current resident or

Presort StandardUS Postage

PAIDPermit #14

Princeton, MN55371

Volume 37 • Issue 2 June, July, August 2010

Circulation to 74,000 Registered Nurses, Licensed Practical Nurses and Student Nurses in Alabama Alabama State Nurses Association • 360 North Hull Street • Montgomery, AL 36104

The Official Publication of the Alabama State Nurses Association

Hospital Heros Page 6

2010 Convention ASNA & AlaONL

Registration

Page 9

Inside this IssueAlabama Board of Nursing Vacancies . . . . . . . . . . . . . 2

ASNA Board of Directors . . . . . . . . . . . . . . . . . . . . . . 2

CE Corner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-19

Convention Registration (Pull out section) . . . . . . . . 9-12

ED’s Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Financial Corner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Legal Corner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

LPN Corner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Membership News . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

President’s Message . . . . . . . . . . . . . . . . . . . . . . . . . 3

Research Corner . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Save These Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Save These DatesASNA/AlaONL/AANS CONVENTION 2010

Renaissance Riverview Plaza Hotel, Mobile, AL

September 30 through October 2, 2010CONVENTION

REGISTRATION IN PULL OUT SECTION

ATTENTION RN’s2010 IS RN’s RENEWAL YEAR

ABN DEADLINE ISNOVEMBER 30th

The ABN will have on-line capability, including payment by credit card. You may also pay

by personal check.

Attend the ASNA Convention to meet your CE needs!

Now On ASNA Webpage

www.alabamanurses.org• ASNAScholarship

Information• MembershipApplications

Members Only Section ASNA Web Page

www.alabamanurses.org

Look for important convention issuesVisit ASNA’s website for:

• Bylawchanges-maycontactASNA ifyouneedmoreinformation.• ASNABallot• ProposedResolutions

It’sthattimeagain,andtheASNABoardofDirectors/AlaONL/AANS invites YOU to attend the 97th AnnualASNA Convention. We continue to offer the bestcontinuing education, networking and participationopportunitiesforafairpriceandinaconvenientformattomeetyourneeds.

Thursday, September 30, 2010 is the Mable Lamb Continuing Education Day from 8:00 a.m. to 4:30 p.m.There is something for everyone and you may registerseparately for this event. Opening Ceremonies beginat 5:00 p.m. with Dr. Debbie Hatmaker as the keynotespeaker. A reception in honor of Dr. Hatmaker will befrom6:00p.m.until7:00p.m.WearehavinganAwards/Celebration Dinner Thursday Night from 7:00 p.m. until10:00p.m.Plan to come for the educationor come earlyfortheConventionandstaytomeetandgreetothernurses.Itwillbealotoffunandagreatnetworkingopportunityforallwhoattend!

Friday, October 1, 2010 begins with a ContinentalBreakfastfrom7:30a.m.until8:30a.m.Pollswillbeopenfrom7:45a.m.until8:30a.m.Exhibitswillbeopenfrom8:00a.m.to12:30p.m.andyou’llwanttovisitthemall.Weofferanotheropportunityforcontacthourswhenyouviewthe Poster Presentations available from 8:00a.m.–12:30

p.m. Optional Continuing Nursing Education Sessionsfrom 9:00 a.m.–11:00 a.m. Plenary Session from 12:30p.m.–1:30 p.m. The House of Delegates from 1:30 p.m.until6:00p.m.Thisisyouropportunitytohaveyourvoiceheard.We’llbediscussingANAchanges,Resolutions,andothermattersofimportancetoASNA.Dr.MarlaWeston,ANA/CEOwill be a speaker.Followedby an eveningofleisureortriptothecasinoinBiloxi,Mississippi.

Saturday, October 2, 2010 will begin with Breakfastroundtablesat7:00a.m.PlenarySessionfrom8:15a.m.–9:15a.m.TheASNAHouseofDelegateswillthenconveneat 9:15 a.m.–12:15 p.m. Lunch and the closing plenarysessionwill be from12:30p.m. until 2:00p.m.WehopeyouwilljoinusandtakeadvantageoftheCEofferings,tonetworkwitholdfriendsandmakenewones,andtogiveyourself the gift of professional involvement. Several funactivitieswillbeinterspersedthroughoutthemeeting.

Mark your calendar now! Come be a part of Alabama nursesmakingadifference.Findouthowgooditcanfeeltorepresentyourdistrictandyourprofessionasweaddressthe critical nursing issues facingus today.Please use theConvention 2010 special pull-out section for all yourregistrationneeds.

We look forward to seeing YOU there!

We’ll See YOU There!Inside Alabama Nurse

Page 2 • The Alabama Nurse June, July, August 2010

ASNA Board of Directors

President. . . . . . . . . . . . . DebbieFaulk,PhD,RN,CNEPresident-Elect . . JoyceVarner,DNP,GNP-BC,GNCSVicePresident. . . . . . . . . . . JackieWilliams,MSN,RNSecretary. . . . . . . . . . . . . . . . . MardellDavis,PhD,RNTreasurer. . . . . . . ArleneMorris,EdD,MSN,RN,CNEDistrict1. . . . . . . . . BrianBuchmann,BSN,RN,MBADistrict2. . . . . . . . . PamelaMoody,PhD,RN,FNP-BCDistrict3. . . . . . . Delores“Dee”Sherman,MSN,BSN, RN, HCPNDistrict4. . . . . . . . Henrietta“Henri”Brown,DNP,RNDistrict5. . . . . . . . . . . . . .MargaretHoward,ADN,RNCommission on Professional Issues . . . . DebraLitton,RN,MSN,MBS, CNAVA Consultant. . . . . . . . . . . . . . JeanellForee,BSN,RNSpecialInterestGroup:AdvancePracticeCouncil. . . . . .KarenDavidson,DSN, CRNP

ASNA STAFF

ExecutiveDirector,JosephF.Decker,II,MA,BADirectorLeadershipServices,

CharleneRoberson,MEd,RN-BCASNAAttorney,DonEddins,JD

AdministrativeCoordinator,BettyChamblissProgramsCoordinator,AprilBishop

334-262-8321Phone

VISION STATEMENTOur Vision

ASNA is the professional voice of all registered nurses in Alabama.

OUR VALUES

• Modelingprofessionalnursingpracticestoothernurses

• AdheringtotheCode of Ethics for Nurses• Becomingmorerecognizablyinfluentialasan

association• Unifyingnurses• Advocatingfornurses• Promotingculturaldiversity• Promotinghealthparity• Advancingprofessionalcompetence• Promotingtheethicalcareandthehumandignityof

everyperson• Maintainingintegrityinallnursingcareers

OUR MISSION

ASNA is committed to promoting excellence in nursing.

ADVERTISING

For advertising rates and information, please contactArthur L. Davis Publishing Agency, Inc., 517Washington Street, PO Box 216, Cedar Falls, Iowa50613, (800) 626-4081, sales@aldpub.com. ASNA andthe Arthur L. Davis Publishing Agency, Inc. reservethe right to rejectanyadvertisement.Responsibility forerrorsinadvertisingislimitedtocorrectionsinthenextissueorrefundofpriceofadvertisement.

Acceptance of advertising does not imply endorsementor approval by the Alabama State Nurses Associationof products advertised, the advertisers, or the claimsmade. Rejection of an advertisement does not imply aproductoffered foradvertising iswithoutmerit,or thatthemanufacturerlacksintegrity,orthatthisassociationdisapproves of the product or its use. ASNA and theArthur L. Davis Publishing Agency, Inc. shall not beheldliableforanyconsequencesresultingfrompurchaseor useof an advertiser’s product.Articles appearing inthispublicationexpresstheopinionsoftheauthors;theydo not necessarily reflect views of the staff, board, ormembershipofASNAor thoseof thenational or localassociations.

© Copyright by the Alabama State Nurses Association.

PUBLICATION TheAlabamaNursePublicationSchedulefor2010

Issue Material Due to ASNA OfficeSept/Oct/Nov Aug9Dec/Jan/Feb2011 Nov1

Guidelines for Article DevelopmentTheASNAwelcomesarticlesforpublication.ThereisnopaymentforarticlespublishedinThe Alabama Nurse.1. Articles should be microsoft word using a 12 point

font.2. Articlelengthshouldnotexceedfive(5)pages8x113. Allreferenceshouldbecitedattheendofthearticle.4. Articles (if possible) should be submitted

electronically.

Submissionsshouldbesentto:edasna@alabamanurses.org

orEditor,The Alabama Nurse

Alabama State Nurses Association360NorthHullStreetMontgomery,AL36104

Correction from Mar/Apr/May issue of

Alabama NurseHeather Rankin, is President-Elect

of the ALANA not the AANA.

Alabama Board of Nursing VacanciesTherewillbe2 RNpositionsopenand1 LPN position

open as of January 1, 2011. The term of Pamela Autry,Nursing Practice; Sylvia Nobles, Advanced Practice; andGreg Howard, AFLPN will expire December 31, 2010.RNapplicationsonlyareavailablefromtheASNAoffice.Call Betty! Call Greg Howard, AFLPN 1-205-554-2000Ext.2270 for LPN application. RN candidates must beemployedinNursingPracticeorAdvancedPractice.

Awards Nominations Made Incredibly Easy

The Awards nomination process just got easier. Youcan now nominate some deserving person/organizationforASNAawardsbygoingtotheASNAwebsiteatwww.alabamanurses.org. On the home page click on “ASNAAwards Criteria/Nomination Forms”. All the awards andthe criteria are listed. You can go under the awards andenter the information right on line or you can downloadthe form, fill it in and send it back to ASNA by email,mail or fax.For aperson,youcandownloadand fill outthe Biographical Form or you can send in a CurriculumVitae (CV) if you like. You can download a letter ofsupportform,fillitoutandsenditbacktoAprilatASNAoryoucansend ina letterbymail,emailor fax.AwardsforthisyearmustbesentinbyJuly23,2010.Therearealotofveryspecialpeopleout thereweneedtohonorandrecognizefortheirefforts.Pleasetakethetimetodothis.WechallengeeachoftheDistrictstosendinanominationfor each of the awards. Come on–Make the AwardsCommittee’sjobharder;itwouldthrillus.

Condolences to:Jackie Williams in the death of her husband.

Voncile Stallworth in the death of her brother.

The family of Geraldine Allen.

June, July, August 2010 The Alabama Nurse • Page 3

The President’s Message

Debbie Faulk, PhD, RNASNA President

Theotherday Igotanemailfrom a friendwho is amemberofthesamenursingorganizationof which I am a member andfor which I have served asan officer. My friend stated,“Before I write my check torenewmymembership,Iwantedtoknowwhat ______________has done over the past year.”I thought “what an excellentquestion.” Iwasnot in the leastoffended by the question; in fact it causedme to ponderwhyIhadnotaskedthesamequestioninthepast.IbelievethatbeingamemberofoneorseveralprofessionalnursingorganizationsdemonstratesapersonalcommitmenttothenursingprofessionandshowsthatIvalueprofessionalism.Deciding which organization(s) to join can beoverwhelmingandcandependonseveralfactorsofwhichone is cost. Peoplewho join groups and/or organizationshave a right to inquire about return on investment. Youallknowbynow that I believe thatmembership inANAandASNA is critical topromoting excellence innursing.ANAandstateassociationsaretheonlyorganizationsthatspeakfornursingasawhole. In thismysixthPresident’smessage,IwouldliketoprovideseveralexamplesofhowASNA puts your dues to work in order to achieve themission of promoting excellence in nursing. I hope thatthe outcome will be assurance that your investment inASNAisawisechoiceandadecisionthatIbelieveshouldcontinue.

First of all, the executive director, Mr. Joe Decker,

has been at the state legislature almost every day duringthe 2010 session to lobby for an increase in the scopeofpractice for Alabama’s advanced practice nurses and forincreasesinscholarshipfundsforstudentspursingdegreesinnursingeducation.Whatpercentageofyourdueswouldyouallocatetothisextremelyimportanttask?Whowoulddo this if not the executive director of ASNA? Doesthe specialty nursing organization to which you belonghave the resources to do this task? Could or would youpersonallybeon“GoatHill”4-5daysaweektalkingwithlegislators?Indollaramounts,howvaluableisthistasktoyouasaprofessionalnurse?AlthoughtherearemanyotherhealthcarerelatedissuesthatMr.DeckerhasfollowedforALLAlabamanurses,thetwomentionedabovearecriticaltopromotingexcellence innursingandprovidingnursingcareforAlabamians.

Secondly,ASNAhassponsoredanumberofcontinuingeducationprogramsoverthepastthreemonths.Let’stakethe Elizabeth Morris Clinical Education Day–FACES‘10 as just one example.Where in the state can you get8.4excellent clinicalCEs for thepriceof$59.00?ASNAsponsors approximately 8 CE programs at various sitesand 5 independent study courses per year through theAlabama Nurse or ASNA website. These CE programspromote excellence in nursing via education and offerthe most “bang for your buck.” The annual ASNA stateconventionoffersanentiredayofCEonawidevarietyoftopics.RegistrationisdiscountedforASNAmembers,thusaportionofyourduesgoestowardsponsorships.

Thirdly, ASNA has a great website providing ease ofaccess to information regarding anumberof nursing andhealthcare issues.Whatdollaramountwouldyouputonthisvaluableservice?Icouldgoonandonwithexamplesbut let me end with one final example and that is theexcellentASNAstaff.Idon’tknowhowmanyofyouhave

What is ASNA (Really) Doing for Me?

by Joseph F. Decker, IIExecutive Director

ASNA’s annual Elizabeth A. Morris Clinical Education Session (FACES 2010) on 20April at the Eastmont BaptistChurch in Montgomery wasanother huge success. We hadover 700 attendees (a newrecord) and a terrific lineupof speakers and educationaltracks. That lineup includedNCLEX prep for students,3 different clinical tracks,additional tracks on Diabetes,Medical and Mental Health,andasessiononSexualAssaultForensicNursing.PlenarysessionsincludedVanessa Barlow’s lecture on Workplace Bullying andDr. Arlene Morris’ feature on Professional Etiquette for Nurses. As always, the staff and volunteersatEastmontBaptistwereoutstanding–helpful,friendlyandwelcoming.And if youmissed the lunch of steak, bakedpotato, green beans, salad and some killer deserts–don’tmake thatmistake again! Itwas awesome. Iwant to saya special thanks toyourASNAstaff foragreat jobonceagain; Betty Chambliss, April Bishop and Charlene Roberson performed superbly as usual. By the way,Charlene really had to come through under pressure thisyear,aswehad4speakerscancelwithinoneweekoftheevent due to death, a death in the family, an unexpectedsurgeryandanaccidentwith injury. [Onaverysadnote,thedeathwasourownDr. Geraldine Allen ofSelmaandthe Troy University School of Nursing who succumbedfollowing a long battle with cancer the week beforeFACES.Ourthoughtsgowithherfamilyandfriends.]Wehope everyone had a great time at FACES this year andwilljoinusagain.Checkoutthephotosonourwebsiteatwww.alabamanurses.org. and elsewhere in this edition oftheAlabama Nurse.

With the 2010 state legislative session now complete,thisyear a totalof828billswere filed in theHouseand597 in the Senate; 199 passed by the House, 111 in theSenate.WithelectionsforallmembersofbothHouseandSenate thisNovember, thenextquadreniumwill convene

inMarch2011.FYI, therewillbe8openseats (of35) inthe Senate thisNovember, and 11 (of 105) in theHouse.Itpromisestobeaveryinterestingelection.TheGeneral Fund budget($1.6billion)passedwithoutmuchdifficultybeforetheendofthesession.TheEducation Budget ($5.5billion)alsopassedandweretained$237,000 in nursing scholarship funding for 2011. The bingo bill (SB 380/Sen. Bedford and Rep. Black) despite all the publicityand furor could not muster the votes in the House andwas withdrawn from consideration for this year. It hadpreviously passed in the Senate by a narrowmargin. Toremind, it required a 60% majority vote because it wasintended as a constitutional amendment. Proponentsbelieved that this bill would allow the state to control,taxandregulatebingoelectronicgamingandwouldhaveyieldedmillionsofdollars in taxrevenue instatecoffers.Opponents said the bill was corrupt and would give toomuchpowertocasinooperators(andtheLegislature),andresultinincreasingsocialproblems.Inanyevent,ifithadpassed itwouldhavebeenon theballot inNovember forvoters to approve/disapprove. Am sure we’ll see someversionofthatbillagainnextyear.

