current resident or

Presort StandardUS Postage

PAIDPermit #14

Princeton, MN55371

Official publication of the Idaho Nurses AssociationQuarterly circulation approximately 21,000 to all RNs, LPNs, and Student Nurses in Idaho.

Volume 36, • No. 1 May, June, July 2013

Page 9

Page 10

Page 8

Page 12-13

Page 4

Page 7

A Review Comparing Glycemic Effect of Insulin Therapies: Continuous Subcutaneous Insulin Infusion Versus Multiple Daily Injections

The Effectiveness of Family Involvement in Treatment of Schizophrenia: A Review

How Does Delayed Versus Early Pushing Affect Vacuum and Forcep-Assisted Deliveries?

The Meskhetian Turk Refugees: Their History, Cultural Practices and Nursing’s Role

Reflections on a Nursing Journey: Surprises, Challenges and New Opportunities

Changes in the Nurse Legend Recognition Program

Inside This Issue

Save the Date – September 27, 2013The 2013 INA Fall Conference

Delivering Quality & Innovation in Patient Care

WHERE: Boise Hotel & Conference Center 3300 S. Vista Avenue Boise, Idaho

Additional details and registration will be available soon on the INA website at

http://idahonurses.orgExhibitor opportunities are available now.

Member Benefit Highlight: Navigate Nursing (Discussion Board and

Online Webinars)

The American Nurses Association’s Navigate Nursing is dedicated to helping you become a stronger nurse leader. You have the skills and knowledge to deliver professional care to patients. We aim to provide you with valuable leadership resources to help you do your job better.

We believe in healthy work environments and a healthier you! Use this site for information on how to create professional success, improve patient care environments, and expand your personal development.

Whether you’re an advanced practice nurse, staff nurse, a novice or expert, Navigate Nursing has resources you can use. Navigate Nursing will provide resources to help you find your way through your career challenges on the course to a better you!

Upcoming webinar topics include*:• 6/19/2013NavigatingtheNewSafePatientHandling

Guidelines• 7/17/2013NavigatingQuality:FundingQuality

Improvement Programs on Your Unit• 8/21/2013NavigatingCollaborativeRelationships:

Developing Synergy between Clinical Nurses and Nurse Managers

• 9/18/2013NavigatingtheStaffingConundrum• 10/16/2013NavigatingQuality:TheValueofFront

Line&NurseManagersinUnderstandingQuality• 11/20/2013NavigatingtheChangingEconomic

Environment for Nurses• 12/18/2013NavigatingShiftwork:5TipsforManaging

Fatigue

*schedule subject to change

INA/ANA members receive discounted registration rates. For more information and to register for webinars, visit http://nursingworld.org/MainMenuCategories/CertificationandAccreditation/Continuing-Professional-Development/NavigateNursing/default.aspx.

Therese Hooft, R.N.INA Member Since 2011

“The world as we have created it is a process of our thinking. It cannot be changed without changing our thinking.” ~ Albert Einstein

I attended the College of Southern Idaho and Boise State University for my nursing degree. Both schools have provided me with such wonderful professors that have influenced me to

Membership Corner

Check out our website:

www.IdahoNurses.org

Member Spotlight

Therese Hooft

Member Spotlight continued on page 5

Page 2 • RN Idaho May, June, July 2013

Published by:Arthur L. Davis

Publishing Agency, Inc.

www.idahonurses.org

RN Idaho (RNI), the official publication of the Idaho Nurses Association (INA), is a peer-reviewed journal that is published quarterly. Views expressed are solely those of the authors or persons quoted and do not necessarily reflect INA’s views or those of the publisher, Arthur L. Davis Publishing Agency, Inc. The RNI Editorial Board oversees this publication and welcomes nursing and health-related news items, original articles, research abstracts and other pertinent contributions. We encourage short summaries and brief abstracts as well as lengthier reports and original works. An “article for reprint” may be considered if accompanied by written permission from the author or publisher. Authors are not required to be INA members.

Manuscript FormatArticles should be submitted in APA

style (6th edition) as a double-spacedWORDdocument using 12 point font. Acceptable fileformats for documents are:

• WORDfilesin .doc format without embedded photos (please save “down” to .doc instead of .docx if .docx is your default file format)

• .jpgor.tiffforphotographsSubmissions should include the article’s title and the

author(s) name, credentials, organization/employer andcontact information. Authors must address any potential conflict of interest, whether financial or other, and also identify any applicable commercial affiliation. Submissions should be emailed as attachments to INA at ed@idahonurses.org.

current resident or

Presort Standard

US Postage

PAIDPermit #14

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55371

Official publication of the Idaho Nurses Association

Quarterly circulation approximately 19,000 to all RNs, LPNs,

and Student Nurses in Idaho. Volume 33, • No. 1

May, June, July 2010

Volume 33, • No. 1

May, June, July 2010

Page 2

Page 3

Page 4

From the President

Charting Idaho

Nursing History

Keeping It In the

Family: Idaho

Grandparents

Raising

Grandchildren.

