong>2022</strong>.<br />
Fortunately, measles is a vaccine-preventable<br />
illness, with two doses of the MMR (measles,<br />
mumps, and rubella) vaccine being 97%<br />
effective at preventing measles. However,<br />
vaccination rates around the world have<br />
substantially decreased during the COVID-19<br />
pandemic. In fact, it is estimated that 23 million<br />
children missed out on routine immunizations<br />
through routine wellness visits during 2020,<br />
the highest number since 2009. Disruptions in<br />
routine wellness visits and vaccinations among<br />
pediatric populations has ultimately left us all<br />
increasingly vulnerable to a measles outbreak.<br />
What are <strong>North</strong> <strong>Dakota</strong>’s current MMR<br />
vaccination coverage rates?<br />
In <strong>North</strong> <strong>Dakota</strong>, MMR vaccination rates<br />
amongst <strong>North</strong> <strong>Dakota</strong> infants aged 19-35<br />
months decreased more than 6%, from 84.7%<br />
in December 2019 to 78.3% in December<br />
2021. Additionally, kindergarten-entry MMR<br />
vaccination rates decreased from 94.75%<br />
during the 2019-2020 school year to 92.36%<br />
during the 2021-<strong>2022</strong> school year. A reduction<br />
in vaccination coverage can lead to pockets<br />
of un- or under-immunized children across<br />
the state, which lowers our state and local<br />
community’s herd immunity against the<br />
measles virus. Herd immunity, also known as<br />
community immunity, refers to the term in<br />
which a certain threshold of the population<br />
is immune to an infectious disease. As a result,<br />
the infectious disease is no longer able to easily<br />
spread and infect those who are not immune.<br />
Herd immunity against measles is crucial for<br />
keeping all of us, especially those who are<br />
immunocompromised and infants too young<br />
to be vaccinated, safe from inadvertently<br />
contracting measles from the unvaccinated.<br />
Nationally for the 2020-2021 school year,<br />
vaccination coverage rates for all required<br />
vaccines was approximately 1% lower than<br />
that of the previous year. Only 93.9% of children<br />
entering kindergarten in the United States<br />
were vaccinated with two doses of the MMR<br />
vaccine. While a 93% vaccination coverage<br />
rate for measles may not sound concerning to<br />
most people, it is quite concerning to public<br />
health officials. According to Yale Medicine,<br />
“the percentage of the population that needs<br />
to be immune to attain herd immunity varies<br />
by disease and how contagious that disease<br />
is. Measles, for example, spreads so easily that<br />
an estimated 95% of a population needs to be<br />
vaccinated to achieve herd immunity. In turn,<br />
the remaining 5% have protection because, at<br />
95% coverage, measles will no longer spread.”<br />
Once an individual is vaccinated against<br />
measles, they are considered immune for life.<br />
Kindergarteners are our next generation of<br />
<strong>North</strong> <strong>Dakota</strong>ns, which is why it is important<br />
that all those who are eligible be vaccinated<br />
against measles in order to continue to keep<br />
our communities safe into the future.<br />
What is measles, who is at risk, and what are the<br />
side effects?<br />
Measles is caused by a single stranded RNA<br />
virus with only 1 serotype (for reference there<br />
are over 90 serotypes of the pneumococcal<br />
bacteria). This virus falls under the family of<br />
other Paramyxoviridae viruses and the only<br />
known host of this virus is humans. Measles is<br />
transmitted from person to person through<br />
direct contact of infected droplets or through<br />
airborne transmission when an infected person<br />
sneezes, coughs, or breathes. Measles is a highly<br />
contagious virus. In fact, 90% of unprotected<br />
(un- or under vaccinated) people who come<br />
into contact with an infected person will<br />
consequently become infected with measles as<br />
well.<br />
Measles is typically characterized by<br />
a maculopapular rash (a type of rash<br />
characterized by a flat, red area on the skin<br />
that is covered with small confluent bumps),<br />
usually developing within 14 days following<br />
exposure and spreading from the patient’s<br />
head down through their trunk and lower<br />
extremities. Please note that sometimes<br />
immunocompromised patients will not develop<br />
a rash. Other commonly reported side effects<br />
include ear infections and diarrhea.<br />
Even children who were previously healthy<br />
can become severely ill from an infection due<br />
to measles and may require hospitalization.<br />
Here are some quick facts on the seriousness<br />
of this disease and the complications you and<br />
your patients could expect if they were to<br />
become ill:<br />
• One out of five unvaccinated people in the<br />
United States who get measles will require<br />
hospitalization.<br />
• An estimated one out of every 20 children<br />
infected with measles will develop<br />
pneumonia, the most common cause of<br />
death for children with measles.<br />
• Approximately one out of every 1,000<br />
children infected with measles will<br />
develop encephalitis, that could lead to<br />
convulsions and leave a child permanently<br />
disabled or deaf.<br />
• Nearly one to three out of every 1,000<br />
children who are infected with measles will<br />
die.<br />