Anotherconstitutionalamendmentthatdidpassonthelast day of the session: SB 121, theRoads and Bridges construction bill (Sen. Barron; Rep. Beasley). This billwould take$100million/year for thenext tenyears fromtheAlabamaOil&GasTrustFundanddistributeitaroundthe state viaALDOT and the counties/municipalities forconstructionandimprovementofroadsandbridges,whichmost folks agree need help. It was also touted as a jobscreationbill togenerateconstructionjobsforAlabamiansin a tough economic time. The Oil&Gas Trust Fundcurrently has $2.6 billion and is considered the “savingsaccount” for the state aswell as a source of funding fortheGeneral Fundbudget every year.Opponents objectedto “raiding” the state savings account and to the term(10years fora totalof$1billion)ofwithdrawalswithoutreview.

A solution to the state’sPACT funding problem was finalizedonthelastdayof thesession(SB162,Sen.TedLittle,Rep.Ford,asamendedandsubstituted).Toremind,that issue involves the troubled prepaid college tuitionplan begun in 1989 with over 44,000 students currently

had the opportunity tomeet these fine, dedicated people(Joe Decker, Charlene Roberson, April Bishop, BettyChamblissandDonEddins).Letmeassureyoutheyworktirelessly to ensure that ASNA achieves its mission. Aportionofyourduespaystheirsalaryanditismoneywellspent!HavingapaidstaffensuresthatnursesinAlabamahaveaconsistent,organizedvoiceandresourcesintimeofneed.WhenitcomestotheASNAstaff,YOU,thepayingmember,receiveanexcellentreturnoninvestment.

At present we have approximately 1,400 members ina statewhere there are over 60,000 nurses (I always geta gasp from audiences when I give this statistic). I amPROUD of my ASNA, the organization manages to doGREAT things for ALL Alabama nurses with limitedresources.Thoseofyou,whoareamongthe1,400,pleaseknow that your hard earned money (dues) IS helpingachieve excellence in nursing for Alabama nurses. NexttimeyoupayyourduesandponderwhatASNAhasdoneforyou,pickup thephoneoremail the staffor theALLvolunteer board of directors and ask how yourmoney isbeingspent.Atthesametime,IwouldalsoencourageyoutoponderwhathaveyoudoneforASNA?

Asalways,inordertomakeadifferenceinhealthcare,nurses must be united.While we have many voices anddiversevalues,wecandialogue,agreetodisagree,andyetshowothers thatwe speakwith one strongCIVIL voice when it comes to providing quality access to care forAlabamacitizensandtopromotingexcellenceinnursing.We at ASNA strongly believe that this advocacy can bebestaccomplishedthroughmembershipinASNA.Thankyou for your time and attention. I want ALL nurses inAlabamatoknowthatASNAisworkingwithyou,foryou!IfyouareamemberofASNA,thankyou!Ifyouarenot,JOINusinpromotingexcellenceinnursing.

The E.D.’s Notes

Joseph Decker

The E.D.’s Notes continued on page 4

Page 4 • The Alabama Nurse June, July, August 2010

participating.Biglossesintheinvestmentportfoliointhelasttwoyears,plusmuchhigherincreasesthanforecastincollegetuitionhavepushedtheaccountneardisaster.Theapplication for new students has been closed.Over $500millionincashwillbeinfusedintothePACTaccountoverthe next 17 years for solvency, and tuition caps of 2.5%will beplacedon all state twoyear colleges and all fouryearcolleges excepttheUniversityofAlabama(UA,UAB,UAH)andAuburn.Theywillbeallowedtoraisetuitionastheywish.Asyoumight imagine, thatcausedquiteastirfromanumberoflegislators.Bytheway,tuitionincreasesatstatecollegeshavefaroutpacedinflationoverthelast15years.Wemaynothaveheardthelastofthisdiscussion.

Our nursing scholarship bill (SB234/HB398)failedtoreach a floor vote in theHouse during the last two daysofthesession,andisdeadforthisyear.Weactuallywereon theSpecialOrder calendarbothdays,but squabbling/filibusterover thePACTbill, theRoadsandBridgesbill,a bill to purchase a prison facility in Perry County (SB473, Sen. Barron and Rep. Knight) and oddly, SB 342,Licensure Exemption for Religious Based Care Facilities(Sen. T. Little and Rep. Bridges) delayed everythingtremendously, resulting in adjournment sine die 22Aprilbeforeourbillcouldbeaddressed.Wewillpersistandtryagainnextyear,butremainverydisappointedintheslowprogress of ourbill in theHouse and the inability of themainsponsor,Rep.(Dr.)BentleyofTuscaloosatopushfora conclusion since itpassed theSenatebackonFebruary18.

ASNA PAC has withdrawn its endorsement for Mr. Terrence JohnsonintheDistrict82racefortheAlabamaHouse of Representatives. This is an unfortunate turn ofevents, and was prompted by receipt of information of

The E.D.’s Notes continued from page 3 whichwewerepreviouslyunaware.ASNAPACcontinuesto endorse ASNA nurse member April Weaver (R) in District 49 (Bibb,Shelbycounty).Ms.Weaverisrunningfor an open seat to be vacated byRep.CamWard. ThisracewillbedecidedbytheprimaryvoteinJune,sincethedistrict is heavily Republican. We encourage all nursesto supportMs.Weaver by donating to her campaign andvolunteering to help. We did attend a fundraising eventforMs.Weaveron18April inAlabaster,whichwasverysuccessful.Itwouldbeatremendoussteptohaveanurseand ASNA member in the Legislature to speak for ourprofession in public policy debates. We urge all of ourmembers tobe informedabout the issuesandcandidates,getinvolvedandaboveallVOTEintheprimaryon1Juneand the general election in November. You can make adifference.

Dr. Joyce Varner,ASNAPresident-electandIattendedthe ANAConstituent Assemblymeeting 12-14March inWashingtonD.C. The primary focuswas preparation forthe ANA House of Delegates this June in D.C. In fact,Dr. Varner andDr. Debbie Faulk, ASNA President andothersareorganizinganorientationsessionforourASNAdelegatesthisyear.OneofthehotbuttonissuesthisJunewill be a pending ANA bylaws amendment to officiallydelete the “labor organization” status of ANA withrespecttotheDepartmentofLaborandNLRB.Whiletheoutcomeofthistopicisstillindoubt,webelievethatsincethemajorityof theANAdelegatesare fromstateswithaheavylaborunionpresencetheattempttoeliminateANA’slaborstatuswillbedefeated.Moreasitdevelops.

Finally,hereassomedatestorememberfor2010:ANAHOD 16-19June WashingtonDCASNAConvention 30Sept–2October Mobile, Riverview Plaza

Hopetoseeyouateveryevent.

LPN Corner

Hanging Loose in an Uptight World

by Gregory Howard, LPN

Are you stressed? Do you lack the energy to do thethings you need or want to do? Learning to hang loosemaybe just what you need. Weliveinaworldthatchangesfasterthen we can adjust, and everychange insists that we changepersonally in some way. Andlikewithmostpeoplechangehasthe potential to cause a certainlevelofstress.Theworldweliveinhasbeenreducedinsizesuchthat,whathappensinonepartoftheworldaffectsusall.

Someofthethingsthatcauseus themost stress are: the energy crises, reports ofwarsand deaths, soaring gasoline prices, economic crises, thedecreasing jobmarket, crime, drug and alcohol addition,familybreakdownandgangsandteenageviolencearebutafewofthelonglist.Thesethingsleaveusperplexedandstressed as towhat to donext orwhat to try and changefirst.Theseconcernsoftenleadtoanxiety,depressionandfear.Sowetortureourselveswiththe“WhatIf’s,It’sJustnotfair,”Ifonly”and“Ishouldhave”.Weplaytheblamegameanddon’trealizethatsometimeswesetourselvesupfor failure by not allowing for flexibility in the goalswesetorourexpectationofothers.

So how do we stay cool and hang loose in time ofstress?

1. Thinkpositiveandturnoffthenegativethoughts.2. Lookforthehumorinlife’ssourgrapes.3. Setrealisticgoalsandallowforflexibility.4. Thinktwice,eventhreeorfourtimesbeforereacting

tonegative situations .Wecanonlycontrolhowwereacttosituations.

5. Find someone you can share your concerns with,gettingasecondopinionor justhavingsomeonetolistentoyoucanmakeadifference.

Engage in those things that relaxyou to relieve stress.The list could includemany things such as:my favorite,shopping, but watch it, reading, playing physical games,mechanical relaxation equipment, exercising, massagetherapy,crosswordpuzzlesandonandon.

Work hard to cut loose the bad memories, hurtdisappointment and bitterness of yesterday and “hangloose”.Look for the gold and gold youwill find, if onlyinsmallamounts.Lookforthebadandyouwillcertainlyfind it and it will cause you grief. It sometimes takeslooking beyond what’s in front of you to realize theunspokentruth,forhereliesthekeytocopingandhangingloose in our uptight world. Just remember we are notperfect.

Legal Corner

by Don Eddins, BS, MS, JD

It’s no happenstance thatopinion polls have shownregistered nurses to be themost admired professionals inAmericaeveryyearthisdecade,saveone.

And we can understand thenation’s fascination with thosecourageous firemen who riskedtheir lives during the tragicevents of “911” and salute thenation’s firemen for cracking RNs domination of theachievementthatoneyear.

Registered nurses’ perennial recognition as the mostbelovedprofessionalsinthenationisrewardingforthoseofusassociatedwiththeAlabamaStateNursesAssociation.

Andcertainly,suchdistinctioniswell-deservedbecausenogroupinourcountrycaresmoreandworksharderforthegoodofthosetheyservethannurses.

That’sone reason that I am sodisappointed asASNAattorney when a nurse calls me about a notice from theAlabamaBoardofNursingrelatingtoadisciplinaryactiononamatterthenurseeasilyhaveavoided.

Take pre-charting for instance. RNs know that youdon’tatnoonputdownthatamedicationwasadministeredat2:00p.m.

Whatifthenurseisinvolvedinanaccidentandhastoleaveat1:00p.m.?What if thepatienthas anemergencyandisnotonthewardat2:00p.m.?

The answer in both scenarios is that the nurse wouldhaveviolatedtheAlabamaNursePracticeAct.

Another matter relating to records that I sometimesmustrepresentnursesonisimpropercorrections.

Sometimes the fact that medications were notadministered or that a procedure was not followed justdon’t get noted. A nurse can make a correction but itmust be done the properway.Know your local facility’sprocedureformakingcorrectionssothatyoudon’tgetintotroublewiththeboard.

Many good nurses don’t want to spend valuable timewith paperwork or logging information on a computer.Afterall,thatistimetakenfromdirectcare.

Even so records are vitally important. If a nurse issubpoenaedfortestimony,he/shedoesnotwanttoshowupwithshoddyorincompleterecords.

At the same time, it is important to record thatwhichshould be recorded and nothing more. Show that themedications were administered according to protocol ina timely manner. Show that the patient was checked onschedule,according toprotocol, for theparticular illness.But a lengthy, non-required narrative might give theimpression that the supervisor or physician should havebeenalertedaboutacondition.

Animportantthingtorememberisthatit’sallrighttoask.Nursesareprofessionals,buttheystillhavequestions.Makecertainyouaredoingthingstherightway.

Registered nurses who are members of the AlabamaState Nurses Association have an advantage over others.TheycancalltheASNAortheASNA’sattorney(myself)foradvice.Theadviceisfreeaspartofyourmembership.

AllofAlabama’s registerednurses shouldbeproudofthemselves for the respect theyhaveearnedfromsociety.Let’smaintainthatloftystatus.

June, July, August 2010 The Alabama Nurse • Page 5

by Genell Lee, MSN, RN, JDExecutive Officer

www.abn.alabama.gov

• RenewbetweenSeptember1,2010–November30,2010 RNFEE: $75.00 TransactionFee: 3.50 TOTAL: $78.50 • RenewbetweenDecember1,2010–December31,2010 LATERNFEE: $125.00 RENEWALFEE: 75.00 TransactionFee: 3.50 TOTAL $203.50

ADVANCED PRACTICE NURSES: TIME TO RENEW YOUR APN APPROVAL & RN LICENSE!

• RenewRNlicenseandAPNapprovalbetween September1,2010–November30,2010 RNFee: $75.00 APNFee: $50.00(peradvancedpractice approval) TransactionFee: 3.50 TOTAL: $128.50

• Renew RN license and APN approval betweenDecember1,2010–December31,2010

LateRNFee: $125.00RNFee: 75.00APNFee: 50.00(peradvancedpractice approval)TransactionFee: 3.50TOTAL: $253.50

ANYLICENSEISSUEDONORBEFOREAUGUST31, 2010 WILL LAPSE ON DECEMBER 31, 2010 IFNOTRENEWEDBYMIDNIGHT.

ANYADVANCEDPRACTICEAPPROVALISSUEDON OR BEFORE AUGUST 31, 2010 WILL LAPSEON DECEMBER 31, 2010 IF NOT RENEWED BYMIDNIGHT.

January 1, 2011:Date you are required to have yourlicensecardavailableforemployerinspection.Subscribersto the online license verification systemmay not ask foryourlicensebutyouarerequiredtohaveitavailableshouldyouremployerrequesttoseeyourcard.

Payment: Credit Cards:VISA,MasterCard,Discover,American

ExpressDebit Cards: VISA, MasterCard (Cardholder’s name

andaddressinthepaymentinformationmustmatchbankrecordsEXACTLY)

Prepaid VISA or MasterCard Debit Cards: May bepurchasedatseverallocations:CVS,Rite-Aid,Walgreen’s,WesternUnion,creditunions,etc.

Donotuseprepaidcardsuntilactivated.$3.50 transaction fee should be included in pre-paid

debitcardtotalattimeofpurchase.

RETIRED LICENSE STATUSAre you retired from nursing but want to keep your

license? The Board now offers an inactive license thathas a RETIRED status. You can renew your license in

the retired status for only $50.00. You will be asked todeterminewhethertorenewActiveorRetiredinoneofthefirstscreenswhenyourenewonline.

The Retired status does not allow you to practice nursing; you are provided a license card that shows you used to practice but are now Retired. An active license is required to practice nursing.

To assure that the retired status is not used to bypassCErequirements, thereactivationfeeforaretired licensewithintwoyearsis$500plusthe$75renewalfee(total=$575).Thereactivationfeeaftertwoyearsis$150plusthe$75renewalfee.

CONTINUING EDUCATIONThe CE Earning Period is January 1, 2009 until

December31,2010.Ifyouhaveatwo-yearlicense,youarerequiredtohave24contacthoursofcontinuingeducationinordertorenew.IfyouwerelicensedbetweenJanuary1,2009andAugust31,2010,thenumberofcontacthoursofcontinuingeducationthatarerequiredispostedinthepro-ratedCE hours chart on theBoard’sweb site,www.abn.alabama.gov,under“ContinuingEducation.”

AnyCEcontacthours submittedbyaBoard-approvedprovider(onewithanABNP#)shouldbepostedonyourindividualCErecord.Donotduplicatetheentry.Besureand earnyourCEprior to thedayyou attempt to renew.Board-approvedprovidersmaynothavesufficienttimetosubmit yourCE onNovember 30, 2010 if youwait until3:00P.M.oraftertoearntheCEonthatday.

You should check your individual CE record on theBoard’s web site with your license number and last 4digitsofyoursocialsecuritynumbertoseewhatyouhaveearned thus far. If youhave insufficientCEhourswhenyouattempttorenew,youwillnotbeallowedtocompletetheprocess.

While the CE earning period is until December 31,2010, if you wait until December to earn your CE andrenew,thelatefeedoesapply.

CRNA,CRNP,CNM:Requiredtohavesix(6)contacthoursofpharmacologyinordertorenew.

Ifyouwere licensedbyexamination,youare requiredtohavea four (4)hourmandatoryclasson functionsand

activities of the Board of Nursing in order to renew. Ifyou fail to view the mandatory class for new graduates,youwillnotbeeligible to renew.Themandatoryclass islocatedontheBoard’swebsiteatwww.abn.alabama.gov.

REGULATORY QUESTIONSThere are regulatory questions you are required to

answer in order to renew. The regulatory questions aidthe Board in determining if you have the fitness andcapacitytopractice.Ifyouanswer“Yes”toanyquestion,you shouldprovideadetailedexplanation in the textboxprovided.Ifyouanswer“Yes”toacriminalhistory,submitcertifiedcourtrecords.

Do not wait until the last day of renewal to submit arenewal application with a “Yes” answer. We do revieweachapplicationandyouarenotguaranteedtoberenewedif you fail to submit the appropriate documentation toexplainyour“Yes”answer.

STATISTICAL QUESTIONSThere are a few questions on the renewal application

regardingemploymentstatus,typeofnursingpractice,andareaofnursingpractice.Pleaseanswerthequestionsaskedsothat theBoardcanaccuratelyreport informationaboutthenursingpopulationinAlabama.