Inside This Issue

Inside This Issue

Inside This Issue

Inside This Issue

Inside This Issue

Inside This Issue

Check Out

Our Website:

www.IdahoNurses.org

Mark your Calendar

for the Big Event!

Idaho Nurses Association 2010 Spring Conference

“Promoting a Healthy Idaho”

April 29-30, 2010

St. Luke’s Regional Medical Center–Boise, Idaho

Presented by:

Idaho Nurses Association • Idaho Public Health Association • Idaho Rural Health Association

With support from:

Idaho Area Health Education Center

Thursday, April 29th

INA House of Delegates Meeting Reception

Friday, April 30th

Spring Conference

Featured Speakers Include:

• Carol Moehrle, RN, Director, Idaho North Central District Health Department

• Carmen Nevarez, MD, MPH, President-elect, American Public Health Association and Public Health

Institute Medical Director and Vice-President of External Relations

Visit http://idahonurses.org for additional

information and to register.

Also see article on page 5.

Contact hours for this continuing nursing education activity have been submitted to the Washington State

Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission

on accreditation. Please contact Marilyn Floyd at the Idaho Nurses Association for more information about

contact hours for this event.

Join INA Today

We need you!

Membership application

http://nursingworld.org/joinana.aspx

CHARTING IDAHO

NURSING HISTORY

Verlene Kaiser

Randall Hudspeth

PhotographsPhotographsofhighresolution(300dpipreferred)maybe

submitted digitally as a separate file in .jpg or .tiff format. Submit a signed photo release form (available online at http://idahonurses.org/displaycommon.cfm?an=1&subarticlenbr=21) and supply a caption and photo credit for each photo. Photo release forms should be submitted by FAX or scanned and emailed in the same manner as manuscripts. Photographs should be emailed in the same manner as manuscripts. All photos become the property of INA.

Publication Selection and RightsArticles will be selected for publication

based upon the topic of interest, adherence to publication deadlines and guidelines, the quality of writing, and peer review by members of the RNI Editorial Board. When there is space for one

article and two of equal interest are under review, preference will be given to INA members.

RNI reserves the right to edit articles to meet style and space limitations. One-time publication rights are reserved by RNI.

AdvertisingProduct, program, promotional or service announcements

are usually considered advertisements. To place an advertisement, please contact our publisher, Arthur L. Davis Publishing Agency, Inc., at sales@ALDpub.com or by phone 800-626-4081.

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Editorial Board: Tracy Flynn, PhD, RN, CNE, Co-EditorBarbara McNeil, PhD, RN-BC, Co-Editor Anna Hissong, MSN, RN-BC, CCCELynne WeilDorothy M. Witmer, EdD, RN

RN Idaho welcomes comments, suggestions and contributions. Articles, editorials and other submissions may be sent directly to the INA office via mail, fax or e-mail. Please call the INA office if you have any questions.

Join INA TodayWe need you!

Membership applicationhttp://nursingworld.org/joinana.aspx

For advertising rates and information, please contactArthurL.DavisPublishingAgency, Inc., 517Washington Street, PO Box 216, Cedar Falls, Iowa50613, (800) 626-4081, sales@aldpub.com. INA and the Arthur L. Davis Publishing Agency, Inc. reserve the right to reject any advertisement. Responsibility for errors in advertising is limited to corrections in the next issue or refund of price of advertisement.

Acceptance of advertising does not imply endorsement or approval by the Idaho Nurses Association of products advertised, the advertisers, or the claims made. Rejection of an advertisement does not imply a product offered for advertising is without merit, or that the manufacturer lacks integrity, or that this association disapproves of the product or its use. INA and the Arthur L. Davis Publishing Agency, Inc. shall not be held liable for any consequences resulting from purchase or use of an advertiser’s product. Articles appearing in this publication express the opinions of the authors; they do not necessarily reflect views of the staff, board, or membership of INA or those of the national or local associations.

RN Idaho is published quarterly every February, May, August and November for the Idaho Nurses Association, a constituent member of the American Nurses Association.

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May, June, July 2013 RN Idaho • Page 3

INA welcomes the following new members who joinedDecember1,2012throughFebruary28,2013:

Katherine AlkireJennifer AmidonDyana BloodTiffany BrackusLihsien CaudillRaeleen DorrKelleen FakenbridgeLisa IsaksenDiana MeyerSandra NadelsonSara PalmaAddie Perry

Kim RemienCynthia RiceLaura RitchieAnnette RobillardMary RobinsonDiana RoskensShelley SinclairEllison ThrallMary WeeksHolly WoodcockAmy Woods

In MemoriamINA is pleased to honor deceased registered nurses

who graduated from Idaho nursing programs and/orserved in Idaho during their nursing careers. Included, when known or when space allows, will be the date when deceased and the Idaho nursing program. The names will be submitted to the American Nurses Association for inclusion in a memoriam held in conjunction with the Membership Assembly. Please enable the list’s inclusiveness by submitting information to ed@idahonurses.org

Arkoosh (Ledbetter), Bonnie Edith, 2/16/2013.Saint Alphonsus School of Nursing, Boise, ID. Bonnie had a sense of justice, dedication to her community, a love for learning, and a continued commitment to her profession through her Registered Nurse daughter.