Measles can be a serious illness among<br />
any age group. However, there are several<br />
populations that are at a particularly higher<br />
risk for severe complications. Those populations<br />
include children younger than the age of<br />
five years, adults over the age of 20 years,<br />
individuals who are pregnant, and those who<br />
are immunocompromised.<br />
Are there any long-term complications<br />
associated with measles?<br />
Yes, there are potential long-term<br />
complications that can follow a prior infection<br />
with the measles virus. Subacute sclerosing<br />
panencephalitis (SSPE) is a very rare, but fatal<br />
disease of the central nervous system that<br />
results from a measles viral infection acquired<br />
earlier in life. While SSPE is rarely reported in the<br />
United States, patients who survived measles<br />
during early childhood, specifically before<br />
the age of two years old, are at an increased<br />
risk of developing this condition generally<br />
seven to ten years later. Patients who develop<br />
SSPE may experience a slow progression of<br />
symptoms including mild mental deterioration,<br />
memory loss, changes in behavior and mobility<br />
impairment. Over a period of months to<br />
potentially years, many patients proceed to<br />
generalized convulsions, dementia, coma, and<br />
death.<br />
Vaccine hesitant parents of your pediatric<br />
patients who are due for their MMR vaccination<br />
may not know about SSPE. <strong>The</strong>y also may not<br />
know about SSPE’s potentially life-threatening<br />
complications later in life if their unvaccinated<br />
child does end up contracting measles. You<br />
can help your community maintain high<br />
levels of herd immunity by encouraging and<br />
educating your patients and their parents on<br />
the benefits of MMR vaccination as well as the<br />
risks associated with measles infection. Because<br />
preventing measles also means protecting<br />
against measles induced SSPE later in life. For<br />
more information on SSPE, check out this video<br />
or visit the NIH’s website.<br />
If measles is an eliminated disease in the United<br />
States, how come we continue to see cases?<br />
In 2000 the United States declared measles<br />
an eliminated disease. Meaning the country<br />
had become free of infections. However, there<br />
were nearly 1,300 cases of measles reported<br />
in the year 2019. <strong>The</strong> measles outbreaks that<br />
occurred during 2019 in the U.S. were all<br />
linked to infected travelers that had entered<br />
communities with high-risk populations of un- or<br />
under vaccinated people. <strong>The</strong>se communities<br />
did not mount the herd immunity needed to<br />
prevent an outbreak of measles. So, while<br />
measles is an eliminated disease, ultimately the<br />
next measles outbreak may only be just one<br />
plane ride away.<br />
With many <strong>North</strong> <strong>Dakota</strong>ns considering<br />
returning back to their pre-pandemic<br />
international travel plans, we can expect<br />
that some individuals may begin traveling<br />
to areas of the world, including African and<br />
Eastern Mediterranean regions, where measles<br />
outbreaks continue to persist. <strong>The</strong> risk of<br />
bringing measles back into the state of <strong>North</strong><br />
<strong>Dakota</strong> through international travel puts several<br />
of our communities who have higher levels of<br />
un- or under vaccinated residents at greater risk<br />
of potential measles outbreaks.<br />
What is the recommended vaccination<br />
schedule for the MMR vaccine?<br />
<strong>The</strong> CDC’s Advisory Committee on<br />
Immunization Practices (ACIP) recommends<br />
that those without presumptive evidence of<br />
immunity against measles be vaccinated with<br />
either the MMR or the MMRV (measles, mumps,<br />
rubella, and varicella) vaccine.<br />
CDC recommends two doses of a measlescontaining<br />
vaccine routinely for children,<br />
starting with the first dose at age 12 through<br />
15 months and the second dose at age four<br />
through six years. Adults should also be up to<br />
date on MMR vaccinations with either one or<br />
two doses (depending on risk factors) unless<br />
they have other presumptive evidence of<br />
immunity to measles. Providers generally do<br />
not need to actively screen adult patients for<br />
measles immunity in non-outbreak areas of the<br />
United States.<br />
<strong>The</strong>re are situations in which special<br />
populations may be recommended to be<br />
vaccinated against measles. Additionally,<br />
individuals who may have missed their routine<br />
immunizations are encouraged to catch up<br />
on their vaccines. For more information on<br />
vaccinating these populations, please visit the<br />
CDC’s immunization schedules.<br />
Do nurses need to be revaccinated against<br />
measles?<br />
Once an individual is vaccinated against<br />
measles or has recovered from a prior<br />
infection of measles, they are considered to<br />
be immune for life. Oftentimes, health care<br />
workers including nurses are at an increased<br />
risk for exposure to serious, and sometimes<br />
deadly, diseases. If you work directly with<br />
patients or handle material that could spread<br />
measles infection, you should get appropriate<br />
vaccinations to reduce the chance that you will<br />
get or spread this vaccine-preventable disease.