POSSIBLE DISCIPLINARY ACTIONDonotsubjectyourlicensetodisciplinebytheBoard.

Topreventdisciplinary,followtheseguidelines:• Answer truthfully to all the questions on the

application.Submitsupportingdocumentation.• You are required to attest (affirm) that the

informationcontainedinyourCErecordisaccurate.If it is not accurate, review and make correctionsbeforesubmitting.

• DO NOT CONTINUE TO WORK IF YOURLICENSE LAPSES. Each year the Board has anumber of individualswho continueworking afterthelicenselapses.Todososubjectsyourlicensetodisciplineandthefinestartsat$600andgoesupto$1,000.00!

All Alabama Registered Nurses: Time to Renew Your License!

Page 6 • The Alabama Nurse June, July, August 2010

Membership

REMEMBER: 70% of your dues are tax deductible!New/Reinstated Members:

District 1PatriciaPhillipsElmore,NCC,WHNP–NewAuroraA.Dunn,CRNP–RejoinMarilynD.McAnalley,RN,BSN,MSN,CRNP–NewMarthaL.Mulligan,RN–NewWandaJenkins,RN–NewDonnaM.Herrin-Griffith,MSN,RN,CNAA,CHE–RenewDonnaKeenum,RN–NewElizabethFosterLewis,CRNP–NewHeatherJ.Rankin,CRNA–NewKristinaSmith,CRNA–New

District 2StevenGalvez,BSN,MSN,CRNP– RenewRachelA.Williams,RN–NewPatriciaA.Faile,RN,MSN–RenewMichelleJones,RN–NewMelindaElmoreHunnicutt,RN–NewPamelaDavis,LPN–NewLoisGriffin,MSN,FNP–RejoinElenaWilson,RN–RejoinTracyL.Bagwell,RN–NewEvonneR.Brown,RN–NewDonnaComer,CRNP–RejoinMaishaMoore,RN–NewRobinBrushParnell,RN–NewMargaretB.Tucker,RN–NewSusanVaughan,RN–New

District 3DoloresThomas,CRNP–RejoinRubyBoydJordan,BSN,RN–New

CrystalFreeman,DNP,FNP-BC,RN–NewPatriciaH.Posey,RN–NewLesaBrundidgeOden,MSN,NP-C,FNP-BC–NewCorneliaH.Boyd,MSN,CRNP–RejoinKarenL.Davidson,BSN,MSN,DSN,CRNP–RejoinLaurenM.Cain,RN–NewWhitneyA.Gray,RN–NewMargieA.Jordan,RN–NewBrendaWikingstad,RN–NewHeatherJ.Rankin,CRNA–NewJessicaH.McDonald,RN–NewTrimayoSandersPasley,RN–NewJaneS.TarpleyTuck,RN–NewKellieL.Williams,RN–NewKimberlyD.Helms,RN–RenewEricLavonLewis,RN,BA–NewRobinB.Abel,CRNP–NewLeshaA.Freeman,RN–NewDe’AundriaT.Harris,RN–NewJanaMorgan,RN–NewKansaaC.Wainman,RN–NewJamieMcNuttWyatt,RN–NewCharmaineQ.Yates-White,RN–NewMaarthaB.Eason,RN–RenewJuliaM.Elsberry,RN–RenewJanaS.TarpleyTuck,RN–RenewMelissaA.Samuelson,RN–Ne

District 4BettyeL.Goff,RN,BSN–NewKristyJohnsonHooks,CRNP–NewAliceR.Pope,RN–New

JoyD.Harden,RN–RenewTamaraBettisGrace,RN–NewVenishaTaylor,LPNKelliR.Boots,RN–NewDoloresMuscatBray,CRNP–NewJamesA.Fant,RN–New

District 5JoyceLoyd,MSN,RN–NewMarjorieL.Butterfield,MSN,CRNP,NP-C–RejoinAnnieF.Alexander,CRNP–RejoinCarolM.Stewart,CRNP–RenewTerrenceT.Johnson,BSN,RN– RenewErinU.Brown,RN–NewSusanC.Duckett,BSN,RN–NewTerriL.Singletary,RN,CCN–NewDianeA.Young,BSN,RN–NewFlorenceJ.Henderson,BSN,RN– RenewTeresaM.Watkins,BSN,RN,CRNP– RenewCarolK.George,MSN,RN,CNS,CNOR–RejoinDinahHenderson,FNP–RejoinLisaV.West,RN–NewMilaJ.Thomas,MSN,RN–RejoinDeniseL.Loden,RN–NewMechelleCaswell-Herrera,RN–NewLisaG.Dye,RN–NewFayeL.Rayford-Outsey,RN–NewBrittanyK.Sanford,RN–NewJudithL.St.Onge,RN–NewKellyCreteVaughan,RN–NewAmyA.Sanderson,BSN,RN–New

HOSPITAL HEROSSoutheast Regional

Hospital Council Winners

(groupphotoL-R)

Robert Wages, chief engineer, Flowers Hospital, Dothan; Becky Clayton, pictured accepting on behalf of the late Steve Clayton, bio medical safety technician, Southeast Alabama Medical Center, Dothan; Liz English, RT(R), radiology supervisor, Southeast Alabama Medical Center, Dothan; Mary Ann Bearman, RN, charge nurse, Medical Center Enterprise, Enterprise; Carol Gordon-Brantley, RN, MSN, quality review clinician, Flowers Hospital, Dothan; *Burnell Seals, RN, BSN, MHA, nursing supervisor, Flowers Hospital, Dothan; *Julia Bignoli, RN, critical care nurse, Southeast Alabama Medical Center, Dothan; Cheryl Hampton, nursing administrative assistant, Mizell Memorial Hospital, Opp; Debbie Franklin, RN, MS, risk management, Mizell Memorial Hospital, Opp; Larry Jones, director of materials management, Mizell Memorial Hospital, Opp. Pictured with winners (far right) is Southeast Regional Hospital Council President Ronnie Dean, V.P., Operations, Southeast Alabama Medical Center, Dothan.*ASNA Members

Financial Corner

by Mark Miehle

Weareoftenaskedforourtipsforasuccessfulfinancialretirement.There areno absolutes in savingor investing,butthesewouldbeatthetopofourlist.Soovertheyearshereareour“BigFive”forsuccessfulretirement:

1) DiversificationI’msurethatyourMomprobablytoldyou“don’tputall

youreggsinonebasket”.Thesameistruewithsavingforretirement.Anyinvestmentcangoupordown.Weallwantthemtogoup,but investmentscangodown.Investingindifferent stocks gives you protection if something goesterriblywrongtooneofyourstocksorfunds.(RememberEnron,HealthSouth andMCI).Even if you are investedinmutualfundsdon’tputallyourmoneyinonefund.JimCramerofCNBCMADMONEYfamesaysdiversificationistheonlyfreelunchyouwillgetwhileinvesting.Spreadyour investments out over different stocks or funds byinvestingindifferentindustries.

2) RiskAlong the same lines of diversification, avoid putting

allofyourmoney inhigh risk investments.Don’tgetmewrong,someriskisgood.Buttheclosertoretirementyouget,thelessriskshouldbeinyourportfolio.

3) PlanSeveralSourcesofRetirementIncome.When you retire you won’t have a pay check coming

inanymore.To replace thatpaycheckwe recommend3sources of income:

– SocialSecurity(Let’shopeitisstillthere!)– EmployerPlans(Pensions,401(k)’s,403(b)’s)– PersonalPlans (Mostpeoplewe seehaven’tplaced

much emphasis on personal plans). With the bigdecline in the market and with many companies

cutting back on theirmatching, more peopleare recognizing theimportance of havingtheir own programscomplimenttheothertwo.

4) Establish An IRA(Individual RetirementAccount)foryourPersonalPlan

An I.R.A. is your ownretirement account. IRA’s provide tax advantages anda lot more choices in what you can invest in, versus anemployersponsoredplan.TherearetwotypesofIRA’s:thetraditionalandtheRoth.Bothhavetaxadvantages.Consultwithafinancialplanneroraccountanttodeterminewhichisbestforyouinyoursituation.

5) PayAttentionAvoid being an Ostrich investor. When an Ostrich

senses trouble theywill bury their head in the sand andhope that the trouble will go away. We have seen a lotnursesnotopen their retirementplan statementswith thehope that their account will come back. This stuff isn’teasy.But ignoring the problem is not the solution.Get abook,watchavideo,orget aplanner tohelpyou. Ifyoudon’tpayattentionwhowill?

Turns outmomgave some pretty good advice. I hopeourBigFivehavebeenhelpfulforyou.MoreimportantlywhenyouretireIhopeyouhavelotsofbasketswithlotsofeggsineachone.

Mr.Miehle is aprincipal atFirstFidelityGroupLLC.FirstFidelityGroupprovidesfinancialservicesforthenon-physicianprofessional. Mr.Miehle can be reached at (205) 266 2136 ormrmiehle@firstfidelitygroupllc.com

EditorialNote:Thefinancialarticlespresentedinthiscolumnareforinformational/educationalpurposesonly.NoendorsementbyASNAisgivenorimplied.

Five Tips to a Successful Retirement

Page 8 • The Alabama Nurse June, July, August 2010

Nonsurgical method for diagnosing breast cancer is safe and nearly as effective as surgical biopsy.

Somemethods ofminimally invasive biopsy for breastcancer are nearly as accurate as surgical biopsy, but havemuchlessriskofharm,accordingtoanewreportfundedbytheAgencyofHealthcareResearchandQuality(AHRQ).

The report compares traditional surgical biopsies withvarious types of “core needle biopsies” which involveremoving tissue through a special large hollow needleinserted through the skin. The report, initiated in 2007,will provide important information so that women andtheir doctors canwork together tomake the best possiblediagnosticchoiceforeachindividualpatient.

Based on reviews of published scientific evidence togauge the effectiveness, risk, and impact of core needlebiopsiesonpatients,thereportfoundthatcertaincoreneedlebiopsies could distinguish between malignant and benignlesionsapproximatelyasaccuratelyasopensurgicalbiopsy,whichincommonlyconsideredthe“goldstandard”methodof evaluating suspicious lesions.Core needle biopsies alsohave amuch lower riskof severe complications thanopensurgicalprocedures.

Research Corner

The report also found that women who are initiallydiagnosedwith breast cancer by surgical biopsy aremorelikely to undergo multiple surgical procedures duringtreatment than women who are initially diagnosed withbreast cancer by core needle biopsy. The report does notrecommend changes to Federal policy or to decisionsregarding insurance coverage, nor does it make clinicalrecommendationsregardingunderwhatcircumstancesopensurgicalbiopsiesorcoreneedlebiopsiesshouldbepursued.Thesedecisionsshouldbemadebyapatientinconsultationwithherphysician.

Opensurgicalbiopsies,whichinvolveremovingasampleoftissuefromthesuspiciousareathroughasurgicalincision,are highly accurate. The procedure may be performedunder general anesthesia, sedation plus local anesthesia,or local anesthesia only.While generally considered safe,opensurgicalbiopsiesaresurgicalproceduresthat,likeallsurgeries, carry a small amount of risk.Given that only afraction of womenwho undergo breast biopsy proceduresarediagnosedwithcancer,useoftraditionalbiopsyleadstolargenumbersofwomenwhodonothavecancerundergoinganinvasivesurgicalbiopsy.

In contrast, a core needle biopsy is a procedure thatremovesbreasttissuethroughahollowcoreneedleinsertedthroughtheskin.Theprocedureisusuallyperformedunderlocal anesthesia. Multiple core-needle samples may betaken from thesuspiciousarea.Because it is less invasive,core-needle biopsy costs less than open surgical biopsy,consumes fewer resources, and generally is preferred bypatients, according to the report. It also noted that recenttechnologicalimprovementstocoreneedlebiopsy,includingstereotactic guidance, ultrasound guidance, and vacuumassistance,haveimprovedthemethod’saccuracy.

The report, Comparative Effectiveness of Core Needle and Open Surgical Biopsy for the Diagnosis of Breast Lesions, was prepared by the ECRI Institute’s Evidence-basedPracticeCenterunder contract toAHRQ’sEffectiveHealthCareProgram.Theprogram is intended toprovideinformation in order to help patients, doctors, nurses, andothers choose the most effective treatments. Information,includingthenewreportandsummaryguidesforcliniciansandpatients,canbefoundatwww.effectivehealthcare.ahrq.gov.

Reprinted from February, 2010 issue of Research Activities

Demographic and health factors influence the type of prostate cancer screening received by men over age 40.

Prostate cancer screening patterns changed between2002and2006forblackmenoverage40versuswhitemenin the same age range. This indicates that physicians arebecomingmoreawareofthehigherriskforprostatecanceratayoungerageamongblackmen,andareincreasingtheirscreening in this group, a new study suggests. The study,involving 229,574 men in this age group without prostatecancerprovidesa4-yearsnapshotoftheuseoftheprostatespecificantigen(PSA)assayanddigitalrectalexamination(DRE)inscreeningforthedisease.

Afteradjustingforotherdemographicandhealthfactors,blackmenhadhigheroddsofhavinghadarecentPSAtestaloneorbothaPSAandaDREtestthandidwhitemen(67percent vs. 61 percent higher, respectively). HispanicmenweremorelikelythanwhitementohavehadarecentPSAtest,butlesslikelytohavehadarecentDREtest(61percenthigher and 22 percent lower, respectively)The use of bothtests combined did not differ significantly between thesetwopopulations.

Mostmen(whoweresurveyedin2002,2004,and2006)reported having both a PSA and DRE test in the past 2years for each year surveyed. Factors associated with useofbothtestsincludedolderage,beingmarriedorwidowed,being employed, having higher levels of education andincome, having health insurance, and having a personalhealthcareproviderorausualsourceofcare.Thedatawascollected through theBehavioral Risk Factor SurveillanceSystem,establishedby theCenter forDiseaseControl andPrevention,oneof the largestState-based telephonehealthsurveyseverimplemented.Theresearchersrecommendthatfurtherresearchbeuntakentoseewhetherthesepatternsofscreening test use, especially among black men, continueto changeover time.The studywas funded inpart by theAgencyforHealthcareResearchandQuality(HS13353).

Moredetailsarein“Patternsinprostate-specificantigentest use and digital rectal examinations in the BehavioralRiskFactorSurveillanceSystem,2002-2006,”byLouieE.Ross,Ph.D.,YhennekoJ.Taylor,M.S.,LisaC.Richardson,M.D., M.P.H., and others in the April, 2009 Journal of the National Medical Association 101 (4), pp. 316-324.Foramoredetailedanalysisoftheblackmeninthestudy,see “Prostate-specific antigen test use and digital rectalexaminations among African-Americanmen, 2002-2006,”by Dr. Ross, Shelly-AnnMeade, M.S., Barbara D. Powe,Ph.D., R.N., and others in the July 2009 Journal of the National Black Nurses Association 20(1),pp.52-58.DIL

Reprinted from February, 2010 issue of Research Activities

June, July, August 2010 The Alabama Nurse • Page 9

2010 ConventionSo You Are an ASNA

DelegateBeing a Delegate to a state convention can be an

exciting experience but one that also has some inherentresponsibility.Asyoumayknow, theHouseofDelegates(HOD) is the governing and official voting body of theAlabama State Nurses Association (ASNA). The Housemeets annually. Members of the HOD have a crucialrole in providing direction and support of the work ofthe Alabama State Nurses Association. Delegates areelected to theHOD towork for thebettermentofASNAand the nursing profession. Each delegate is expectedto study the issues thoroughly, attend each sessionof theHOD (including theOpenForums), and engage in activelisteninganddebate.Also,delegatesareencouragedtousetheextensiveresourcesandcollectiveknowledgeavailableat eachmeeting to provide direction and support for thework of the organization. Such a commitment benefitsthe individual delegate, the association, and the nursingprofession.

Ifadelegateinunabletoattendthe2010ASNAHouseof Delegates, his/her district nurses association (DNA)should be notified at once. When alternate delegatesare substituted for delegates, it is the responsibility ofthe District President to notify ASNA of the changeimmediately.

Important information for ASNA Delegate RegistrationDelegates are encouraged to register for convention

in advance to expedite the on-site credentialing process. Seetheregistrationforminthepulloutsectionofthisissuefor registration fees. Full registration includes, ThursdayEveningAwards/CelebrationDinner,SaturdayandSundaybreakfast and lunch.Additional tickets can be purchasedfortheseevents.UtilizethespecialpulloutsectionofThe Alabama Nurse to register for convention. Please notethecutoffdateforthehoteldiscountis August 30, 2010. ASNA has blocked a certain amount of rooms for thisconvention. Please consider that off-site hotel registrationofdelegatescausesafinancialhardshiptotheorganizationiftheroomblockisnotmet.