Belveal-Nicholson, Leila F., 02/27/2013. SaintAlphonsus School of Nursing, Boise, ID. and Idaho State University, Pocatello, ID. Leila was the 10thCertified Registered Nurse Practitioner in Idaho. She spent 15 years with the Idaho Department ofCorrections, responsible for oversight of nursing care.

Hilvers-Bristol, Eleanor “Ellie” Jean, 2/20/2013.University of California MSN Program; Captain and

flight nurse for the U.S. Air Force; administrator and educator at St. Luke’s Medical Center, Boise, ID. Ellie was passionate about education, caring for others and seeking adventure.

Howard, Anne Stella (Kalange), 12/14/2012. Shemodeled the quote, “It is more blessed to give than to receive.”

Kraft, Lois Marie,01/08/2013.Hercareerspanned42years,servingthepoorestofthepoor.

Lane, Renae E.,01/15/2013.BoiseStateUniversity.She loved nursing and all the people she worked with in her life.

Shannon, Betty Marie, 01/29/2013.OregonSchoolof Nursing, Portland, OR. Betty worked as the charge nurse for the Ontario Breast Cancer Detection Center from1991to2001andhadacompassionforothers.

Vahey, JoAnn T., 03/23/2013. St. Agnes HospitalSchool of Nursing, Philadelphia, PA. and Columbia University, New York. Past (1973) Chair of theDept. of Nursing at Boise State University. JoAnn championed and led baccalaureate education in Idaho, continuing education for R.N.s and accreditation standards-work.

Page 4 • RN Idaho May, June, July 2013

by Mary Kay DiGrazia, R.N., B.S.N.Saint Alphonsus Medical Group

Federal Way Family Practice, Boise, Idahomarydigr@sarmc.org

Howdoesanursing journeyof36yearsandcountingstart? I remember a vague memory as an eight year old in the Emergency Department (ED) after a bike accident. I was told, “This won’t hurt;” but it really did hurt. Then, starting in grade school, I developed a fascination and curiosity about learning the workings of the human body. While a busy high school student, I began my volunteer work at the hospital. All of these experiences contributed to my journey as a registered nurse.

Surprises During four years of academically challenging work

in nursing school, my decision to become a nurse never wavered. My first nursing position on a general surgical unit stimulated more clinical experiences in the first nine months of work than I encountered in four years at the university! As a new nurse, my eyes were wide open; everyday was a learning adventure. I recall that during this first nursing position and during my early years in nursing, some of my very BEST teachers were the L.P.Ns that worked side by side with me. Their care at the bedside was remarkable. Continuing to work in the general surgical unit as charge nurse, over time, I realized that I missed the bedside patient care. This realization led me to my next adventure.

Wanting a critical care nursing experience but not enthusiastic about lots of machines found in an Intensive Care Unit (ICU), my career path choice was taking a nursing position in the ED. During those years as nurse in the ED, we learned everything “on the job” and again I benefitted from having great teachers. Dealing with cardiac, orthopedics, medical and trauma care, I was challenged hourly beyond my wildest dreams. Patient education took on a new meaning; it had to be quick and concise. Our ED team was tight-knit and extended out into the community including the police, paramedics and firemen.Duringmy 20 years in the ED, the settingmorphed from five rooms where the physician could sleep most nights to a Level II trauma center with Life Flight outreach. I experienced caring for the “best and worst” of humanity. After two decades in one place, I realized it was time to move on.

As I began a search of job listings for registered nurses, the item, “RN OIPPSCU,” caught my eye. Not really knowing what that acronym meant (Orthopedic Institute Pre and Post-op and PACU care), I went for a very brief interview and was hooked. I knew this was the place I wanted to work; it seemed to be a type of controlled critical care chaos! Working on a team with years of experience was a treat bringing new skills and a sharing ofknowledge.Sixofusontheteamturnedage50duringthe same year and we had over 100 years of nursingexperience. Again, my role in educating my patients and their families about what to expect before and after surgery was a highlight; I wanted to ensure their surgical path was smooth and less frightening.

Challenges After decades of critical care nursing, I then

experienced the physical, mental and emotional strains from this type of work and realized that nurses don’t always know how to take care of themselves. My decision to step away from a career I loved in order to take time to heal was one of the most difficult decisions I have ever made. In dealing with the trauma of nursing, I was not making the healthiest choices for myself and had to take action to change.

New Opportunities When one door closes, it seems that another one opens!

As I focused on caring for myself, I continued to learn and began teaching surgical and recovery room nurses how to document in the electronic health record (EHR). This new role stretched my brain and stimulated thinking outside of the box. My thought was that I was supposed

to be retired from nursing by the time computers entered nursing care. In fact, initially, I didn’t know a right mouse click from a left one. But I found myself teaching use of the computer and loving it. When the nurses achieved skill and competency, my work was complete and I looked toward a new direction for my nursing journey.