<strong>July</strong>, August, September <strong>2022</strong> <strong>The</strong> <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong> Page 21<br />
If you have not yet received your MMR vaccines yet, now is a great<br />
time to do so! If you fall into one of the following populations you may<br />
want to consider MMR or MMRV vaccination:<br />
• If you were born in 1957 or later and have not had the MMR vaccine,<br />
or if you don’t have a blood test that shows you are immune to<br />
measles or mumps (i.e., no serologic evidence of immunity or prior<br />
vaccination)<br />
• Health care workers born before 1957 who lack laboratory evidence<br />
of immunity or laboratory confirmation of disease.<br />
<strong>Nurse</strong>s without presumptive evidence of immunity should get two<br />
doses of MMR vaccine, separated by at least 28 days. <strong>The</strong> MMR vaccine<br />
is very effective at protecting people against measles, mumps, and<br />
rubella, and preventing the complications caused by these diseases.<br />
• MMR Vaccine (Measles, Mumps, and Rubella Vaccine) | Oxford<br />
Vaccine Group<br />
<strong>North</strong> <strong>Dakota</strong> Data<br />
• Coverage Rates | Department of Health (nd.gov)<br />
Related Articles<br />
• UNICEF and WHO warn of perfect storm of conditions for measles<br />
outbreaks, affecting children<br />
• Herd Immunity: Will We Ever Get <strong>The</strong>re? Yale Medicine<br />
• Vaccination Coverage with Selected Vaccines and Exemption<br />
Rates Among Children in Kindergarten — United States, 2020–21<br />
School Year | CDC MMWR<br />
• Subacute Sclerosing Panencephalitis | NIH<br />
How can I address vaccine hesitancy among my patients?<br />
We can all agree that it is important for health care providers,<br />
including nurses, to have conversations about the benefits of<br />
immunizations with their patients. Today however, having those<br />
conversations regarding the importance of routine immunizations can<br />
be uncomfortable at times. Especially if you do not feel equipped with<br />
the communication skills needed to diffuse vaccine misinformation your<br />
patients may have found online. Below are strategies you can use to<br />
help you feel more confident recommending vaccines to your vaccine<br />
hesitant patients.<br />
• Know your patient’s vaccination status before their appointment.<br />
• Respectfully address your patient’s vaccine concerns by practicing<br />
empathy and active listening without being judgmental.<br />
• Use presumptive language with your patients.<br />
- Example: “Your child needs their MMR, varicella, and<br />
pneumococcal vaccines today.” versus “What do you want to do<br />
about your child’s shots that they are due for today?”<br />
• Do your part in building patient-provider trust at all medical<br />
encounters, including non-vaccine related appointments.<br />
Your recommendation matters. YOU play an essential role in<br />
promoting and building trust in vaccinations. <strong>Nurse</strong>s are consistently<br />
found to be one of the most trusted professions in our country. It is<br />
important to provide patients with high quality, evidence-based<br />
information regarding their vaccine-related questions. Before<br />
considering vaccine information on the internet, check that the<br />
information comes from a credible source and is updated on a regular<br />
basis. While the internet is a useful tool for researching health-related<br />
issues, it should not replace a discussion with a health care professional.<br />
Clear and consistent messaging across all levels of health care needs<br />
to be followed in order for patients to feel safe and prepared to<br />
get themselves and their families immunized. Research has shown<br />
that vaccine-hesitant individuals became less hesitant after a brief<br />
recommendation from a health care professional. It is important that<br />
all nurses in <strong>North</strong> <strong>Dakota</strong> offer a strong recommendation to vaccinate<br />
against measles to all vaccine eligible patients ages 12 months and<br />
older.<br />
For more information, please consider checking out the following<br />
resources:<br />
General Information<br />
• Measles, Mumps, and Rubella (MMR) Vaccination | CDC<br />
• Vaccination Is the Best Protection Against Measles | FDA<br />
• Measles (Rubeola) For Healthcare Providers | CDC<br />
• Global Measles Outbreaks (cdc.gov)<br />