To ensure eligibility for the credentialing process,delegates are required to present their current ANA membership card and one picture ID at the DelegateRegistrationdesk.Ifyoudonothaveacurrentmembershipcard please contact April Bishop, Programs Coordinatorforassistance.Eachdelegatewillbeissuedanamebadge,adelegateribbon,andinformationalmaterialsuponproofof identification. The name badge and delegate ribbonmust beworn in order to be admitted to the floor of theHouseofDelegates.

PleasecalltheASNAofficeat1-800-270-2762or334-262-8321ifyouhavequestionsorconcerns.

ASNA & AlaONL Registration

Name&Credentials ____________________________________________________________________________

Address: _____________________________________________________________________________________ City State Zip

DayPhone(______) _______________________________ Fax(_______) ______________________________

E-mail ___________________________________ CreditCard#:___________________ Exp.Date: __________

Registration: Fees include educational sessions and food events for the days registered including single day registration.IndividualsregisteringthedayoftheConventionwillbeissuedfoodticketsONLYifavailable.Additionalguestticketsmaybepurchasedforfoodfunctionsonly.Registration for the Full Convention does not include the Mable Lamb Educational Day on Thursday, September 30, 2010. Pre-convention ends at 5:00 p.m. Thursday, September 30, 2010. All food activities for the full convention start at 5:00 p.m. Thursday, September 30, 2010.

Payment:Amountofregistrationisdeterminedbypostmarkifmailedordatereceivedincaseofphone,fax,oronline.PaymentorPurchaseOrdersmustaccompanyregistrationinordertobeprocessed.AllregistrationsreceivedafterSeptember15,2009willbeprocessedonsite.

Before August 3, 2010willbeconsideredearlyregistration.After September 1, 2010willbeconsideredregularregistration.

Confirmations: Only e-mail confirmations will be sent (approximately two weeks after receipt of registration form). NoconfirmationwillbesentafterSeptember11,2010.

Cancellations:AwrittenrequestmustbereceivedpriortoAugust31,2010.Arefundminusa$20processingfeewillbegiven.NorefundwillbegivenafterAugust31,2010.Wereservetherighttocanceltheactivityifnecessary.Inthatcaseafullrefundwillbegiven.

Continuing Education:TheAlabamaStateNursesAssociationisaccreditedasaproviderofcontinuingnursingeducationbytheAmericanNursesCredentialingCenter’sCommissiononAccreditation

AlabamaBoardofNursing(ValidthroughMarch30,2013).

Contact Hours: MableLambCEDay7.0–ANCC,8.4–ABN.ASNAConvention(includesposters),9–ANCC,10.8–ABN.

Returned Check Fee:$30returnedcheckfeeforanyreturnedchecks.

How to Register for ConventionRegisteronlineatwww.alabamanurses.org.orsendregistrationformand

paymentto(checkmadepayabletoASNA)ASNA,360NorthHullStreet,Montgomery,AL36104-3644or ifpayingbycreditcardFaxto334-262-8321(donotmailiffaxingorregisteringonline).

Forhotelreservations,contacttheRenaissanceRiverviewPlazaHotelat1-800-922-3298.Roomratesare$129.00foraSingle/Double.PleaseinformthehotelthatyouarepartofASNAwhenmakingreservationsbyAugust30,2010TOBEINCLUDEDINTHEROOMBLOCK.Reservationsmadeafterthatdatewillbebasedonaspaceandrateavailability.

64 South Water Street, Mobile, Alabama 36620

Mable Lamb Continuing Education Day Workshops, Thursday, September 30, 2010 (includes Lunch only)

Circle one of the following choices:

______ ASNAmember$79 ______ Non-member $99 AM Workshops Afternoon WorkshopsI-A II-D II-GI-B II-EI-C II-F

NOTE: Add $10 to above fees if received after August 31, 2010

2.) Convention, Thursday night, September 30, 2010, Friday and Saturday, October 1-2, 2010 (includes tickets to all meal functions listed in this application)–Select one of the following choices:

ASNA Delegates Only (must register for entire convention)*ReceivedonorbeforeAugust3,2010 _______$239ReceivedafterSeptember1,2010 _______$259

Non Delegates–Full convention *ReceivedonorbeforeAugust3,2010 ____ASNAMember–$295 ____NonMember–$320

ReceivedafterSeptember1,2010 ____ASNAMember–$310 ____NonMember–$335

Daily Registration *ReceivedonorbeforeAugust3,2010 ____ASNAMember–$199/day ____NonMember–$220/day

ReceivedafterSeptember1,2010 ____ASNAMember–$210/day ____NonMember–$235/day

Additional Meal/Function Tickets• Thursday,September30,2010–Luncheon ______$35

• Thursday,September30,2010–Reception ______$10

• Thursday,September30,2010–AwardsBanquet SelectOne()OvenBakedSalmonor()FiletMignon ______$85

• Friday,October1,2010–Breakfast/Breaks/Lunch ______$65

• Saturday,October2,2010–RoundtableBreakfast ______$35

• Saturday,October2,2010–Luncheon ______$30

Total Enclosed: $___________*ASNA Special Dues members (65+/Retired or Completely Disabled) receive an additional 10% discount onregistration.RegistrationspostmarkedorreceivedafterSept.15,2010willbeconsidered“at-door”.

INDICATE BANQUET CHOICEThursday, September 30, 2010

FiletMignon OvenBakedSalmon

Alabama Nurses 2010 DNP

Candidates from Samford University

Ida V. Moffett School of Nursing

Page 10 • The Alabama Nurse June, July, August 2010

2010 ConventionPosters:

1. Over Their Heads–Is Your Health Care Education Understandable?

~SusanC.Duckett,BSN,RN

2. Public Health Nursing: Scholarship That Promotes Healthy Communities

~Drs.KarenHamilton&AliceJ.Godfrey

3. Shoulder Arthroscopy and SLAP Lesions ~EvaHardy,MSN,CRNP

4. CNL Innovation in Rural Alabama Hospitals

~Drs.KathleenA.Ladner&MistyJohnson

5. Effective Delivery Methods of Cultural Competence Education for Health Care Professionals

~Dr.PatriciaAnnPugh

6. Spreading Quality and Safety Concepts in the Classroom

~Drs.JudithSt.Onge&TraceyHodges

7. Good Works in Nursing ~SusanG.Williams,MSN,RN

8. Travel Nursing 101 ~MichelleA.Landrum,RN,ADN

9. Mobilization is Not a Choice: Can Healthcare Facilities Continue to “Work Around” the Issue of Mobilizing Our Patients?

~PeggyBone,MSN,RN,CIC

10. Control of Glucose in Post-Op Coronary Artery By-Pass Graft (CABG) Patients

~RebeccaHuie,BSN,RNandDebraLitton,MSN,MBA,RN,NE-BC

11. Reducing the Unnecessary Use of Urinary Catheters in a Surgical Intensive Care Unit by Implementing an Evidenced-Based Bundle of Care

~Dr.MichaelBurton,RebeccaHuie,BSN,RN,andDebraLitton,MSN,MBA,RN,NE-BC

Nominations and Election of Officers AlabamaStateNursesAssociation’s (ASNA)nominationandelectionofOfficers shallbeconducted inaccordance

withRobert’s Rules of Order, 10th Edition duringtheofficialmeetingoftheASNAHouseofDelegates(HOD).

1. NOMINATIONSA. NominationsCommittee

a. NominationsfromtheNominationsCommitteeshallbeaccomplishedaccordingtoASNABylaws.B. Nominations from the floorof theHODshall be accomplishedaccording toRobert’s Rules of Order, 10th

Edition.

2. ELECTIONOFOFFICERSA. Electionswillbebysecretballot.B. Only credentialed delegates will be allowed to vote at the ASNA Convention. See ASNA website

(alabamanurses.org)undermembersonlysectionforconventioninformation.

Preliminary Ballot for ASNA ConventionCandidates for 2010-2012

President-elect: Deborah Andrews Vanessa Barlow Lori Lioce Arlene Morris Stuart Pope

Write-in candidate: _______________________________

Treasurer: Ellen Buckner Marilyn Rhodes

Write-in candidate: _______________________________

Commission on Professional Issues (Vote for 4) Diane Buntyn Julie Freeman Ruth Harrell Lygia Holcomb Carthenia Jefferson Cynthia Means Robin Normand Larry Slater Lucille Taylor

Write-in candidate: _______________________________

Nominating Committee (Vote for 3) Anita All Wendy Dubose

Write-in candidate: _______________________________

Details about buying shrimp

will be available at Convention.

Optional Bus Trip to Casinos in Biloxi will be available later.

June, July, August 2010 The Alabama Nurse • Page 11

2010 Convention

Thursday, 30 September 2010

8:00 AM–11:20 AM WorkshopsI A Preceptor Training (presented by Auburn

Montgomery faculty) Drs.MarilynRhodes,AllisonTerry,CindyMcCoy,

andJulieFreeman,MSN,RN The contentwill focus on skills preceptors need to

guidestudentsintheclinicalarea • Opportunitiestosharenursingexpertisewith nursingstudents. • Challengesassociatedwithguidingstudentsin theclinicalsetting. • Fourmajorcategoriesoflearningtheories. • Effectivestrategiesforeachofthelearning theories. • Variousevaluationstrategies. • Potentialstressorsfornursingstudentsthatmay impactlearning.

I B Clinical A Thiscontentwillhaveaclinicalfocus • Organ Donations,Dr.JuvondaS.Hodge • Ototoxic Medications, Drs.ElizabethVandeWaaandMarkDeRuiter • Incontinence,Dr.BarbaraBroome

I C State of Prescriptive Privileges for Advance Practice Nurses in Alabama

Lori Lioce,MSN, FNP-BC,NP-C,RDH, PresidentoftheNursePractitionerAllianceofAlabama

The content will focus on the state of prescriptiveprivilegesforAdvancePracticeNursesinAlabama

• BarrierstolegislativechangeinAlabama • HistoryoflegislativeeffortsfortheAdvance PracticeNurse. • Waystobecomeinvolvedinthe2011legislative session. • Handsontipsforwritingletterstolegislators. • Overallbecomebetterpreparedtoparticipatein politicalelections.

12:15–1:15 PM–AlaONL Annual Meeting Keynote Address Leadership with Community Outreach Dr. Linda Roussel, Immediate Past President of

AlaONL Thecontentwillfocuson • LeadershipopportunitiesforNursesinAlabama inthecommunitysetting • DetermininghowNursesmakeapositive differenceinAlabama’scitizenswhileworking withinthecommunitystructure

1:30–4:50 PM WorkshopsII D The Returning Veteran FacilitatedbyHelenWilson,MSN,RN The content will focus on the long-term effects

followingwarinjuriesandtheirrehabilitation • Headtrauma • Rehabilitationwithartificiallimbs • Serviceanimals

Continuing Nursing Education SessionsII E Geriatric Intensive Drs.ArleneMorrisandJoyceVarner Thecontentwillfocusonspecificneedsofgeriatrics

suchas • Geriatric–specifichospitals. • Pharmacologyoftheelderly–dosanddon’ts. • Risksandoptionsforelderabuse. • Psychosocialneedsfromsuddentogradual progressiontoincreasingfrailty.

II F Changing the Delivery of Nursing Education Drs.MarilynRhodesandDebbieFaulk Thiscontentwillfocusofspecificmethodstochange

howNursesareeducated • FourchangesrecommendedbytheCarnegie FoundationStudy • Proandconsofeachsuggestedchange • Waysnursingfacultyfromalllevelscanwork togethertoreformnursingeducationtomeet futurechangesinhealthcareandinthevarious educationalsettings.

II G Clinical B Thecontentwillhaveaclinicalfocus • Disparities in Chronic Disease, Dr.ErrolE.Crook • Stress and Anxiety Management, Dr.NathanielAbston • Solutions for a Global Epidemic–Type 2 Diabetes and Obesity, Dr.AnitaH.King

5:30 PM–6:30 PM Keynote Address Dr.DebbieHatmaker The content will deal with the emerging issues in

Nursingfromanationalperspective

Friday, 1 October 2010

9:00 AM–11:00 AM Continuing Nursing Education SessionsIII H Environmental Justice HelenWilson,MSN,RN The content of this workshop will be focused on

environmentallegislativeissues • Realisticlegislativeprocesstofacilitatepassage ofabillorjointresolution • EnvironmentalissuesspecifictoAlabama • Grassrootsinvolvementatapersonallevel

III I Cardiovascular Sessions Thecontentofthiswillhaveacardiovascularfocus • Cardiovascular Update,Dr.ClaraV.Massey • Cardiovascular Diseases in Women, Dr.MichaelWilliams

12:30 PM–1:30 PM Health Literacy JudyBurnham The focus of this session is the utilization of

electroniclibrarydatasources • Identificationofavailabletools • Whentousewhattools • Howtoaccessvarioustools

5:00 PM–6:00 PM Plenary Session Dr.MarlaWeston ThecontentwilldealwithANAchanges,resolutions

andchangesimportanttoASNA

Saturday, 2 October 2010

7:00 AM–8:00 AM Breakfast Roundtables Thefocusisafrankguideddiscussionaboutvarious

topics.Attendeesarewelcometomovefromtabletotableasdesired.

• Applied Nursing Research,Dr.DebbieFaulk • Travel Nursing,MicheleLandrum,RN • Legal Issues in Nursing,DonEddins • Coal Ash,MarilynJohnson,RN • Parliamentary Procedure,VoncileStallworth, MSN, RN • Retaining Older Nurses in the Workplace, DebbieLitton,MSN,RN • Nightingale Project,Dr.SueMorgan

8:15 AM–9:15 AM Concierge Medicine and Its Impact on Healthcare Drs.MaryAnnetteWrightandJaniceVincent The session will discuss the practice of concierge

medicine inwhich a primary care provider chargesanannual fee inexchange forpersonalizedmedicalservices.Contentwillinclude

• Advantagesanddisadvantages • Impacttohealthcaredeliveryandproviders

12:45 PM–1:45 PM Bridging the Gap Between Community and Health

Care ProvidersDr.MarthaArrieta The session will address specific gaps and various

approaches to provide the best care to Alabamacitizens.

Page 12 • The Alabama Nurse June, July, August 2010

2010 ConventionAlabama State Nurses Association

Alabama Organization Nurse LeadersAlabama Association Nursing Students

Annual Convention Agenda

Thursday, 30 September 2010Mable Lamb Nursing Continuing Education Day(Pre Convention Nursing Continuing Education)

7:30 AM Registration

8:00 AM–11:30 WorkshopsI

9:00 AM ASNABoardofDirectors

10:00 AM AlaONLBoardofDirectors

11:30 AM–1:30 PM AlabamaOrganizationofNurse LeadersAnnualMeeting Lunch Keynote: Leadership with Community Outreach, Dr.LindaRoussel

1:30–4:30 PM WorkshopsII

Thursday, 30 September 2010Alabama State Nurses Association House of Delegates

5:00 PM–6:30 PM OpeningCeremonies KeynotePresentation Dr.DebbieHatmaker

6:30 PM–7:00 PM Receptioninhonorof Dr.Hatmaker

7:00 PM–10 PM AwardsBanquet

Friday, 1 October 2010

7:30 AM–8:30 AM Registration ContinentalBreakfast

7:45 AM–8:30 AM Polls Open

8:00 AM–12:30 PM Posters

8:00 AM–12:30 PM Exhibitors

9:00 AM–11:00 AM OptionalContinuingNursing EducationSessions

11:30 AM–12:30 PM LunchinExhibitArea

12:30 PM–1:30 PM PlenarySession

1:30 PM–5:00 PM ASNAHouseofDelegates

5:00 PM–6:00 PM PlenarySession

6:00 PM + EveningatLeisureortripto Mississippi

Saturday, 2 October 2010

7:00 AM–8:00AM BreakfastRoundtables

8:15 AM–9:15 AM PlenarySession

9:15 AM–12:15 PM ASNAHouseofDelegates

12:30 PM–2:00 PM Lunch ClosingPlenarySession

2010 Convention Preliminary ExhibitorsAlabama-NorthwestFLAssociationAuxiliaryofthe

GideonsInternational

AlabamaEyeBank

AlabamaOrganCenter

BayMedicalCenter

DCHHealthSystem

EZWay,Inc.