A position in clinic nursing in a family practice setting sounded interesting and I believed that this was where most OLD nurses finished careers. Boy was I mistaken! Instead, this is my current position and I am more energized and busier than ever. Our clinic has three physicians and I work alongside our medical assistants as the onlyR.N. Every day I feel engaged in at least 50different jobs from patient care, triage and teaching to quality control, ordering and stocking. I love taking care of our patients from cradle to grave and establishing an ongoing relationship with them, instead of the episodic care I provided in previous positions. I’ve become attached to our patients and look forward to seeing them on a regular basis.

This is no ordinary family practice clinic in our community. Our waiting room sounds like an international airport as we hear the voices of refugee families and focus our time on their care needs.About 65% of our patientsare from all over the world and our language list has expanded to 30 or more different languages.We have alarge group of interpreters and a language line phone.

Many of our clients have been in refugee camps all of their lives, have received only minimal health care and suffer from post-traumatic stress disorder (PTSD). From our interactions, I have learned about different cultures and their diverse needs. Every aspect of their medical care presents a challenge: the language, transportation to the clinic, limited access to care, and partial understanding of health treatment and care. Realizing these barriers, our physicians make home visits and we have a Curbside Care van to take us to the refugee community housing to see our families. We have become experts on immunizations. As a registered nurse, I see the many rewards of this work: watching the refugee families become healthier, integrating their lives into the community, and seeing how quickly the kids learn English and are going to school.

As I reflect back on my nursing journey, I realize that going on a medical mission was always in the back of my mind and propelling me forward. I have wanted to give back through my nursing but the opportunity never presented itself until now. My mission is in my own backyard and I am more blessed and grateful for having followed the path to this place and to be able to provide service to a special group of people.

I Became a Nurse Because...Reflections on a Nursing Journey: Surprises, Challenges and New Opportunities

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May, June, July 2013 RN Idaho • Page 5

by Margaret Wainwright Henbest, RN, MSN, CPNP, Executive Director

Idaho Alliance of Leaders in Nursing – Nurse Leaders of Idaho

The Idaho Nursing Action Coalition (INAC) reports good news and major progress. The INAC has been awarded grant funding which will accelerate work on its three priorities and is announcing its third annual IdahoWorking Summit to be held June 13 in Boise. Inaddition, members of the Coalition recently attended a working summit of the national Campaign for Action in Washington, DC.

Grant Awarded to INACThe Robert Wood Johnson Foundation (RWJF),

formally announced on March 19th that the INAC willbe one of only 20 states to be part of a new $3millioninitiative, the Future of Nursing State Implementation Program. The program is designed to help states prepare the nursing profession to address our nation’s most pressing health care challenges: access, quality, and cost. The Center to Champion Nursing in America (CCNA), an initiative of the American Association of Retired Persons (AARP), the AARP Foundation and the RWJF serves as the national program office for the Future of Nursing State Implementation Program. According to Susan B. Hassmiller, PhD, RN, FAAN, the RWJF senior adviser for nursing and director of the Future of Nursing: Campaign for Action, “This grant is designed to spur progress in Idaho, which already is doing impressive work to transform nursing education, practice, and leadership. The RWJF is committed to helping states build a more highly educated, diverse nursing workforce that will improve health outcomes for patients, families, and communities.”

The initiative provides two-year grants of up to $150,000 to 20 state-based Action Coalitions thathave developed or made substantial progress toward implementing the Institute of Medicine’s (IOM) recommendations. The grant also calls for states to obtain matching funds. Steve Millard, president of the Idaho Hospital Association and co-lead of INAC noted, “Our focus on meaningful outcomes that will truly transform health care in Idaho was a key factor in being selected. We are part of a powerful movement working to shape the future of health care for all Americans.” INAC is grateful for this support.

Through the grant, INAC will strengthen resources statewide for nurses transitioning for the first time into the nursing profession, as well as nurses who are transitioning

Idaho Nursing Action Coalition: A Grant Awarded & the Upcoming Idaho Working Summit

into nursing leadership and nursing educator roles. These efforts are designed to retain nurses in the profession, in order to reduce nursing shortages in the future. At a time when Idahoans will have increased access to insurance coverage, but perhaps not to providers who can meet their health care needs, INAC will also research opportunities to improve their access to Advanced Practice Registered Nurse (APRN) care and service.

The Working Summit of the National Campaign for Action

With all 50 state action coalition representatives,Margaret Henbest and Sandie Nadelson recently attended a working summit of the national Campaign for Action (CFA)heldinWashington,DC,onFebruary27ththroughMarch1st.Bothparticipantswereinformedandenergizedby the opportunity to network with coalition colleagues. During the two days of the summit, participants were challenged to examine the goals and action steps that were the focus of their state’s efforts and to identify strategies that would ensure achievement of goals. It became clear that successful transformation often requires that one stop doing something.