Addressing Vaccine Hesitancy<br />
• How to Have Productive Vaccine Conversations: Moving the Needle<br />
Toward Vaccine Acceptance - NDSU CIRE YouTube<br />
Measles Complications<br />
NDC3 is improving health<br />
and wellness in communities<br />
across <strong>North</strong> <strong>Dakota</strong><br />
Through a network of local leaders, community organizations and health systems, NDC3<br />
delivers programs to help individuals manage chronic health conditions, prevent falls,<br />
and foster well-being. If you are coping with high blood pressure, heart disease, COPD,<br />
arthritis, diabetes or other chronic conditions, NDC3 can support your efforts to live life<br />
as fully and independently as possible.<br />
Better Choices, Better Health: Diabetes<br />
(online)<br />
Aug. 16, <strong>2022</strong> - Sept. 20, <strong>2022</strong><br />
3:00 PM - 5:30 PM<br />
See All Dates<br />
Cost: $0<br />
Contact Name: Amanda H<br />
Contact Email: bcbh@sanfordhealth.org<br />
Contact Phone: 701-417-4905<br />
People with type 2 diabetes attend the class in<br />
groups of 12-16. Participants will make weekly action<br />
plans, share experiences, and help each other solve<br />
problems they encounter in creating and carrying out<br />
their self-management program. Physicians, diabetes<br />
educators, dietitians, and other health professionals<br />
both at Stanford and in the community, have<br />
reviewed all materials in the class.<br />
This "virtual" class will be held via Zoom. Don't know<br />
how to use Zoom? Don't worry we will help you! All<br />
participants must have audio and visual technology<br />
to participate.<br />
Diabetes Prevention Program<br />
Aug. 23, <strong>2022</strong> - Aug. 15, 2023<br />
5:15 PM - 6:15 PM<br />
See All Dates<br />
Cass County Annex Building<br />
1010 2nd Ave. S<br />
Fargo, ND 58103<br />
Cost: $0<br />
Contact Name: Rita Ussatis<br />
Contact Email: Rita.Ussatis@ndsu.edu<br />
Contact Phone: 701-241-5700<br />
National Diabetes Prevention Program (NDPP) is a<br />
collaborative, community-based, lifestyle change<br />
program designed for people with pre-diabetes.<br />
It is based on the Centers for Disease Control and<br />
Prevention’s curriculum and National Diabetes<br />
Prevention Recognition standards.<br />
This class is 24 sessions, <strong>The</strong> first 12 classes will<br />
be weekly, followed by 4 biweekly class and then<br />
monthly for the 1 year duration.<br />
Melissa Kainz, DNP, MSN, RN, Community Clinical Coordinator,<br />
Division of Health Promotion 701-328-4568 | mkainz@nd.gov<br />
NDC3.org
Page 22 <strong>The</strong> <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong> <strong>July</strong>, August, September <strong>2022</strong><br />
How <strong>Nurse</strong>s Can Counter Health Misinformation<br />
Georgia Reiner, MS, CPHRM, Risk Analyst,<br />
<strong>Nurse</strong>s Service Organization (NSO)<br />
<strong>The</strong> wealth of health information available online can be beneficial<br />
for patients, but only if that information is accurate. Although recent<br />
issues on misinformation have centered on the COVID-19 pandemic,<br />
misinformation has been a problem in many other areas related to<br />
wellness and healthcare, such as dieting, exercise, and vitamins and<br />
supplements. Although misinformation isn’t new, the internet and social<br />
media have supercharged the ability for it to spread.<br />
<strong>Nurse</strong>s and nurse practitioners have the power to counteract<br />
misinformation, but first, they need to understand why people may be<br />
inclined to believe information that is not grounded in science.<br />
Why do people believe misinformation?<br />
Several factors can lead to people accepting misinformation:<br />
Health literacy. Health literacy refers not only to the ability to read and<br />
understand health information, but the appraisal and application of<br />
knowledge. People with lower levels of health literacy may be less able<br />
to critically assess the quality of online information, leading to flawed<br />
decision-making. One particular problem is that content is frequently<br />
written at a level that is too high for most consumers.<br />
Distrust in institutions. Past experiences with the healthcare system<br />
can influence a person’s willingness to trust the information provided.<br />
This includes not only experiences as an individual but also experiences<br />