Gentiva

Jackson Hospital

MiddleTennesseeSchoolofAnesthesia

SylviaRayfield&Associates/IcanPublishing

TroyUniversitySchoolofNursing

UAHCollegeofNursing

UniversityofAlabama-CapstoneCollegeofNursing

June, July, August 2010 The Alabama Nurse • Page 13

Continuing Education

Authored by: Charlene M. Roberson, MEd, RN-BC,Director of Leadership Services, Alabama State NursesAssociation, Psychiatric/Mental Intake Coordinator atBaptistHealth,authordisclosesnoconflictofinterest

Objectives: At the completion of this course theparticipantshouldbeableto:

1. Listthe“idealcandidate”profileforoutpatientopioidtreatmentusingbuprenorphine

2. Explainthenurse’sroleinthetreatmentprocess.3. Relatethepharmacologyofbuprenorphine.

Directions: Read the monograph Outpatient Opioid Addiction Treatment Using Buprenorphine. Complete thePostTest and evaluation and return both completed formstoASNA(360N.HullStreet,Montgomery,Alabama36104or (F) 334-262-8578). A Continuing Nursing Educationcertificateofcompletionwillbesenttoyouuponsuccessfulcompletionof thepost-test andevaluationsheet.Youmustscoreatleast80%onthepost-testtopass.Shouldyouscorebelow80%,youwillbenotifiedandofferedtheopportunitytoretakethepost-testforanadditionalcostof$5.00.

Board of Nursing Transcript: ASNA will enter thecourseonyourAlabamaBoardofNursing transcript (you will be unable to successfully enter the course on your transcript) within twoweeks of successful completion oftheactivity.

Contact hours & Accreditation: This 3.0 contact hour course (60 minutes equal 1.0

contact hour) activity is provided by the Alabama StateNursesAssociation.

TheAlabamaStateNursesAssociation isanaccreditedprovider of continuingnursing educationby theAmericanNursesCredentialingCenterCommissiononAccreditation(ANCC).

PharmacologyHours–3.0(ANCC)This 3.6 contact hour course (50 minutes equal 1.0

contact hour) activity is provided by the Alabama StateNurses Association, which is approved by the AlabamaBoard of Nursing, provider number ABNP002 (validthrough30March2013).

PharmacologyHours–3.6(ABN)Theactivityisvaliduntil8May2012

Intended Audience: NursesFees:

ASNAMember:$20 Non-member:$30ShippingandHandling: $4.00–if ordering by mailA $30 fee will be assessed for all returned checks or dishonored check/payments.

Outpatient Opioid Addiction Treatment Using

Buprenorphine The Drug Addiction Treatment Act of 2000 provided

a new option for the treatment of opioid addiction usingbuprenorphine in an office based setting. The Food andDrug Administration (FDA) has approved only two Schedule III, IV, or V drugs for the treatment of opioidaddiction. They are the buprenorphine products–Subutex(buprenorphine) and Suboxone (buprenorphine/naloxone[Narcan]–this combination reduces the potential for abuse by the parenteral route). These drugs are preferred foropioidoutpatienttreatmentbecausethepatientfeelsnormal–nothighandtheirintensecravingsforopioidsarereduced.Withdrawalsymptomsareminimizedandiftakenproperlythere is little risk of overdose. There are other forms ofbuprenorphine(e.g.,Buprenex)butnoneoftheseotherformsareapprovedforthetreatmentofopioidaddiction.Thisdoesnotprecludetheirusefordetoxification.TheFDAapprovalof buprenorphinehasno legal impact onothermedicationassistedopioid treatmentoptionssuchasMethadone (most cost effective and often the only medication that insurance will reimburse for opioid treatment)orLAAM(levo-alpha-acetyl-methadol).thesetwooptionsareusuallyclinicbased.

Pharmacological facts about opioids–Opioidreceptors(molecules) are located on the surface of cells. Opioidcompoundsattachandexert theireffectson these receptorsites. The brain has three different opioid receptors–mu,kappa,anddelta.Themuandkappareceptorsarealsofoundinthespinalcordandtheirfunctionthereistomediatepaintransmission to thebrain.However, themu receptor is theonemostrelevanttoopioidabuse.Onceactivated,itsaction

Outpatient Opioid Addiction Treatment Using Buprenorphineistoexertanalgesic(painrelief),euphorigenic(euphoriaor“high”), and addictive effects. Kappa and delta receptorshavesome,butverylimitedinvolvementinopioidaddiction.

Opioidsreactwiththereceptorsinthreedifferentways.Theyareagonists (or fullagonist),antagonists,andpartialagonists.Medicationsthatactivatethereceptorsinthebrainarecallagonists.Theybindtoandactivatethereceptorsitecausing thedesiredeffects in theperson.Opioidswith thegreatestabusepotentialarefullagonists–morphine,heroin,methadone, oxycodone, and hydromorphine. Antagonistsalso bind to opioid receptor sites but instead of activatingtheyblock them.Ananalogywouldbeakey that fits intoa lockbut doesnot open the lock andprevents otherkeysfrombeinginsertedintothelock.Examplesarenaltrexone(ReVia) and naloxone (Narcan). Partial agonists blendsomecharacteristicsofbothagonistsandantagonists.Theypartiallybindandactivatereceptorsitesbutnottothesamedegree as full agonists. Patients who are not addicted to opioidsfeelthesameeffectsforagonistandpartialagonistswhen the opioids are given in low doses. As the dosageincreases the effects (analgesic and euphorigenic) are alsoincreased. However, at some point with these increasingdoses,a“ceilingpoint”isreachedwiththepartialagonists.When this occurs the drug changes characteristics to actlike an antagonist. In short they unlock the receptor sites,activate them (sometimes only partially–depending on thepatient’sresponse),anddisplace(orblock)fullagonistsfromthereceptorsites.

Therepeatedadministrationofamuagonist(opioid)willresultintoleranceanddose–dependentphysicaldependency.Toleranceisbothasubjectiveandobjectiveresponsetothesameamountofmedication.Thepersonneeds to increasethedosageamountinordertoachievethedesiredresponse.The desired response for an addicted person is usuallyeuphoria.Physicaldependencyismanifestedbywithdrawalsymptoms in response to a reduction, cessation or lossof themedication at the receptor sites.Themost commonsymptoms of opioid withdrawal are diarrhea, lacrimation,rhinorhea,yawning,piloerection (goose flesh),crampsandaches, sweating, and papillary dilatation. In the averagepersonthesesymptomsarenotlifethreatening,unlessthereisaco-occurringcardiacconditionorotherlife-threateningailment.

There are two types ofwithdrawal associatedwithmuopioid agonists. The first is spontaneouswithdrawal. Thisdescribes a person who is physically dependent and hasbeenusingmuagonistopioidsonadailybasisandsuddenlydiscontinuesorprofoundlydecreasesopioiduse.Mostoftenwithdrawal symptoms occur according to the followingtimeframe:

• Short acting agonists–heroin, oxycodone, andhydrocodone–6-12 hours after last dose; peak inintensity36–72hours;lastapproximately5daysandamilderversionofwithdrawalmaylastlonger

• Long-actingagonists–methadone–about24-72hoursafter the last dose; peak in intensity in 1-2 weeksandmaylastinamilderversionuptoamonth.

The second type of withdrawal is called precipitatedwithdrawal. This occurs when a personwho is physicallydependentonopioids isadministratedanopioidantagonist(naltrexone or naloxone). It is important to note that thesedrugs will have no impact on an individual who is notphysically dependent on opioids. Whereas, if physicallydependent, they will experience symptoms similar tospontaneous withdrawal; however, the onset is faster andthe duration is shorter. An easy way to understand themechanism is that the antagonist displaces agonists fromreceptor sites and does not activate the receptor site sothere is adecrease in theagonist effect (morepainor lesseuphoria).Inadditionif thepersonisphysicallydependenton the drug and receives a large dose of a partial agonistit can displace the agonist from the receptor site and notfully activate the receptor site.This ismost often seen onindividualswhohaveahighlevelofphysicaldependence.

Drug action is described by three different properties–affinity, intrinsic activity, and the dissociation properties.Affinity relates to the strength or bonding to the receptorsite.Itisvariableandbasedontheindividualdrug.Intrinsic activitydescribesthedegreeorintensitytowhichthedrugactivates the receptor sites. Although similar in definitionthese are two very different properties. An antagonist isanexampleofadrugwithahighaffinityforbondingtoareceptorsitebutlowintrinsicprosperitiesbynotactivatingthe site. Dissociation describes the measure by which thedruguncouplesordisassociatesfromthereceptorsite.Somedrugs have a high affinity for the receptor site but theydissociate easily. Buprenorphine is an example of a drug

that slowly dissociates from the receptor site and it has alongdurationofaction;itshalf–lifeisapproximately24-60hours.

The primary characteristic separating dependence fromaddictionisthattheaddictedindividualwillcontinuetousedespitethenegativeconsequences.Almostallabuseddrugshavethefollowingcharacteristics:

• Fastrouteofadministration–smoking,injection• Shorthalflife• Fast lipophilic properties (determines how quickly

the drug reaches the brain) so the user willimmediatelyexperiencethedesiredeffect

• Easeofadministration Low cost

Buprenorphine–Thetwoformsofbuprenorphinegivenfor opioid outpatient treatment are Subutex and Suboxone(buprenorphine and naloxone combination).Botharegivensublingually. Subutex is available in either 2mg or 8mgstrengths. Suboxone comes in twodosage strengths, eitherbuprenorphine 2 mg/naloxone 0.5 mg or buprenorphine8 mg/naloxone 2mg. Buprenorphine is a partial opioidagonist and it produces the same expected side effectsof euphoria and respiratory depression as a full agonist(heroin or Methadone) but to a greatly reduced effect–enough to prevent cravings but not enough for euphoria.When administered in lower doses the patient does nothave withdrawal symptoms. Moderate doses provide theindividualaplateauor“ceilingeffect”.Higherdoses,inanacutely opioid intoxicated patient can displace the opioidagonist properties and precipitate withdrawal symptoms.For safety, the person is initially dosed one day at a timefor several days before a prescription is given. A typicalregimeincludesgivingtheperson2-4mgsublinguallyandmonitor forat least twohours. If symptomsofwithdrawaldevelop within this 2–hour time frame they are usuallyadministered another 2-4 mg. Typically the first day’sdosage should not exceed 8 mg just to be sure that the“ceiling effect” is not reached. If the person continues toexperiencewithdrawalsymptomsafterreceiving8mgtheyareusuallygivensymptomaticoverthecountermedications.Thisphenomenonisrarethough.Mostindividualsinitiallystabilizesomewherearound16mgasamaintenancedose.Oncetheyarefreeofallwithdrawalsymptomsforseveraldays themedication is tapereddownward.Thisadjustmentusuallytakesseveraldays.

There is a rare potential for abuse, particularly byindividuals who are not physically dependent on opioids.A greater potential is for intravenous abuse and thisis greatly reduced with the Suboxone (a combination of buprenorphine and naloxone). The drug is givensublinguallybecausebuprenorphine sublinguallyhasgoodbioavailability and naloxone has poor bioavailability.Botharepoorlyabsorbedfromthegastrointestinaltract.Sowhenthe drug is ingested sublingually the buprenorphine effectwill predominate. When an opioid dependent individualcrushes and injects naloxone its antagonistic effect willpredominate and the personwill experience a precipitatedwithdrawal. Occasionally buprenorphine will precipitateawithdrawal and thisusuallyoccurswithhigher levelsofopioid addiction, or high doses of themedication or shortintervals(lessthan2hours)betweendosing.Thewithdrawalisintenseandrapid.Priortothefirstdoseofbuprenorphine,theperson shouldhavenoopioids in their system.This isespecially important for long acting opioid agonists (e.g., methadone). Thereforewhen a person arrives for the firsttreatment,itisessentialforthehealthcareproviderstoseephysicalevidenceofearlywithdrawalandhaveknowledgeofwhenthepatientlasttookanopiate.

Outpatient Opioid Addiction continued on page 14

Page 14 • The Alabama Nurse June, July, August 2010

WITHDRAWAL SYMPTOMS

Objective Subjective

Elevatedpulseand dysphoricmoodbloodpressure

Vomiting/diarrhea nausea

*Diaphoresis *muscleaches/cramps/ bone pain

*Lacrimation low back pain

*Rhinorhea abdominalpain

Dilatedpupils *insomnia

*Piloerection craving

*Yawning *anxiety/irritability/ restlessness

Mildfever

*earlywithdrawalsymptoms

Safety of buprenorphine–It isconsideredsafebecauseof the “ceiling effect” and poor bioavailability. Themaximum effective dose is usually between 16-32 mgdosage range for sublingual tablets, after that the “ceilingeffect” becomes evident. There is a reduced incidence ofrespiratorydepression.Occasionally, liver enzymes elevatewith themaintenancedosages;however, there seems tobelittleornoevidenceoforgandamagewithchronicuse.ThedrugdoescarryaFDAwarningstatingapotential for thedevelopmentofhepatitiswithorwithoutjaundice.Thismayvary from transient asystomaticelevationof liver enzymesto hepatic failure, hepatic necrosis, hepatorenal syndrome,andhepaticencephalopathy.Thesecasesarevery,veryrareandusuallyassociatedwithpreexistingHBVorhepatitisC.Some individuals enter treatment programs with ongoingintravenousdrug abuse and ahistoryof previous injectionof hepatotoxic agents. Therefore, it is essential to have aninitialbase line liverpaneland it is recommended tohaveperiodicliverfunctionmonitoring.

Another reason that this drug is so well tolerated isthat there is no significant disruption of cognitive orpsychomotor functions once on the maintenance dose.Initiallyindividualsmayhaveimpairmentofmentaland/orphysical functionswhich limitsperformanceofpotentiallydangerous tasks such as driving or operating machinery.In addition they may experience a transient orthostatichypotensionespeciallyduringinitialstabilization.

Thisdrugordrugcombinationisidealforadministrationin the clinic setting. It is long acting so as thewithdrawalsymptoms subside the pill can be dosed every other day.There is ease of administration with the pill being takensublingually.Thepillsmaybeobtainedatalocalpharmacy;however,onedrawbackisthatnotallpharmaciesroutinelycarry thismedication so the physicianmay need tomakearrangementswithadesignatedpharmacy.

A number of studies have been completed evaluatingits effectiveness. Results conclude that it ismore effectivethan a placebo and as effective as moderate dosages ofmethadone and LAAM. It is not as effective when apersonneedsahigherdosageofanopioidagonist.So thisis not the treatment of choice for individuals with higherlevels of opioid dependency. There are very few studiesevaluating the total effectiveness of buprenorphine forcompletely withdrawing individuals from opioids. Moststudies of medically assisted opioid withdrawal usingopioids (methadone is the most common in literature) reveal poor outcomes. The most often reason cited is thewithdrawal syndrome.Buprenorphine,whichhasaneasierwithdrawal process than methadone, may be a betterchoice for individuals with milder opioid addictions. Theidealcandidatesare individualswhohavebeenobjectivelydiagnosedwithopioiddependencyandarewillingtofollowsafety precautions for treatment. The individual should bewilling to comply with the program requirements, haveno contraindications, and choose this treatment form afterreviewingallothers.

Phases of Buprenorphine Therapy Treatment–Thethreephasesareinduction,stabilization,andmaintenance.1.) The induction phase is the medically monitored

and supervised beginning of the program. It mustbe started in the physician’s office and all dosagesmust be administered as observed treatment. Oncethe patient is safe, the subsequent dosagesmay beadministered through a prescription.Theonlygoalis to determine the lowest dosage strength, whichmarkedly reduces or eliminates use of any other

opioids. Ideally the person should experience nowithdrawal symptoms, cravings or side effects.Most patients are stabilized within 2-3 days. Theymust be in early stages of withdrawal; if not, theingestion of buprenorphine may (probably will)precipitate withdrawal. It is essential to providepatient education during this time. Patientswill beuncomfortable and need help internalizing whythey are in treatment but still feel badly. In highlymotivated patients who have detoxified themselvesfor several days before the commencement oftreatment theymayhave fewerphysicalwithdrawalsymptomsyetmayhaveintensecravings.

2.) The stabilization phase occurs when both thephysical need and intense cravings are markedlyreduced. The dosing will be adjusted and inmost instances the patient may go to everyother day dosing because of the long half-life ofbuprenorphine. Once stabilized the patient canusuallymovetoweeklymonitoring.

3.) ThemaintenancephaseisreachedwhenthepersonisdoingwellonasteadydoseofSubutexorSuboxone.Each patient’s treatment is individualized. Thisphase may last indefinitely. As long as the personis receiving a buprenorphine product theymust bemonitoredwithongoingassessmentsandurinedrugscreens.Forsomethistreatmentmaybeasshortasafewdaysformedicalwithdrawal (detoxification) to aslongasseveralyearsonthemaintenancetherapy.Patients must be involved in the treatment plan toachieve optimum success, regardless of the lengthoftreatment.Individualsinthisphasemaybesafelymonitoredmonthly.