The highlight of this national summit had to be the generous opportunities to formally network with colleagues on specific topics. These small breakouts, identified by the attendees themselves, were called “unconferencing sessions” and were very effective in sharing experience, gaining insight and creating connections. Participants got a chance to share their big ideas for the CFA itself. Suggestions included implementing a national media campaign with a high profile spokesperson, encouraging nurses to run for office, pushing for a federal solution to remove barriers to practice and care, and increasing scholarship and research opportunities.

INAC’s Working Summit In Boise, Idaho on June 13, 2013 – Mark Your Calendars

On June 13th, 2013 in Boise, INAC will hold itsthird annual working summit. Drawing upon the work outlined in the Idaho State Implementation Project (SIP) grant entitled, “Advancing Nursing in Idaho to Improve Health,” and the work done at the recent national Summit, attendees of the INAC Working Summit will participate in updating INAC priorities and help to shape the work to be accomplished over the next year. Details of the upcoming INAC Working Summit will be available through the Nurse Leaders of Idaho Website: www.nurseleaders.org or bycontactingMargaretHenbestat208-367-1171.

Member Spotlight continued from page 1

continue my nursing education. I love the flexibility and endless opportunities nursing has to offer, but most of all I love being in such a rewarding profession. I am still fairly new to the profession of nursing, but my experience thus far has been in family practice and sub-acute nursing.

Currently I work at St. Alphonsus Regional Medical Center in Boise in the rehabilitation department where I work with patients experiencing stroke, spinal cord injuries, traumatic brain injuries, or rehabilitating from various surgeries and not quite ready to discharge home.

In what ways has membership in INA been valuable to you?

I first joined the INA as the activity coordinator for District31.Morerecently,IwaselectedtoserveasPresidentof my district. Membership in the INA has been an integral part of my nursing career. It has allowed me to meet other nursing professionals in various areas, provided me with resources relative to my field, and has given me the opportunity to grow personally and professionally.

Why would you encourage other RNs to join INA?I highly encourage all RNs to join this professional

nursing association. The INA is a wonderful way to get to know nurses all over the state of Idaho and to network within the field. The quarterly newsletter, RN Idaho, is packed with great information and encourages all members to submit articles and get involved. By joining the INA, nurses can take an active step in advocating for the nursing profession, having a voice, and helping to bring about change.

Page 6 • RN Idaho May, June, July 2013

by Sandra Evans, M.A.Ed., R.N., Idaho Board of Nursing Executive Director

sandra.evans@ibn.idaho.gov

As you read this update from the Idaho Board of Nursing, the 1st regular session of the 62nd IdahoLegislature will have adjourned and the Administrative Rules of the Board pending before the legislature will have become final. Implementation of these rules, coupled with changes to the Idaho Nurse Practice Act enacted a year agothatgointoeffectonJuly1,2013,willtransitionIdahoto one of a small number of states that have achieved full enactment of all provisions of the national Consensus Model for the Regulation of Advanced Practice Registered Nurses (APRNs).

APRN Consensus Model in IdahoOnJuly1,2013,advancedpracticenursesinIdahowill

be licensed in four distinct roles designated by their new protected titles:

• APRN,CNM(CertifiedNurseMidwife)• APRN,CNP(CertifiedNursePractitioner)• APRN,CNS(ClinicalNurseSpecialist)• APRN,CRNA(CertifiedRegisteredNurse

Anesthetist)

Proper credentialing for APRNs in Idaho after July 1, 2013, will be, for example, Jane Doe, DNP, APRN,CNP. Even though Idaho APRNs are currently able to practice independently, when the new rules become final, the APRNs will be clearly licensed to practice as “independentpractitioners”(IDAPA23.01.01.280.02).

Consistent with the APRN Consensus Model, beginning 1/01/16, applicants seeking initial APRNlicensure will be required to provide evidence of graduate or post-graduate-level education in at least one of the above APRN roles and at least one population focus, to include:

• Family/individualacrossthelifespan• Adult-gerontology• Women’shealth/gender-related• Neonatal• Pediatrics• Psychiatric-mentalhealth

For APRNs who complete advanced practice education prior to 1/01/16, grandfathering provisionswill allow for

licensure and practice in Idaho consistent with criteria currently in place. Other jurisdictions that have achieved full enactment of the APRN Consensus Model include Montana, New Mexico, North Dakota, the Northern Marianna Islands, Utah and Vermont.

Board of Nursing BusinessSince the last ‘update from the Board’, the nine

members of the Idaho Board of Nursing continued their usual business with meetings on January 31 – February1,2013andonMarch1,2013 (by teleconference)duringwhich they conducted business related to their mission to protect the public health, safety and welfare. Board members, Dr. Susan Odom, R.N., Moscow, Chair; Vicki Allen, R.N., Pocatello, Vice Chair; Janine Baxter, R.N., Post Falls; Whitney (Hausske) Hunter, Boise, consumer member; Jill Howell, R.N., Jerome; Christopher Jenkins, R.N., Homedale; Carrie Nutsch, L.P.N., Jerome; Rebecca Reese, L.P.N., Coeur d’Alene; and Clay Sanders, CRNA, Boise, considered business related to their strategic goals which are to:

• License/certifyqualifiedpersonsforpractice;• Determine,communicateandenforcestandardsof

conduct and scope and standards of practice;• ReceiveandinvestigateallegedviolationsoftheAct/

rule and initiate disciplinary actions and alternatives to discipline;

• Determine,communicateandenforcestandardsfor educational programs preparing individuals for practice at all levels;

• Cultivateagovernanceframeworkandculturethatsustain Board relevance and support accomplishment of vision, mission and goals;

• FostercommunicationbetweentheBoard,itscolleagues, internal and external stakeholders and the public; and

• Supportorganizationalinfrastructurenecessarytoaccomplish the vision, mission and goals.