of those in groups people affiliate with. Many people of color and those<br />
with disabilities, for example, have had experiences with healthcare<br />
providers where they did not feel heard or received substandard care,<br />
eroding trust. In addition, some people have an inherent distrust of<br />
government, leading them to turn to alternative sources of information<br />
that state government provided facts are not correct.<br />
Emotions. Emotions can play a role in both the spread and<br />
acceptance of misinformation. For example, false information tends to<br />
spread faster than true information, possibly because of the emotions it<br />
elicits. And Chou and colleagues note that during a crisis when emotions<br />
are high, people feel more secure and in control when they have<br />
information—even when that information is incorrect.<br />
Cognitive bias. This refers to the tendency to seek out evidence that<br />
supports a person’s own point of view while ignoring evidence that does<br />
not. If the misinformation supports their view, they might accept it even<br />
when it’s incorrect.<br />
How to combat misinformation<br />
Recommending resources, teaching consumers how to evaluate<br />
resources, and communicating effectively can help reduce the negative<br />
effects of misinformation.<br />
Recommendations. In many cases, patients and families feel they<br />
have a trusting relationship with their healthcare providers. <strong>Nurse</strong>s<br />
can leverage that trust by recommending credible sources of health<br />
information. Villarruel and James (https://www.myamericannurse.com/<br />
preventing-the-spread-of-misinformation/) note that before making a<br />
recommendation, nurses should consider the appropriateness of the<br />
source. For example, a source may be credible, but the vocabulary used<br />
may be at too high a level for the patient to understand. Before making<br />
a recommendation, nurses should consider the appropriateness of the<br />
source for the patient’s health literacy level. Kington and colleagues<br />
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8486420/) explain the<br />
importance of evaluating sources to ensure the information provided is<br />
science-based, objective, transparent, and accountable.<br />
Although the tendency is to recommend government sources such as<br />
the Centers for Disease Control and Prevention and National Institutes<br />
of Health, as noted earlier, some people do not trust the government. In<br />
this case, sources such as MedlinePlus, World Health Organization, and<br />
condition-specific nonprofit organizations (e.g., the American Heart<br />
Association, American Cancer Society, Alzheimer’s Association) might be<br />
preferred.<br />
Education. <strong>The</strong> sheer scope of the information found online can<br />
make it difficult for even the most astute consumer to determine what<br />
is accurate. <strong>Nurse</strong>s can help patients by providing tools they can use<br />
to evaluate what they read. <strong>The</strong> website Stronger suggests a fourstep<br />
process for checking for misinformation (https://stronger.org/<br />
resources/how-tospot-misinformation), and MedlinePlus offers additional<br />
resources for evaluating health information (https://medlineplus.gov/<br />
evaluatinghealthinformation.html). UCSF Health (https://www.ucsfhealth.<br />
org/education/evaluating-health-information) provides a useful short<br />
overview for patients on how to evaluate the credibility and accuracy of<br />
health information and red flags to watch for.<br />
Communication. From the start, the nurse should establish the<br />
principle of shared decision-making, which encourages open discussion.<br />
A toolkit from the U.S. Surgeon General on misinformation (https://<br />
www.hhs.gov/sites/default/files/health-misinformation-toolkit-english.<br />
pdf) recommends that nurses take time to understand each person’s<br />
knowledge, beliefs, and values and to listen with empathy. It’s best to<br />
take a proactive approach and create an environment that encourages<br />
patients and families to share their thoughts and concerns (see “A<br />
proactive approach”). <strong>Nurse</strong>s should remain calm, unemotional, and<br />
nonjudgmental.<br />
misinformation instead of the recommended treatment plan, this<br />
documentation would demonstrate the nurse’s efforts and could help<br />
avoid legal action.<br />