Precipitated and Withdrawal Symptoms–There aretwo times when a precipitated withdrawal may occur.The first is when a person has higher levels of opioiddependency and the second is when there is a short timeperiodbetweenadoseofa full agonist, e.g., heroin andadose of buprenorphine–usually less than 2 hours. Thiswithdrawal is characterized as being fast and intense.Thebest preventative action includes an adequate assessmentbeforehandforissuessuchaslevelofdependency,patternsof opioid use, and the half-life of their drug(s) of choice.And the second is to monitor the initial or trial dosing.Buprenorphine can precipitate an opioidwithdrawal if theperson is opioid dependent and the opioid receptors arecurrentlyoccupiedbyopioids.Thereforeitisimperativethatthe opioid receptors be free of opioids.When the drug ofchoiceisshortactingitiseasytowaitseveralhoursbutwithlongactingdrugssuchasmethadoneitissometimedifficulttoassess.Theeasiestwaytoassessistomakesuretherearevisible symptoms of early stages ofwithdrawal before thebuprenorphinetreatmentisstarted.

Prior to starting the withdrawal process patients andtheir families and significant others need to know aboutthe following easily managed symptoms: reduced energy,anorexia, irritability, and insomnia. Over the counterdrugs are usually effective in relieving these withdrawalsymptoms.Theyinclude

Symptom OTC Medication

Muscleaches ibuprofen800mg/8hours

Pain acetaminophen1000mg/4hours

GIdistress Maalox30ml/2hours

Insomnia diphenhydramine50mg/HS

Ifthesesymptomsbecometoointensethephysiciancanalways return the patient to a higher dosage of the drug.Taperingof thedrug is an individualprocess.Anda slowtaper is usually more effective in promoting treatmentsuccess. Often a patient wants to taper more quickly thatthephysicianconsiderseffective.Theyneedhelpinsettingrealistic goals involving a slow taper unless there is amedical necessity to taper quickly, (e.g., foreign travel, impending incarceration, etc.).

Pregnancy–There has been very little research dataon pregnant women or neonates and buprenorphine. As aresultofthisFDAclassifiesbuprenorphineasaPregnancyCategory C drug. (Pregnancy Category C drugs have 1.) animal reproduction studies have shown an adverse effect on the fetus, 2.) lack of adequate well-controlled studies in humans, or 3.) benefits from use of drug in pregnant women may be acceptable despite its potential risks.) In additionto the consideration of the FDA’s potential warnings,health care providers must also consider the possibilityof infectious diseases, e.g., Hepatitis, HIV/AIDS, etc. andlifestyle issues–poornutritional status and lackof prenatalcareinthesewomen.

Another pregnancy consideration is the use ofbuprenorphine andnaloxone (Suboxone) combination. It is

not recommended as naloxone is aPregnancyCategoryBdrug,(Pregnancy Category B drugs 1.) animal reproduction studies failed to demonstrate a risk to the fetus and 2.) there are no adequate well-controlled studies in pregnant women.) Although it is a Category B pregnancy drug itshould be used with extreme caution in pregnant women.Boththemotherandfetuswillbedependentontheopioidsand the administration of naloxone could precipitatewithdrawal in both. If buprenorphine is determined to bethedrugofchoiceforthepregnantwomanitshouldbeusedasamonotherapyinordertoavoidtheriskoffetalexposureto naloxone. There is greater potential for abuse so therecommended standard is tomonitor the patient and drugconsumptionevery1-2weeks.Ideally,thedrugofchoiceforoutpatientopioidwithdrawaltreatmentremainsmethadone.

Adverse Effects–Side effects or adverse effects aresimilartoallopioids;however,theytendtobelessintense.The most common are nausea, vomiting, headaches, andconstipation. Sometimes these side effects are so severethat individualswant to discontinue the treatment process.Thisisrareandthesesymptomscanusuallybemanagedbyover thecountermedications.At times, especiallyearly inthe treatmentprocess, it isdifficult todistinguishbetweenadverseeffectsandunresolvedwithdrawalsymptoms.Thesesymptomsareusuallyself-limitinglastingonlyacoupleofdays.

Interactions/Contraindications–The concomitantuse of benzodiazepines, other opioids, and/or alcoholhave led to death when buprenorphine has been injectedintravenously. In case of an emergency, the treatingclinicianshouldbemadeawareof theaddiction toopioidsand the current treatment with Subutex or Suboxone. Inoverdosesituations theprimary focusshouldbeonairwaymanagement.Anotherconcernisanimpairedliverfunction.They may not be able to metabolize the buprenorphineandmay need a dosage adjustment (usually downward) toprevent opioid intoxications or precipitated withdrawal.Concurrent use of buprenorphine and HIV antiretroviralmedications should be carefully monitored because theymaybeinhibitedormetabolized;therefore,creatinganeedfordosageadjustment.Additionaldrugsthatrequiredosageadjustments include: ketoconazole (antifungal medicationoftenusedwithHIV/AIDSpatients),someantibiotics,HIVproteaseinhibitorsandnon-nucleosidereversetranscriptaseinhibitors(HIV/AIDSmedications),andcertainbarbituratesusedtocontrolepilepsy.Inadditionbuprenorphineshouldbeadministeredcautiouslytoelderlyordebilitatedindividualsand especially to individuals with severe impairment ofhepatic,renal,orpulmonaryfunction.

Allergic Reactions–Some allergic reactions occur. Byfarthemostcommonaredermatological–rashes,hives,andpruritus. Occasionally a personmay have bronchospasms,angioneurotic edema (swelling of deep layers of the skin),and anaphylactic shock. Use buprenorphine cautiouslywhenusedconcurrentlywithantiseizuremedications (e.g,. carbamazepine [Tegretol], or sedative hypnotics (e.g., Phenobarbital).Theplasmalevelsofthesedrugsshouldbemonitoredfrequently.Thepresenceofhepatitisorimpairedliverfunctionshouldbecarefullyevaluatedbeforetreatmentwith buprenorphine. Both of these are often present inindividualsabusingopioids.Thedrugisnotcontraindicatedif the liver enzymes are mildly elevated. Liver enzymesshould be monitored before induction and monitored ona frequent basis during treatment. Alcohol is a sedative-hypnotic drug and the concurrent use of alcohol presentsproblems.Patientsshouldbeadvisedtoabstainfromalcoholuseduringtreatment.Iftheyarewithdrawingfromalcoholand have seizures the buprenorphine will not control theseizures.

Cost and Supply–Supplycanbeaproblemasthisdrugisnot readilyavailableatallpharmacies.Somephysiciansmaintain supplies of the drug in the office setting. If not,they will need tomake arrangements for the drugs to beavailable and they need to develop a relationship withpharmacies in order to provide collaboration for adequatepatient education regarding dosage and follow up at thephysician office. In addition when using buprenorphinein an outpatient setting there are additional governmentreleaseformswhichmustbesignedinorderforthepatient,doctor and pharmacist to communicate about the patient’sopioidtreatment.Costisamajorfactor.Incertainareasofthe country funding resources are available. This is not acommonpracticeinAlabama.

Office Protocols and Responsibilities–The out patientoption has both advantages and challenges. Some of theadvantages include availability of treatment in the localarea, limiting contact with drug-abusing patients (peers),minimizing potential stigma of treatment, ability to tailortheservices to individualneedsofpatients,and theability

Outpatient Opioid Addiction continued from page 13

Outpatient Opioid Addiction continued on page 15

June, July, August 2010 The Alabama Nurse • Page 15

tocontinuetoworkduringtreatment.Conversely,challengesinclude the learning curve for the treatment team anddifficulties in providing a cost effective multidisciplinaryteam approach involving physicians, nurses, counselors,social workers, educational, and vocational services.Other challenges include issues surrounding inappropriateprescribing, medication diversion, and patientconfidentiality.Despitebeingmorecosteffectivethananinpatienttreatmentprogram,notallinsuranceplanscovertheoutpatient option. Buprenorphine is a treatment for opioidaddiction only and not for addiction to other classes ofdrugs.Whenpatientsabusemorethanonedrugtheypresentsomeuniquechallengesandmayneedtobereferredtomoreintensivetreatmentoutsidetheofficesetting.Anappropriatecandidatewouldbeonewhois:

• Interestedintreatment• Nocontraindicationstothebuprenorphine• Evaluatedtobeacandidatewhowillbereasonably

compliantwiththetreatment• Understandstherisksinvolvedandwillingtofollow

therecommendedsafetyprecautions,• Consents to treatment after reviewingall treatment

options

Historically,inappropriatecandidatesarethosewhohave• Co-morbid dependence on high dosages of drugs

and/or dependency on benzodiazepine or othercentralnervousdepressants–includingalcohol

• Significantuntreatedpsychiatriccomorbidity• Activeorchronicsuicidalorhomicidalideations• Multiple previous treatment failures (except for

multiple previous detoxification attempts followed by a relapse which indicates a need for long-term maintenance therapy)

• Poorresponsetopreviousbuprenorphinetreatment• Significantmedicalconditions.

This treatment process includes extensive patienteducation before the treatment is initiated. Componentsincludeknowledge,understandingandagreementtoadhereto the office expectations, rules, and philosophy. Types ofinformationinclude

• Generalproceduresandprotocols• Officehours• Phonenumbers• Proceduretomakeappointments• Fees• Propermedicationadministrationandstorage• Procurementofthemedications• Side effects both expected and unexpected aswell

astheprecautions• Patient’srightsandresponsibilities.

Both the patient and physician should sign a treatmentcontract. At a minimum the contract should includeinformationaboutthefollowing:

1. Voluntary participation is essential and the patientmustaccepttheconditionsofthetreatmentplan.

2. Pregnancy–Women of childbearing age are notprecluded from the treatment; however, theyshould have a HCG (urine human chorionic gonadotropin) negative test before treatment isstartedandtheyshouldbemonitoredmonthlyoratleast intermittently thereafter. The physician needstoknowif thepatient ispregnant,plans tobecomepregnant, or is breastfeeding. (It is not known if buprenorphine is harmful to unborn children or infants.)

3. Use of alcohol and/or illicit drugs–Patients shouldnotuseeitherofthesedrugsduringtreatment.Botharecontraindicated,alcoholbecauseitisasedative–hypnoticdrugandillicitdrugsleadtoarelapse.

4. Use medication only as prescribed–Each doseis individualized to the patient and if a changeis desired they must call for an appointment anddiscusswiththephysician.

5. Scheduled appointment–Patients need to arrangetheir schedule to meet all appointments. Ifappointments are missed it may result in beingunabletoobtainmedicationuntilthenextscheduledappointment.

6. Compliance with required pill counts and drugtests–botharemandatoryforeachvisit.

7. Counseling and referrals–Patientmust agree to notonlykeepappointmentsbutalsoacceptanyreferral,(e.g., psychosocial counseling, 12-step or other self-help programs.)

8. Under the influence of illicit drugs or alcohol–Patients are not to come to the office under theinfluence because it is unsafe. They will not bemedicated andmaybe dropped from the program.Howeveriftheyareopentothisrelapseandaskforhelptheyshouldbecongratulatedandacknowledged

fortheopenness,becausethisbehaviorisconducivetorecovery.

9. Recoveryandrelapse–Relapse toopioiddrugsmaybe life threatening. The treatment plan must beadjusted immediately. If a trusting relationship hasbeenestablishedthepatientmaybemorewillingtonotify the physician or other health care providersaboutarelapsebeforeitisnotedonthedrugscreens.The treatment staff must develop a matter-of-factapproachtothisbehavior.

10.Diversion–Patientsmustagreenot to sell, share,orgiveawayanyofthebuprenorphine.Ifthedrugsarestolen a police reportmust be filed and a copy ofthepolicereportshouldbetakentotheofficetobeplacedintheirrecord.Thepillswillnotbereplaced.

11.Safestorage–Themedicationisharmfultochildren,other household members, guests, and pets. Themedication must be stored in a safe place and inchildsafetycontainers.Patientsshouldbeinstructedto call 911 or poison control if anyone other thanhimself or herself ingests the medication. Lostmedications will not be replaced. The medicineshouldnotbekeptinplacesoftemperatureextremesorabathroommedicinecabinet.

12.Othersafetymeasures–Thepatientshouldnotdriveor operate heavymachinery, or attempt dangeroustasksuntiltheyknowhowthemedicationwillaffectthem.Dangerousorinappropriatebehaviorwillnotbe tolerated in the office and the person may bedischargedfromtheprogramiftheyengageintheseactivities.

Thestaffandespeciallynursesshouldevaluatefor“redflag”behaviors.Thesebehaviors indicatepoorcompliancewith the program and should be confronted immediately.Nursingstaffshouldsupportpatientsinmakingappropriateresponsestochangethesebehaviors.Thebehaviorsincludethefollowing:

• Missingappointments• Refusingdrugtesting (urine and breathalyzer) • Positivedrugscreenforillicitdrugs• Negativedrugscreenforbuprenorphine• Runningoutofmedicationtoosoon• Notfollowingtheprescribedmedicationschedule• No (or poor) response to phone calls or other

contactsfromtheclinic• Notengagingincounselingorselfhelp• Depression,withdrawal,orsocialisolation• Neglecting tomentionanewmedicationoroutside

treatment• Appearingintoxicatedordisheveledintheofficeor

soundingintoxicatedonthetelephone• Frequent,urgent,orinappropriatephonecalls• Neglecting tomention a change in address, phone,

employment,orhomesituation• Inappropriateangeroutburst• Frequentphysicalinjuriesorautoaccidents• Notpayingbills• Requestforhigherdosesforstabilization• Evidenceoftamperingwithdrugtests• Changesinbehavior• Weightloss

Procedure to set up Out Patient Treatment: Settingupanofficebasedpractice foropioid treatment involvesalengthylegalprocess.Aphysicianmustobtainawaverthatreleases them from the separate registration requirementof the Narcotics Addiction Treatment Act of 1974 and itsenablingregulations.TheDepartmentofHealthandHumanServices(HHS)isresponsibleforthewaverprogramanditisadministeredbytheSubstanceAbuseandMentalHealthServices Administration (SAMHSA) located within HHS.Physicians must meet certain specified criteria (eithereducationorcertification)beforeawaverisconsidered.Thephysician notifies SAMHSA of the intent to provide thistype of treatment. The notification must be accompaniedwith the physician’s qualifying credentials, trainingcertificates,and/orothersupportinginformation.Theymustcertify having the capacity to refer patients to appropriatecounseling and other non-pharmacological therapies. It israrethatpharmacologicalinterventionaloneachieveslong-term success. The drug therapy should be combinedwithconcurrentbehavioraltherapiesandneededsocialservices.Also,thecertificationmustincludevalidationthattheywilluse certain treatment medications and adhere to patientlimits of nomore than 100. SAMHSAwill communicatewith the Drug Enforcement Administration (DEA) in theDepartment of Justice and provide information that thephysicianhasmetallqualifications.TheDEAin turnwillissue a unique identificationnumber; this is in addition totheir original DEA number. Both DEA numbers must beplaced on all buprenorphine prescriptions. Federal lawpermits physicians to prescribe and dispense only theapproved opioid medications Subutex (buprenorphine)and Suboxone (buprenorphine/naloxone) for office-basedtreatment. Federal law specifically prohibits delegatingprescribing of opioids for detoxification to nonphysicians–

NursePractitioners,AdvancePracticeNurses,andPhysicianAssistants even though they have been given prescriptiveauthorityforScheduleIII–Vdrugs.

Selected examples of Schedule III–V drugs include the following:

• III–narcotics containing less than 15 mghydrocodoneperdose(Vicodin,Lorcet)or90mgofcodeineperdosage,i.e.codeinewithacetaminophen

• IV–propoxyphene (Darvon), butorphanol (Stadol),alprazolam (Xanax), temazepam (Restoril),phenobarbital,choralhydrate

• V–primarily cough or diarrhea medicine whichcontainingnomorethan200mgcodeineper100ml(RobitussinACorPhenerganwithcodeine

Nursing Management–Although federal law preventsnursesfrombothprescribinganddispensingbuprenorphineproductsforthetreatmentofaddiction,theyareanintegralpartoftheteam.TheNurse’sroleincludesthefollowing:

• During the treatment process evaluation of signsof intoxication, withdrawal assessments–includingscreening, general assessments, complete history,physical examinations,mental status examinations,treatment monitoring, counseling, and supportiveservices.

• Help rule out co-morbid acute or chronic paindisorders and the level of opioid dependence,polysubstance abuse, and co occurring psychiatricmentalhealthdisorders.

• Evaluating the need for ongoing treatments forillnessessuchasHepatitis,TB,and/orHIV.

• Exploring potential pregnancy and childbearingissues.