During the January-February meeting, Board members reviewed reports and outcomes of recent meetings attended; reviewed nursing education program changes and approved new and continuing educational programs; took disciplinary action in response to substantiated violations of the Idaho Nursing Practice Act and Administrative Rules of the Board; considered reports and recommendations from Board-appointed committees; appointed a new committee member to the APRN Advisory Committee; adopted their foundational statements on Communication and Data Sharing; affirmed existing Board policies; approved newly developed policies; and recommended next steps related to several key initiatives currently in progress.

Board Appointment to the APRN Advisory CommitteeThe Board appointed Barbara Blasch, Boise, as the

consumer member to the Advanced Practice Registered Nursing (APRN) Advisory Committee to complete an unexpired three-year term. She joins continuing members Cathy Arvidson, APRN-CNP, Pocatello, Chair; Richard Maggard, RPh, Vice-Chair, Boise; Betty Brosh-Schoenecker, APRN-CRNA, Boise; Keith Davis, MD, Shoshone; Allie Gooding, APRN-CNS, Boise; Phillip Masser, MD, Boise; Charlotte Salinas, APRN-CNM, Boise; and Carmen Stolte, APRN-CNP, Lewiston.

Nursing Education Program Actions and Other Board Business

The Board heard updates on the respective nursing education programs from Northwest Nazarene University, Idaho State University and Stevens-Henager College and granted conditional full approval to the nursing assistant program administered by Stevens-Henager College.

At the January-February meeting, the Board took formal action to revoke the licenses of two R.N.s and two L.P.N.s; and extended the time of revocation of an R.N. license revoked in November, 2012, as a result offindings that the nurses had violated provisions of the Idaho Nursing Practice Act and/or Administrative Rulesof the Board. In addition, the Board approved one non-routine application for R.N. licensure by examination and approved one application for reinstatement of R.N. licensure following previous discipline. The Board also

granted a request for an extension of time on a contested case pending before the Board.

OnMarch1,2013,theBoardmetbyteleconferenceforthe conduct of limited business which included a hearing to entertain oral arguments regarding Board staff and attorney fees related to a case pending before the Board. In addition, the Board took action to revoke one L.P.N. and three R.N. licenses, to suspend one L.P.N. and two R.N. licenses, and to place one R.N. license on probation with conditions as a result of substantiated findings that the nurses had violated provisions of the Idaho Nursing PracticeActand/orAdministrativeRulesoftheBoard.

Board Members and Staff Activities/AnnouncementsMembers and staff of the Idaho Board are actively

involved on the national level in shaping the future of nursing regulation through their participation in activities of the National Council of State Boards of Nursing (NCSBN) as time and interest allow. The Idaho Board has been consistently represented through NCSBN members and chairs of standing and ad hoc committees, as members of focus groups, as content experts on special project task forces and as award and honor recipients. Currently representing Idaho in NCSBN initiatives are:

• VickiAllen,member,CommitmenttoOngoingRegulatory Excellence (CORE®) Committee

• JanineBaxter,member,NCLEX®ExaminationCommittee

• JanetEdmonds,member,TaxonomyofError,Root Cause Analysis and Practice Responsibility (TERCAP®) Workgroup

• SandyEvans,member,Journal of Nursing Regulation Editorial Advisory Board; APRN Member-at-Large, Nurse Licensure Compact Administrators Executive Committee

• WhitneyHunter,member,DistanceLearningEducation Committee

• SusanOdom,Chair,InstituteofRegulatoryExcellence (IRE) Committee

• RebeccaReese,member,NCLEX®ItemReviewSubcommittee

In2013,therehavebeenchangesandtransitionsfortheIdaho Board with the departure of three long-time veteran staff members and the addition of several new staff. New to the Board staff are Deborah Woolery, Management Assistant; Pamela Rebolo, Office Specialist for Licensure by Examination; Diana Anderson, formerly the Board’s Customer Service Specialist, Office Specialist for Licensure by Endorsement and Reinstatement; and Cassie Watson,CustomerServiceSpecialist/Receptionist.

On April 1, 2013, the Board welcomed AnnabethElliott, R.N., MSN, BBA as the new Compliance Manager. In this role, Ms. Elliott is responsible for administration of the Board’s two alternative to discipline programs: the Program for Recovering Nurses (PRN) and the Practice Remediation Program (PRP), which is soon to be developed and implemented. Annabeth has served as the Sexually Transmitted Disease (STD) Program Coordinator for the Idaho Department of Health and Welfare, Division of Health, Bureau of Clinical and Preventive Services for the past nine years and is adjunct clinical faculty at Boise State University. Prior to her employment with the state, she was employed by St. Luke’s Regional Medical Center, Boise, in various positions.