A positive connection<br />
<strong>Nurse</strong>s can serve as a counterbalance to the misinformation that<br />
is widely available online. Providing useful resources, educating<br />
consumers, and engaging in open dialogue will promote the ability of<br />
patients to receive accurate information so they can make informed<br />
decisions about their care.<br />
References<br />
CDC. How to address COVID-19 vaccine misinformation. 2021. https://<br />
www.cdc.gov/vaccines/covid-19/health-departments/addressingvaccinemisinformation.html<br />
Chou W-YS, Gaysynsky A, Vanderpool RC <strong>The</strong> COVID-19 misinfodemic: Moving<br />
beyond fact-checking. Health Educ Behav. 2020;1090198120980675:1-5.<br />
Kington RS, Arnesen S, Chou W-YS, Curry SJ, Lazer D, and Villarruel AM.<br />
Identifying credible sources of health information in social media: Principles<br />
and attributes. NAM Perspect. 2021:10.31478/202107a. https://www.ncbi.nlm.<br />
nih.gov/pmc/articles/PMC8486420/<br />
MedlinePlus. Evaluating Health Information. National Library of Medicine. <strong>2022</strong>.<br />
https://medlineplus.gov/evaluatinghealthinformation.html<br />
Office of the Surgeon General. A Community Toolkit for Addressing Health<br />
Misinformation. US Department of Health and Human Services. 2021. https://<br />
www.hhs.gov/sites/default/files/health-misinformation-toolkit-english.pdf<br />
Stronger. How to spot misinformation. n.d. https://stronger.org/resources/how-tospot-misinformation<br />
Schulz PJ, Nakamoto K. <strong>The</strong> perils of misinformation: When health literacy goes<br />
awry. Nat Rev Nephrol. <strong>2022</strong>. https://www.nature.com/articles/s41581-021-<br />
00534-z<br />
Swire-Thompson B, Lazer D. Public health and online misinformation: Challenges<br />
and recommendations. Annu Rev Public Health. 2020;41:433-451.<br />
UCSF Health. Evaluating health information. n.d. https://www.ucsfhealth.org/<br />
education/evaluating-health-information<br />
Villarruel AM, James R. Preventing the spread of misinformation. Am Nurs J.<br />
<strong>2022</strong>;17(2):22-26. https://www.myamericannurse.com/preventing-thespreadof-misinformation/<br />
Disclaimer: <strong>The</strong> information offered within this article reflects general<br />
principles only and does not constitute legal advice by <strong>Nurse</strong>s Service<br />
Organization (NSO) or establish appropriate or acceptable standards of<br />
professional conduct. Readers should consult with an attorney if they have<br />
specific concerns. Neither Affinity Insurance Services, Inc. nor NSO assumes any<br />
liability for how this information is applied in practice or for the accuracy of this<br />
information. Please note that Internet hyperlinks cited herein are active as of the<br />
date of publication but may be subject to change or discontinuation.<br />
This risk management information was provided by <strong>Nurse</strong>s Service<br />
Organization (NSO), the nation's largest provider of nurses’ professional<br />
liability insurance coverage for over 550,000 nurses since 1976. <strong>The</strong> individual<br />
professional liability insurance policy administered through NSO is underwritten<br />
by American Casualty Company of Reading, Pennsylvania, a CNA company.<br />
Reproduction without permission of the publisher is prohibited. For questions,<br />
send an e-mail to service@nso.com or call 1-800-247-1500. www.nso.com.<br />
Documentation<br />
As with any patient education, it’s important to document discussions<br />
related to misinformation in the patient’s health record. <strong>Nurse</strong>s should<br />
objectively record what occurred and include any education material<br />
they provided. Should the patient experience harm because of following
<strong>July</strong>, August, September <strong>2022</strong> <strong>The</strong> <strong>North</strong> <strong>Dakota</strong> <strong>Nurse</strong> Page 23<br />
Using an Independent Double Check<br />
When Administering High Risk Medications<br />
Appraised by:<br />
Maddie Guthmiller SN, Kendra Essert SN, Megan Dean SN, Morgan<br />
Paul SN, Caroline Senn SN<br />
Allison Sadowsky MSN RN Assistant Professor of Practice (Faculty)<br />
(NDSU School of Nursing at Sanford Bismarck)<br />
Clinical Question:<br />
For patients in acute care settings does the use of double-checking<br />
medications with a second nurse reduce the risk for inadequate patient<br />