• Screeningfordomesticviolence• Evaluation for infectious diseases, ensuring safety,

andpromotingsustainedrecoveryoutcomes• Acting as a case manager–to improve access and

identifycommunityresources• Education–of patients and family members and/

or other supportive individuals, about the drugtherapy. This will include risks, benefits, potentialside effects, expected and unexpected side effects,interactions, program requirements, consents, andtreatmentcontracts.

• Individualizing the treatment plan including thedirectinvolvementofthepatient,andworkingwiththepatientandtheinterdisciplinarytreatment teamto individualize the plan specific to the patient’sneeds

• Enhancingtreatmentreadiness–supportingtreatmentcompletion, resources, providing information aboutthe various resources, explaining reimbursementoptions

• Referrals–helping patients secure care when theoffice based treatment program is not appropriateforthem

• Guiding–providing support for patients in theirselectionofvariousothertreatmentoptionssuchasdaytreatment,residential,etcwhentheofficebasedtreatmentoptionisnotappropriateforthem.

The health care record should reflect that the patientmeetstheDSM–4criteriaforopioidaddiction(compulsiveuse of opioids despite harm).After a thorough assessmentitmaybenotedthatthepatientisphysiologicallydependenton the opioids and meets the DSM–4 criteria for opioidabusebutnotfordependence.Thisisrare.Inthesecasesapatientmaybe placed on a short course of buprenorphineandmaintenancetherapyisnotneeded.

An effective treatment plan will include ongoingmonitoring and updating based on the individual patientneeds. It will need to be adjusted during the treatmentprocess.Componentswillincludetheindividual’sdruguse,as well as additional physical, psychological, vocational,social, or legal needs. This will include (but not limitedto) theneed foradditional therapies suchas social supportnetworks, counseling for self or family, psychotherapy,vocationalsupport,parentinginstructions,domesticviolencehelp,vocationalrehabilitation,socialandlegalservices.

Formostpatientssignificantimprovementisnotedabout3 months into treatment. Some want to leave treatmentearly and they should be encouraged to remain. Relapsesoftenoccurduringtreatmentandfrequentdrugmonitoringhelps prevent. Patients need frequent feedback as to theircondition.

Protocols for Office Based Management–Expertsin the field of substance abuse have selected to use theterm “medical withdrawal” because it defines the role ofhealthcareprovidersinthemanagementofthewithdrawalprocess.Patientswhoaredependentonshort-actingopioidssuchasheroinmaybeginbuprenorphine6-8hoursafterthelast ingestionof the substance.Tobe safemostphysicians

Outpatient Opioid Addiction continued from page 14

Outpatient Opioid Addiction continued on page 16

Page 16 • The Alabama Nurse June, July, August 2010

prefertowait8-12hours.It isimportantthatthepatienttoshow beginning symptoms of withdrawal. The maximumrecommendeddoseofDay1is8mg(givenallatonceorindivideddoses).Aprecipitatedwithdrawalmayoccurwhenswitching patients from Methadone to buprenorphine. Itis important for patientswho are physically dependent onmethadone be carefully selected and carefully monitoredduring this process. An appropriate patient would besomeonewhohadhaddifficultyadheringtotheMethadoneclinicvisitsduetoworkortravelandnotsomeonewhohadbeen non compliant with methadone treatment options.Another selection criteriawouldbe someonewhohas hadadverse reactions to methadone. A person who is stableon methadone should not be considered a candidate toswitch to buprenorphine because of the increased rise ofa precipitated withdrawal. The risk is greatly increasedif the patient is started on buprenorphine shortly after thelastmethadonedoseorifthepersonismaintainedondosesgreaterthan30-40mgday.Ifthepersonmustbeswitchedtheacceptedprotocolistotaperthemethadonetonomorethan30-40mgday.Once this isachievedthefirstdoseofbuprenorphine should not be given until at least 24 hoursfollowingthelastdoseofMethadone(48 hours if the patient is on the levomethadyl acetate (LAAM) protocols. Theinductiondoseshouldbe2mgandnottoexceed8mgina24hourperiod.

Actual Procedure:Patienteducationcomesfirst.Theremustbenosurprises.Beforetheinitialtreatmentthepatientandfamily/significantothersmustunderstandthefollowing:

• Plan to come to the doctor’s office in mildwithdrawal

• Disposeofallillicitdrugsandparaphernaliabeforecomingtotheclinicthefirsttime

• Havesomeonebringyouanddonotplantodriveforatlease24hoursafterreceivingthefirstdose

• Plantobeattheofficeforatleast4hoursthefirsttime as the induction will involve monitoring andmaybemore than one dose (bring a sandwich andmaybeabook)

• Bereadytogiveaurinesample.• Thetabletwillbeplacedundertongueandallowed

tocompletelydissolveslowly.• Do not talk, eat, or drink or swallow while the

medicationisinyourmouth.• Maybringamirrortowatchthetabletslowlyshrink

asitisabsorbedintothebody.

The first time a patient takes the pill the nurse shouldwatchforproperplacementunderthetongue.Itthenshouldbecheckedperiodicallyforshrinkageandchecktoseethatit is completely gone.After the initial induction and untilstabilization occurs the patient receives a once daily dose.After stabilization the personmay receive a daily dose orevery other day dose. Dosages may be increased on thedays that the patient is not in the office. For example ifthe stabilizationoccurs at 8mgeveryotherday (Monday,Wednesday,Friday)theFridaydosemaybeincreasedto16mgtoprovidecoverageforthe2dayweekend.

Another important role of nursing is counseling andreferral for psychological treatment. Successful treatmentusually involves concurrent psychological and behavioraltherapies and referrals are frequent. Typical issues includemotivation, building skills to resist drug use, replacedrug seeking activities with constructive activities,improve problem solving abilities, improve interpersonalrelationships, and improve the family and communityfunctioning.Another issue thatnursesmustevaluate is theliving conditions of the patient. Sometime their situationis such that it is unsafe for them or for the safety of themedication to remain in the current situation. In thosecasesalternativelivingarrangementscanbearranged.Thecooccurringmentalhealth issuesandpreexistingphysicalissues such as infectious diseasesmust be treated. Specialat riskpopulationshighly inneedof consultationwhile in

treatment include:co-occurringpsychiatric illness, chronicpainissues,infectiousdiseases(Hepatitis,HIV/AIDS,etc.),pregnant and /or breastfeeding, adolescents and geriatric,patients polysubstance abuse, recently released from thecriminaljusticesystem,andhealthcareprofessionals.

Thetreatmentforretentionandpreventionofarelapseisindividualized.The course of treatment varies from a fewdays formedically supervisedwithdrawal to several yearsformaintenance therapy.Overall the recovery is long-termand usually requiresmultiple treatment episodes. Some oftheways to prevent relapses are to constantlymonitor theurine drug screens, counting pills frequently, appropriateevaluation of medication dosage by the physician, andfrequent pharmacy checks. Even with this relapses oftenoccur. The cause may be either physical or emotionaltriggers. Frequently the cause is family upheaval.Nursingcare involves helping the patients develop strategies forprevention such as identifying the potential triggers anddeveloping alternative effective coping strategies. Patientsmayneedtobetaughteffectivestressandangermanagementtechniques.Specificexamplesofwordsofencouragementtomaintaineffectivecommunicationinclude:

“Howwouldyouhandlethis?”“Tellmehowyoufeelabout…”“Thismustbeuncomfortable.Whatareyourplans?”“Howcanwehelpyouinyourrecoveryprocess?”“Tellmeaboutthechangesinyourliferightnow.”“Iknowyouareinaroughspotrightnowandyouare doingwell.”“Iunderstandthethingdidnotgowell.Letstalk aboutit.”“Howdoesitfeeltobesosuccessfulinyourtreatment?”

Remember the need for nursing care is to help thepatient grow emotionally and establish effective priorities.Helpingthemmaintainmotivationwillenhancethechancesof ongoing recovery. This can be accomplished with thedevelopment of a trusting relationship in which patientsare able to identify their ownneeds and thendevelop andimplementanactionplanforcontinuedrecovery.

Privacy and Confidentiality–Partoftheroleofnursingis to assure patients that allmedical records and personalinformation will always be safe. In addition they need tobe reassured that their privacy will always be respected.Informationcanbeprovidedtothirdpartiesonlywiththeirwrittenconsent.TherearefederalmandatesfromSAMSHAregarding privacy issues and these guidelines require agreaterdegreeofprivacyforaddictionrecordsthangeneralmedical records as mandated my HIPPA guidelines. Forexample, there are special consent forms with any thirdparty suchaspharmacies.HIPPAguidelinesalsomandatestandardizationofexchangeformatsforallinformation.Itisalsonecessarytodiscussspecificstateissueswhichrequiremandatoryreporting.Exampleswouldbereportingofchildorelderabuse.Patientsshouldbeawareofwhatconstitutesdoctor/patient privilege information and circumstances inwhichconfidentialinformationisprotectedfromdisclosure.

Medicallysupervisedwithdrawalisonlythefirststageoftheaddictiontreatmentanditsgoalistomedicallymanagethe acute physical symptoms. This treatment alone is notsufficient to keep patents abstinent from the opioids. Theobject is to assist the person tomake a smooth transitionfrom physically dependent to a non-dependent state. Themedically supervised withdrawal should be followed withlong-termdrug treatment therapy coupledwithNaltrexone(if needed) to minimize the risk of opioid relapse. Long-termmaintenancetreatmentwithbuprenorphineispreferredto any form of detoxification or withdrawal treatment.Literature references reflect that is the most effectivetreatmentascomparedtosupervisedrapidwithdrawalovershortperiodsoftime.

There is ongoing research as to the length of thewithdrawal process. Most of the literature suggests thatdosagemaysafelybe reducedup to50%perdayand thiswould afford the patient onlymildwithdrawal symptoms,which can be treated with over the counter medications.The literature goes on to say that although safe to reducethis quickly it is rarely accomplished. Most feel the bestmethod is a slow, easy, and comfortable reduction forthe patient, which affords few withdrawal symptoms.Complete cessation usually occurs when the person isreceivingabout2mgpermonthand theyfeelcomfortableabout discontinuing the dose.A noncompliant patientwillprobably need to be transferred to another program suchas Methadone Treatment programs or to a non-medicaltreatmentprogramwheretheycanreceivemoresupervision.

Classification of Medically Supervised Withdrawal–There are three classifications of medically supervisedwithdrawal.

1. The first isShort-Termand is effective forpersonsneeding to be opioid free quickly–foreign travel,jobrequirements,impendingincarceration,etc.Thedosage of buprenorphine is reduced over 3 days(longer of needed) and then discontinued.There is

littledataaboutrelapserates.2. The second classification is Mid-Term medically

supervisedwithdrawal.Theidealpatientissomeonewho has no compelling reason to be opioid freebutwants toparticipate inrehabilitationassoonaspossible.Thewithdrawaltimeususually10-14daysandupto30days.

3. Thelastcategoryofmedicalsupervisedwithdrawalis the Long-Term withdrawal. Theses candidatesare unwilling or unable to engage in rehabilitationservices without agonist medication support. Thisdetoxification last 30-180 days and these patientsmay be suitable candidates for MaintenanceTreatment.

Management of Co-occurring Pain–Patientsonopioidwithdrawal may experience acute or chronic pain, whichmust be treated. This is especially important because ifacute pain is left untreated the patient’s responsiveness toopioidanalgesicswillbereduced.Inthelongruncontrollingthe painwill bemore difficult.Effective treatment beginswithapainassessment to1.) identify the levelof thepainat which the patient can continue to function at a levelappropriate for maintaining activities of daily life and 2.)effectivelymeasurethepainmanagementplan.AfrequentlyutilizedassessmentcriterionistheAHCPRscale.

Onsetandtreatment Whendidpainstart?pattern Howoftendoespainoccur? Haspainintensitychanged

Location Whereisthepain? Istheremorethanonesite ofpain?

Description Whatdoesthepainfeellike? Whatwordsdescribethepain?

Aggravating Whatmakesthepainbetter? Worse?

Previoustreatment Whattreatmenthaveyoutried torelievethepain? Weretheseeffective?

Effect Howdoesthepainaffect physicalandsocialfunction?

Intensity Usingapainscale,ratethe intensityofpain.

(AHCPR,1994)

The first approach to pain management will bemedicationssuchasNSAIDs,acetaminophen,andadjuvantanalgesics such as tricyyclic antidepressants that enhanceopioidseffects.Thesecondapproachisnonpharmacologicalinterventions such as physical and cognitive modalities.Examples of physical interventions include cutaneousstimulation, exercise, immobilization, and acupuncture.Examples of cognitive behavioral modalities includerelaxation and imagery therapy, distraction, reframing,education, hypnosis, counseling, etc. Any time pain ispresent,whethertreatedornot,theremustbeongoingpainassessments. Sometimes acute painmust be treated whileonbuprenorphinemaintenancetherapy.Atypicaltreatmentplan would include the following: 1.) titrate short actingopioid analgesics (short duration pain only), 2.) administeropioid analgesics and temporarily discontinue thebuprenorphineandreturntothetherapyassoonaspossible,3.)dividethebuprenorphinedoseandadministerevery6-8hours,and4.)discontinuethebuprenorphineifhospitalizedand provide methadone (20 mg–40 mg) for treating theopioid dependence and give short acting opioid analgesicsfor treating the pain. It is essential to have naloxone, anopioidantagonistonhandincaseofanemergency.

Thistypeoftreatmentmodalityisoftenconvolutedandfullofsetbacksforthepatients.Nursingcarecangoalongwaytomakeadifferenceinhowthepatientcopeswiththetherapyprocess.

Selected BibliographyAgency for Health Care Policy and Research (AHCPR).

(1994).ManagementofCancerPain.ClinicalPracticeGuidelines(PublicationNo.94-0592ed.).Rockville,MD:AHCPR

Buprenorphine: A Guide for Nurses. (2009). TechnicalAssistance Publication Series (Publication No. 09-4376).Rockville,Md

Gowing L, Ali R, White, JM. Buprenorphine for themanagement of opioid withdrawal. Cochran Database of Systematic Reviews 2009, issue 3, Art. No: CD002025. DOI:10.1002/14651858.CD002025.pub.4

Wilcock FP. Levo-Alpha Acetyl Methadol (LAAM). Itsadvantagesanddrawbacks.Journal of Substance Abuse Treatment 1997,Nov–Dec;14(6):559-64

Outpatient Opioid Addiction continued from page 15

Outpatient Opioid Addiction continued on page 17

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June, July, August 2010 The Alabama Nurse • Page 17

Post Test–Select the one best answer

1. Thethreeopioidreceptorsitesinthebrainaredelta,kappa,andmu.

1. True 2.False

2. Thekappareceptorsiteisthemostrelevanttoopioidaddiction.

1. True 2.False

3. Opioids with the greatest abuse potential, i.e.morphine, heroin, etc. are classified as anantagonist.

1. True 2.False

4. The two types ofwithdrawal associatedwith amuagonistarespontaneousandprecipitated.

1. True 2.False

5. Buprenorphinemaybedosedeveryotherday(oncethepersonisstabilized)becauseofitslonghalf–life.

1. True 2.False

6. Thehalf-lifeofbuprenorphineis12-18hours. 1. True 2.False

7. A characteristic separating dependence fromaddictionisthecontinuedusedespiteknowledgeofnegativeconsequences.

1. True 2.False

8. Subutex and Suboxone are two different names forthesamemedication.

1. True 2.False

9. During the initial dosing buprenorphine is givenuntilthe“ceilingeffect”occurs.

1. True 2.False

10. Buprenorphine products are given sublinguallybecausetheypoorlyabsorbedintheGITract.

1. True 2.False

11. Ifnaloxoneiscrushedandinjectedintravenouslythepersonwillgointoaprecipitatedwithdrawal.

1. True 2.False

12. A precipitated withdrawal usually last for severaldays.

1. True 2.False

13. Early withdrawal symptoms include fever, nausea,anddilatedpupils.

1. True 2.False

14. The maximum effective dose of buprenorphine isusuallysomewherebetween16-32mg.

1. True 2.False

15. Transient hypotension almost always occurs duringthefirstweekoftreatmentwithbuprenorphine.

1. True 2.False

16. During the stabilization phase of opioid treatmentthepatientisplacedonalternatedaysdosing.

1. True 2.False

17. During the early stages of opioid treatment thewithdrawalsymptomscanusuallybemanagedwithoverthecountermedications.

1. True 2.False

18. Methadoneisthedrugofchoiceforopioidtreatmentforpregnantwomen.

1. True 2.False

19. Concomitant use of buprenorphine and othermedicationsrarelypresentsproblems.

1. True 2.False

20. Side effects and/or allergic reactions tobuprenorphineareusuallydermatological.

1. True 2.False

21. SubutexandSuboxonearemorecosteffective thanMethadone.

1. True 2.False

22. Buprenorphinemaybeusedforoutpatienttreatmentofbenzodiazepines(e.g.Ativan)addiction.

1. True 2.False

23. Individuals with severe cardiac problems usuallymakegoodcandidatesforbuprenorphinetreatment.

1. True 2.False

24. During the treatment process when a patient losesorhas theirmedicationsstolen theyare replaced topreventthepatienthavingcravingforopioids.