Judy Nagel, Associate Director of the Board with responsibility for Practice and Education since 2005,has announced that she will be leaving employment with the Board in May to begin enjoying a well-deserved retirement. Judy’s expertise and vision for the future of the regulation of nursing practice and education in Idaho will be missed. All of you who know and have worked with Judy, please join the Board in wishing her well as she embarks on this next exciting life chapter.

Future Board MeetingsAs always, the public is invited to attend any part or

all of each scheduled Board meeting. The Open Forum held on the second morning of each meeting provides an opportunity for dialogue with the Board on topics of interestand/orconcern.Futuremeetingsof theBoardarescheduledforMay2-3andJuly18-19,2013,atlocationstobe announced.

Update on Activities of the Idaho Board of Nursing

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May, June, July 2013 RN Idaho • Page 7

by Verlene Kaiser, BSN, APRN-FNP and Randall Hudspeth, MS, APRN-CNS/CNP

Authors of the book (2009) entitled: Charting Idaho Nursing History. ISBN-13:

978-0984374977

In the past, nurses who have made significant career contributions to Idaho nursing have been recognized initially by the Idaho Nurses Association (INA) and also later by the Idaho Alliance of Leaders in Nursing (IALN). More recently, nurses have been recognized through the March of Dimes Nurse of the Year (MOD-NOTY) award which is presented at an annualdinner eventheld each fall inBoise. InNovember, 2012, theIdaho March of Dimes (MOD) announced that they would not sponsor the annual “Nurse of the Year” event, at least for the immediate future, due to the complexities and cost of sponsoring such an event.

The annual MOD-NOTY dinner served two purposes. It was a major fund raiser for the very worthwhile causes supported by the MOD and at the same time it brought Idahoans together to honor nurses whose careers had benefitted the people of Idaho and whose work had become legendary in their communities and throughout the state. It also recognized currently practicing nurses who were sponsored by their employers for their own good work.

This announcement brought a flood of memories to the authors because of our role in co-chairing thenursing legend identificationprocess since2001.Prior to theMarchof Dimes Nurse of the Year event, there was the INA’s Living Legend Nurse of the Year recognition luncheon at the INA annual meeting. Nurses had been sporadically honored by both the INA and the now inactive Licensed Practical Nurses of Idaho Association (inactivesince2000)attheirrespectivestateconventions,atlocalcommunityevents,orsometimes in conjunction with other organizations for many years.

In early 2000, the INA discussed recognizing retired nurses who had contributedgreatly to nursing practice in Idaho. The INA Board, at the time, felt that nurses were losing their sense of history and not recognizing what was being contributed by nurses for the good of all. The INA Board of Directors approved honoring those “living” (as opposed to those that had passed) retired nurses (does a nurse actually retire?) from throughout Idaho and from all practice settings at the INA annual convention. And because of the knowledge and involvement in writing Idaho’s nursing history, the authors were asked to chair the committee that would organize the INA Living Legend Nurse Recognition.

A committee examined ANA’s Hall of Fame and Distinguished Nurse Recognition criteria and evaluated other state nurses associations’ criteria for nurse honoring activities. The INA board approved the “Living Nurse Legend” criteria:

(1) The nomineemust have demonstrated leadership that affected health and/orsocial history of Idaho through sustained, lifelong contributions in or to nursing practice, education, administration, research, economics or literature. (2)Thenomineemusthavebeenpreparedinaformalnursingprogram.(3)ThenomineemusthaveworkedinorrepresentedthestateofIdahoandhavebeen an INA member at sometime during their career. (4)Theachievementsofthenomineemusthaveenduringvaluetonursingbeyondthe nominee’s lifetime.

Once the quest to identify “Living Legend Nurses” began, the authors immediately encountered the humbleness of nurses who did not seek or really want recognition of any contributions that they had made. Just as quickly, the authors realized that extra effort had to be made to ensure such recognition would be geographically representative of the state and the various practice settings.

At the 2002 INAConvention, the following nurseswere honored as the first groupof INA Distinguished Nurses: Florence Miles, Beth Carpenter, Bee Biggs-Jarrell, Jody DeMeyer, Louise Haney, Rosie Acton, Helen Shewmaker, Grace Jacobson, and Alice Bevans.The2003honoreeswereAlyceA.Sato,GraceE.Smith,MaxineMartin,MardoEaton, Marie Osborn, and Claire Wetherell.

In 2003, the INA contacted Verlene Kaiser to consider a request from the StateChapter of the Idaho MOD to participate in developing a Nurse Legend recognition award to be added to their new Nurse of the Year event. The New Mexico MOD Chapter had such an event in place which was a nationally recognized success. The Nurse Legend

Changes in the Nurse Legend Recognition Program activity was not to be an open call for nominations but a more targeted approach with nominations from a broad base of citizens in the community. In other words the nurse legend nominees’ contributions are a living tribute to their commitment and dedication to nursing and to their community service. At this same time, INA’s interest in continuing the Living Nurse Legend recognition began to wane and this opportunity provided a mechanism to continue recognizing nurses’ contributions which was gratefully accepted.