safety?<br />
Sources Of Evidence:<br />
Cochran, G. L., Barrett, R. S., & Horn, S. D. (2016). Comparison of medication<br />
safety systems in critical access hospitals: Combined analysis of two studies.<br />
American Journal of Health-System Pharmacy, 73(15), 1167–1173. https://doi.<br />
org/10.2146/ajhp150760<br />
Douglass, A. M., Elder, J., Watson, R., Kallay, T., Kirsh, D., Robb, W. G., Kaji,<br />
A. H., & Coil, C. J. (2018). A randomized controlled trial on the effect of a<br />
double check on the detection of medication errors. Annals of Emergency<br />
Medicine, 71(1), 74–82. https://doi.org/10.1016/j.annemergmed.2017.03.022<br />
Koyama, A. K., Sheridan Maddox, C.-S., Ling Li, Bucknall, T., & Westbrook,<br />
J. I. (2020). Effectiveness of double checking to reduce medication<br />
administration errors: a systematic review. BMJ Quality & Safety, 29(7), 595–<br />
603. https://doi-org.ezproxy.lib.ndsu.nodak.edu/10.1136/bmjqs-2019-009552<br />
Manias, E., Street, M., Lowe, G., Low, J.K., Gray, K., & Botti, M. (2021). Associations<br />
of person-related, environment-related, and communication-related factors<br />
on medication errors in public and private hospitals: a retrospective clinical<br />
audit. BMC Health Services Research, 21(1025). Retrieved from: https://doi.<br />
org/10.1186/s12913-021-07033-8<br />
Westbrook, J. I., Ling Li, Raban, M. Z., Woods, A., Koyama, A. K., Baysari, M. T.,<br />
Day, R. O., McCullagh, C., Prgomet, M., Mumford, V., Dalla-Pozza, L.,<br />
Gazarian, M., Gates, P. J., Lichtner, V., Barclay, P., Gardo, A., Wiggins, M., &<br />
White, L. (2021). Associations between double-checking and medication<br />
administration errors: a direct observational study of paediatric inpatients.<br />
BMJ Quality & Safety, 30(4), 320–330. https://doi-org.ezproxy.lib.ndsu.nodak.<br />
edu/10.1136/bmjqs-2020-011473<br />
Synthesis of Evidence:<br />
Five articles were reviewed in relation to this issue of medication errors<br />
related to the double checking of high-risk medications. In nursing<br />
practice, nurses administer drugs that can have a debilitating or deadly<br />
impact to the patient if they are given incorrectly. <strong>The</strong> nurse’s license is<br />
at risk everyday if he or she does not follow the five rights of medication<br />
administration.<br />
<strong>The</strong> first study conducted by Douglass et al. (2018) was a prospective,<br />
randomized, blinded, controlled trail. <strong>The</strong> study conducted a simulation<br />
that included 43 pairs of emergency room and intensive care nurses. <strong>The</strong><br />
study looked at how often the double check was utilized by the nurses,<br />
the effect of the double check, and qualitative factors that affected<br />
the double check. <strong>The</strong> trained evaluator watched the simulations and<br />
found that all nurses in the double check group used a double check,<br />
in the wrong vial scenario, all double-checking groups found the error<br />
versus only 54% of the single check group found that error. In the weightbased<br />
group, 33% of double-checking groups versus 9% in the single<br />
check group found the error. Total, out of the 13 simulations, 54% were<br />
caught by the first nurse independently, 15% were identified by two<br />
nurses working together, and 31% were identified by the second nurse<br />
independently. Factors that effect a double check are the other nurse<br />
not catching the error, or the second nurse rushing the first nurse, and<br />
nurse confusion. <strong>The</strong> use of an independent double check was found<br />
to be superior to that of a single check in medication administration, so<br />
nurses should utilize the double check appropriately.<br />
<strong>The</strong> second study conducted by Westbrook, Li, & Raban (2020) was<br />
a quantitative study. This study was conducted to examine the effects<br />
of double-checking medications to reduce medication errors with<br />
pediatric patients. <strong>The</strong> study included 1523 children within a 340-bed<br />
tertiary pediatric hospital and 298 nurses. <strong>The</strong> interventions included:<br />
observing the nurses and using a time stamping system and average<br />
hourly rates with oncosts. <strong>The</strong> results concluded that there was no<br />
statistical difference found for double-checking administrations. Among<br />
the medication administrations where double checking was mandated,<br />