1. True 2.False

25. Patient who do not comply with the treatmentregulations are frequently dropped from theprogram.

1. True 2.False

26. Relapsesduringthetreatmentprocessarecommon. 1. True 2.False

27. Depression and frequent physical injuries are both“redflag”behaviorsindicatingnoncompliancewiththetreatmentprocess.

1. True 2.False

28. AdvancePracticenursesmayadjust themedicationdownwardwhenneeded.

1. True 2.False

29. Nursing management includes referrals to otherprogramswhenneeded.

1. True 2.False

30. Nurses must actually observe the sublingual tabletdissolve under the tongue for the first couple ofdoses.

1. True 2.False

31. Nursing assessment should include an ongoingreview of the patient’s family dynamics as this isoftenacauseofrelapse.

1. True 2.False

32. The development of a trusting relationship is oneof the first steps in helping patients maintainsmotivationduringthetreatmentprocess.

1. True 2.False

33. SAMSHAprivacyguidelinesare less stringent thatHIPPAguidelines.

1. True 2.False

34. Naltrexone is often used as an adjunct to preventrelapse.

1. True 2.False

35. Ifapatientisinabuprenorphinetreatmentforopioidaddictionandexperiencesacutepainopioidsshouldbeavoidedfortheacutepainmanagement

1. True 2.False

Outpatient Opioid Addiction Treatment Using Buprenorphine 3.0(ANCC)/3.6(ABN)contacthours Activity#:4-0.912

Name: _________________________________________________ Fee and Payment Method

Address: _______________________________________________ City State ZipPhone: ________________________________________________

Email: ________________________________________________

ABNLicenseNumber: ___________________________________

______________________________________ / ______________ CreditCardNumber

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

ACTIVITY EVALUATION

GOAL:Exploretheroleofnursinginbuprenophineoutpatienttreatment.

Circle your response using this scale: 3–Yes 2–Somewhat 1–No

Ratetherelationshipoftheobjectivestothegoaloftheactivity 3 2 1

Rateyourachievementoftheobjectivesfortheactivity 3 2 1

Objectives:

1.Listthe“idealcandidate”foroutpatientopioidtreatmentusingbuprenorphine. 3 2 1

2.Explainthenurse’sroleinthetreatmentprocess. 3 2 1

3.Relatethepharmacologyofbuprenorphine. 3 2 1

Howeffectivewasthisactivityasateaching/learningresource? 3 2 1

Programwasfreeofcommercialbias. 3 2 1

Onascaleof1-5knowledgeoftopicbeforehome-study 5 4 3 2 1

Onascaleof1-5knowledgeoftopicafterhome-study 5 4 3 2 1

Howmuchtimedidittakeyoutocompletetheprogram? _______ hours _______minutes.

ADDITIONALCOMMENTS:

______ ASNAMember ($20.00)______ NonMember ($30.00)______ Check– MakePayabletoASNA______ Visa _____M/C______ ExpDateCredentials: __________________________

____________________________________Signature

Outpatient Opioid Addiction continued from page 16

Page 18 • The Alabama Nurse June, July, August 2010

by Laura Landro

Errors made by doctors, nurses and other medicalcaregiverscause44,000to98,000deathsayear.Hospitalinfections, many considered preventable, take another100,000 lives.Andmistakes involvingmedications injure1.3millionpatientsannuallyintheU.S.,accordingtotheFoodandDrugAdministration.

JulieThao looks atReginaYoung,mother of JasmineGant,asMs.Youngprepares toreadherstatement to thecourt during a hearing in 2006 about her medical errorthat led to Ms. Gant’s death. Hospitals are taking whatmight seem likea surprisingapproach toconfronting theproblem:Not only are they trying to improve safety andreduce malpractice claims, they’re also coming up withprocedures for handling—and even consoling—stafferswhomakeinadvertentmistakes.

The National Quality Forum, a government-advisorybody that sets voluntary safety standards for hospitals,has developed a Care of the Caregiver standard, callingon hospitals to treat traumatized staffers involved inerrors as patients requiring care, then involving themin the investigation ofwhatwentwrong if their behaviorwasnotfoundtoberecklessorintentional.JustCulture,amodeldevelopedbyengineerDavidMarx,stressesfindinga middle ground between a blame-free culture, whichattributesallerrorstosystemfailureandsaysnoindividualis held accountable, and overly punitive culture, whereindividualsareblamedforallmistakes.

AnewstudypublishedintheAprileditionoftheJointCommissionJournalonQualityandPatientSafety,whichexaminesonefatalmedicalmistaketoanalyzewhatwentwrong, shows how assigning blame for errors can be amurkyexercise.

Four years ago, nurse Julie Thao mistook a bag ofepiduralpainkillerforpenicillinandhookedituptoanIVlinethatpumpedthepainkiller—meanttobeinjectedintothe spine later—into the bloodstreamof JasmineGant, a16-year-oldwhowasabouttodeliverababyatSt.Mary’sHospitalinMadison,Wis.Theteen’sheartcollapsed.HerbabywasdeliveredsuccessfullybyemergencyCaesareansection, butMs. Gant didn’t survive.Ms. Thao says shewas fired from the hospital after the death, and shewas

laterprosecutedby thestate forcriminalnegligence.Ms.Thao’s case has helped galvanize efforts to ensure thatcaregivers are treated fairly—without absolving them ofresponsibilityforriskybehavior.

Thestudy,ledbyresearchersatthenon-profitInstitutefor Safe Medication Practices, concludes that while Ms.Thao consciously bypassed multiple safety procedures,there were also a host of system flaws thatallowedandeven encouraged her to do so, contributing to the fatalerror.

Researchers found that Ms. Thao failed to put anidentification bracelet on her patient or use the hospital’sbar-codingsystem,designedtomatchtherightmedicationtotherightpatient.Butthebar-codingsystemhadglitches,and nurses hadn’t been adequately trained on it, so theyoftenbypassedit.

Bothmedications—which looked alike—were broughtintothepatient’sroombeforeordersweregiven,aviolationof policy. Fatigue increased Ms. Thao’s likelihood of making a mistake, the study found. Ms Thao had worked two consecutive eight-hour shifts the day before and then slept in the hospital before coming on duty again the next morning, but there were no rules at the hospital to prevent her from being overworked.

In editorials accompanying the study, patient-safetyexperts, including Charles Denham, co-chairman of aNational Quality Forum safe-practices committee, andHarvardUniversity health-policy professor Lucian LeapeareharshlycriticalofthewayMs.Thaowasfiredbythehospital and then left to fend for herselfwith no incomeand no financial resources to defend herself in chargeslaterbroughtbythestate.“WeallbelievethatJulieshouldbeheldaccountableforherbehavior,butshedidn’treceivesupportfromherorganizationortreatmentthatwasjust,”saysDr.Denham.“Itisclearthatothernursesmighthavemade the same error due to the social conditions andtechnicalsystemsinthehospital.

OfficialsatSt.Mary’s,whichpaid$1.9milliontosettleamalpracticesuitbroughtbyMs.Gant’sfamily,say theytreatedMs.Thaoproperly.Thehospital’spresident,FrankByrne declines to discuss the specifics of Ms. Thao’sdismissal, but says the hospital was supportive; whenit learned the state planned to bring criminal charges,

Dr.Byrne says he did everything he could to stop it andappeared at court proceedings to lend moral support.He included his own commentary in the patient-safetyjournal, describing safety steps taken after Ms. Gant’sdeath,includinglimitingworkhoursfornurses.“Weneverattemptedtoshirkacknowledgmentofoursystemissues,”hesays.

In Ms. Thao’s case, under a plea agreement, felonycharges were amended to two misdemeanor counts.Afterward,hernursinglicensewassuspendedandshewasbarredforseveralyearsfromworkingforanyhospitalthatacceptsfederalfundingfromMedicare.

Safety advocates and nursing groups also questionthe use of criminal charges brought against nurses anddoctors who make unintentional mistakes, saying theyset a chilling precedent. “Criminal accusations againsthealthcareproviderswhowork inasystemsetup to failareextreme,”saysSueSheridan,co-founderofConsumersAdvancing Patient Safety. “By the same token, there hasto be some accountabilitywhen families have suffered atragicloss.”

Dr.DenhamtookMs.Thaoonasapatient-safetyfellowinhisownmedical-researchconcern,TMIT,fortwoyears.Henowretainsher todocontractpatient-safety research.Ms. Thao, who was briefly hospitalized for depressionafter the event, says she considered taking her own life.She says her patient-safety work has helped her to copewithherdespairoverhererrors.

“Every hospital in America is wrestling with how tohold practitioners accountable for key safety behaviors,”says Mr. Marx, whose company, Outcome Engineering,consultswith hospitals, states and nursing boards on theJustCultureModelandhelped train20,000employeesatSt.Mary’s after the Thao case. It’s designed to “addressriskybehaviorsbeforetheyleadtothedeathofapatient,”hesays,coachingthosewhomakeriskydecisions,suchasfailingtowashhandsbeforetouchingpatientsorskippingimportantchecksinadministeringmedications.

“We know just punishing human error does notimprovesafety,”saysSt.Mary’sDr.Byrne.“Butwehaveto separate unavoidable error from reckless behavior andunjustifiablerisk.”

laura.landro@wsj.comReprinted with permission from Laura Landro

New Focus on Averting Errors: Hospital Culture

June, July, August 2010 The Alabama Nurse • Page 19

Continuing Education

2010 Annual Selma Update

Saturday August 14, 20108:00 am until 4:30 pm

Contact Hours–6.5(ANCC)~7.8(ABN)

Location: SelmaMunicipalLibrary–1103SelmaAvenue,SelmaAL36703Park across street from Library to avoid towing.

Agenda:8:00AM Registration8:25AM Welcome~YvonneHatcher,RN8:30AM Clean Air/Smoke Environment–ADPH

Representative9:30AM Environmental Impact of Returning Veterans

& Agent Orange, Gulf War Syndrome–Is it real, Vaccines used on Veterans, Uranium Exposures, & Leishmaniasis~JillStokley,MSN, RN

10:30AM Break10:45AM Why We Need to Break the Single Use

Plastic Bag Habit ~HelenWilson,MSN,RN11:15AM Do You Know What is in Your Water? ~ HelenWilson,MSN,RN12:00PM Lunch1:00PM Toxic Chemicals: In Your Food, In Your

Personal Care Products, In Your Work Environment, and In Your Home ~

HelenWilson,MSN,RN2:15PM Break2:30PM Chemicals Policy Reform ANA, HCWH,

NWD Update~HelenWilson,MSN,RN3:30PM Advocating For a Healthier Environment ~

HelenWilson,MSN,RN4:30PM Evaluations

Objectives:1. Identifytoxicchemicalsinyourpersonalenvironment.2. Discussrealisticchangesthatyoucanmakeinorderto

improveyourlocalenvironment3. Relate how environmental chemicals are adversely

affectingthecitizensofAlabama.

Continuing Education: The Alabama State Nurses Associationis accredited as a provider of continuing nursing education bythe American Nurses Credentialing Center’s Commission onAccreditation.

AlabamaBoardofNursing(validthroughMarch30,2013).

Refunds: IfcancellationisreceivedinwritingpriortoAugust6,2010,a refund(minusa$20.00processingfee)willbegiven.AfterAugust6, 2010, no refundwill be given.We reserve the right to cancel theprogramifnecessary.Afullrefundwillbemadeinthisevent.

2010 Annual Selma UpdateAugust14,2010–Selma,AL

Cost:Member$50 NonMember$65

AfterAug.6,2010Add$15

Name: ________________________________________

NursingLicenseNo.: _____________________________

Address: ______________________________________

______________________________________________

HomePh:______________________________________

OfficePh: _____________________________________

Email: ________________________________________

Credentials: ___________________________________

PaymentMethod:Check _____

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SendregistrationandpaymenttoASNA,360NorthHullSt.Montgomery,AL36104orFaxto334-262-8578Registeronlineatwww.alabamanurses.org

ASNA Summer Pharmacology UpdateSaturday July 17, 2010 8:00 am until 4:00 pmContact/Pharm Hours–6.0(ANCC)~7.2(ABN)

Location:HeronLakesCountryClub–3851GovernmentBlvd,Mobile,AL36693

Objectives:

1. Discuss prescribing protocols for medicationsdiscussed.

2. Relate potential complications with medicationsdiscussedbeyondtheblackboxwarnings.

Continuing Education: The Alabama State NursesAssociation is accredited as a provider of continuingnursingeducationbytheAmericanNursesCredentialingCenter’sCommissiononAccreditation.

Alabama Board of Nursing (valid through March 30, 2013).

Refunds: If cancellation is received in writing priorto July 9, 2010, a refund (minus a $20.00 processingfee) will be given. After July 9, 2010, no refund willbegiven.Wereservetherighttocancel theprogramifnecessary.Afullrefundwillbemadeinthisevent.

Agenda:

7:30–9:00AM Registration

8:00–9:00 AM Open Discussion: Alabama Legislative Initiatives to Expand Advance Practice Scope of Practice. Facilitated by the ASNA Advance Practice Council (NoCEAwarded)

9:00AM–4:00PM

• Drugs to Avoid With Elders–Dr.JoyceVarner• Update on Diabetic Medications– Dr.FayeMcHaney• Drugs in the Critical Care Arena–RickieVarner,

RN• Update on Asthma Medications– Dr.ElizabethVandeWaa• Top tens ~ Top 10 Prescribed Drugs, Dangerous

Drugs, Drugs of Abuse–Dr.ElizabethVandeWaa• Current Medications for Chemical Dependency– Dr.SuzanneAstrabFogger

4:00PMEvaluations

ASNA Summer Pharmacology Update

Name: __________________________________________________________

Address: _________________________________________________________

_________________________________________________________________

Day Phone: ________________ Credentials: ___________________________

Check _________ AmEx ______ Visa _____ M/C _____ Discover _____

Credit Card: _____________________________________________________

Exp. Date: ______________ CVV: __________________________________

Confirmations by Email Only

Cost:ASNA Member $50Non Member $70

After July 9, 2010 add $15.

Sendregistration&paymentto:ASNA,360N.HullSt.Montgomery,AL36104

OrFaxto:334-262-8578

Registeronlineat:www.alabamanurses.org

A Special Thank You to Our Exhibitors and Sponsors at Elizabeth A. Morris Clinical

Education Sessions (FACES)SPONSORS

ArthurL.DavisPublishingAgency,Inc.

EXHIBITORS

Alabama-NWFloridaAssociationAuxiliaryofGideonsInt.

AlabamaOrganCenter

ALLKids

AUMSchoolofNursing

BaptistMedicalCenterSouth

DCHHealthSystem

Jackson Hospital

JSUCollegeofNursing&HealthSciences

MiddleTennesseeSchoolofAnesthesia

NewYorkLife

Rinehart&Associates

TroyUniversity

UAHCollegeofNursing

UniversityofAlabama,CapstoneCollegeofNursing

Elizabeth A. Morris Clinical Education

SessionsFACES

Our annual Elizabeth A. Morris Clinical Education Sessions–FACES 2010 was held on Tuesday, 20 Aprilat the Eastmont Baptist Church inMontgomery.We hadanother tremendously successful event, with over 700attendees, an outstanding lineup of excellent speakersand presenters, and a list of terrific exhibitors. Thiswasour fourth year at Eastmont, and the church staff was,as always, very supportive and welcoming. Those ofyou that enjoyed lunchat thechurchcanalso testify thatthe prepared meal was delicious; never mind the greatdesserts! This year we had an extensive series of tracksfrom which to choose: AANS; several different clinicaltracks and plenary sessions on Workplace Bullying andProfessionalEtiquette.Inaddition,theposterpresentationswere excellent, with 1st place winners Shunesa Harris, RN, Velma Freeman, RN and Dr. Francine Jones (Lateral Violence: A Survey of Registered Nurses, License Practical Nurses and Psychiatric Nursing Technicians), Nicole Overstreet, Jennifer Phillips, Shelli Brock and Amanda Moore, AUM students (Oriented X3—or Not? Use of the Confusion Assessment). Please see a list of our sponsorsandexhibitorstotheright.