36 were independently double-checked, 3296 were primed double<br />
checking and 231 received an incomplete or no double-check. Double<br />
checking was optional for 1577 administrations but applied in 416 of<br />
these. In only seven administrations was an independent double check<br />
performed. Lastly, among all 5240 medications administrations observed,<br />
3563 required double checking according to hospital policy.<br />
<strong>The</strong> third study conducted by Koyama, Sheridan, Maddox, Ling,<br />
Bucknall, and Westbrook (2020), was a systematic review that analyzes<br />
thirteen studies, including ten observative study designs, and three<br />
randomized control trails sampling around 47-1,374 patients. <strong>The</strong> systemic<br />
review examined contemporary evidence of the effectiveness of double<br />
checking to reduce medication administration errors and associated<br />
harm to identify both the strength of that evidence and where future<br />
research needs to focus. <strong>The</strong> study also highlighted compliance with<br />
double checking practices. Double checking adherence rates ranged<br />
from 52% to 97%. Overall, there was insufficient evidence that double<br />
checking versus single checking medications were associated with lower<br />
MAE, however one of the higher quality studies did show a significant<br />
association between double checking and reduction in MAE.<br />
<strong>The</strong> fourth study conducted by Manias, Street, Lowe, Low, Gray, & Botti<br />
(2021), was a retrospective descriptive clinical audit that used 16 hospitals<br />
in Australia from October 1st, 2015, to March 31st, 2017, that found a total<br />
of 11,540 medication errors. Out of 11,540 only 3,260 medication errors<br />
were documented to be in relation to double checking medication.<br />
<strong>The</strong> purpose of this study was to determine the associations of personrelated,<br />
environmental-related, and communication-related factors<br />
on the severity of medication errors occurring in two health services.<br />
Health professionals submitted medication errors to an on-line voluntary<br />
incident reporting system with all medication errors reported during the<br />
18-month period. Single checking of medications was documented in<br />
8271 of medication errors while double checking was documented in<br />
3269 medication errors.<br />
<strong>The</strong> fifth study conducted by Cochran, Barrett, & Horn (2016) was<br />
a direct observational prospective two-phase quantitative analysis<br />
of 12 Nebraska critical assess hospitals observing 6,497 medications<br />
being administrated to 1,374 patients. This study has several different<br />
medication administration safety interventions put in place to<br />
compare medication error rates amongst one another. <strong>The</strong> different<br />
interventions include barcode-assisted medication administration,<br />
automated dispensing cabinets, nurse-nurse double checks, pharmacist<br />
transcription, and onsite pharmacist dispensing. During the dispensing<br />
phase of medication administration, the use of manual double-checking<br />
medications prevented 10% of errors from reaching the patient. Manual<br />
double-checking of medications was proven aside from the other<br />
administration interventions to be the most cost-effective strategy.<br />
Conclusions:<br />
<strong>The</strong> four out of the five articles found that a double check with a<br />
second nurse was effective in reducing medication errors. However,<br />
the study by Westbrook, Li, & Raban (2020) found that there was no<br />
statistically significant safety benefit when using nurse to nurse double<br />
checking. However, the study utilized primed double checking of<br />
medications more often, rather than independent double checking,<br />
which may have skewed the results.<br />
Implications for Nursing Practice:<br />
<strong>The</strong> research studies overall found that a second nurse double check,<br />
specifically an independent second nurse double check was indeed<br />
effective in reducing medication errors in weight-based and high-risk<br />
medications. <strong>The</strong>se reductions in medication errors can improve overall<br />
patient safety. <strong>The</strong>refore, the independent second nurse double check<br />
should be utilized in nursing practice.
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