The criteria developed for the Nurse Legend recognition were based on INA’s Living Nurse Legend and applicable national guidelines. The nominee (1) must have workedroughly 20years of nursing practice ormore in Idaho andbe basically “retired” fromactive nursing (knowing that there is a fuzzy line here) in order that these nominees would not be nominated for the Nurse of the Year recognition which is focused on currentlyemployednurses,(2)hasgonebeyondher/his“assigned”job(whatoneispaidtodo)andhasdemonstrated leadership thataffected thehealthand/orsocialhistoryofIdahothroughlifelongcontributionsinortonursingpractice,(3)achievementsmustbearticulated and must have enduring value to nursing which are a living tribute to their commitment and dedication to nursing and to their community and or family, (4) hasgiven permission for the recognition and is willing to participate in the event (not of paramount importance).

The first MOD-NOTY Nurse Legend recognition began in 2004 and continuedthrough 2012. The following are theNursing Legends during this timewho representnorthern, southeastern and southwestern Idaho.

During the ten plus years of recognizing nurses for career-long contributions, patterns of achievement of these nurses emerged: innovative nurses overcame barriers, expanded the boundaries of scope of practice, guided the progress of the profession, expanded formal education opportunities, and brought recognition to Idaho on a national level. All of these dedicated and committed nurses had one common trait—none sought any self-recognition and most felt that their own contributions were not worth mentioning. Many other nurses deserved to be recognized, but some refused while others went unidentified. Recognizing and saying thank you to some of the early nurse leaders is a treasured opportunity.

A great deal of gratitude is extended to the March of Dimes for the 10 yearsof opportunity they provided to Idaho nursing. The March of Dimes facilitated a mechanism for the honoring of nurse legends and others at the annual MOD-NOTY dinner. Nurses will continue to make significant contributions to the profession and to improve the healthcare of Idaho citizens. Some of today’s nurses will be tomorrow’s legends and the challenge will be to continue seeking ways to identify and recognize them.

MOD-NOTY Nurse Legend Recipients 2004-20122004:DorothyWitmer,JaneCurtis,WandaEvans,DeltaHolloway

2005:ElaineHoggan,KayKindig,PhyllisSheridan

2006:AliceBevans,AlyceSato,JoAnnVahey

2007:LaReeMaeser,MaxineMartin,BonnieSumter

2008:MarieBlanchard,PatsySorenson,AdaSmith

2009:MarieEschen,LorraineGruner,GraceJacobson

2010:MarilynRaeBeech,HelenThomasShewmaker,RosemaryFranaShaber

2011:BeeBiggs-Jarrell,DanKnight,GaryThietten

2012:PatriciaTaylor,JacquelineMcRoberts,SisterMaryAgnesReichlin

Page 8 • RN Idaho May, June, July 2013

Jill Koning, R.N., MSN student, Dept. of Nursing, Gonzaga University, Spokane, WA

E-mail: jkoning@zagmail.gonzaga.edu The author reports no potential conflicts of interest.

Research QuestionIn women beginning the second stage of labor

(Population), how does delayed pushing (Intervention) compared to early pushing (Comparison) affect the use of vacuum and forceps (Outcome) within three hours

after the initiation of pushing (Timeframe)?

Search Strategy Databases searched: The following databases were

systematically searched: Medline/PubMed, CINAHL, andthe Cochrane Library.

Search terms. “Delayed pushing;” “Second stage;” “pushing;” “labor management;” “forceps”

Study selection criteria. The following inclusion criteria were used to determine which studies would be acceptable for further review and consideration as “keeper” studies for the evidence summary.

Population: Healthy nulliparous women with a term (>38weeks) singleton uncomplicated pregnancy and laborcourse. Epidural analgesia present and fetal well-being at the time of pushing is noted.

Interventions:Delayedpushing(usuallydefinedas1.5-3hours) at the beginning of the second stage of labor

Comparisons: Immediate pushing in the second stage of labor

Outcomes: Spontaneous vaginal delivery, operative vaginal delivery, or cesarean section

Time Factors: Three hours after the initiation of pushing

Results of the ReviewTypes of Studies. Of the seven keeper studies, three

were systematic reviews; one of which statistically combined study data using a meta-analysis technique. The remaining four studies were randomized controlled trials (RCTs). The author identified patterns and themes across these seven studies in preparation for the evidence summary.

Study Quality and/or Sources of Bias. Each study was then critically appraised to assess validity, reliability, applicability, and statistical significance. The overall grade for the strength of this body of evidence was rated as between Grade Level I (Good/Strong) and GradeLevel II (Fair), based upon five elements (overall quality, consistency, quantity, clinical impact, and generalizability of the studies) proposed by the Institute of Clinical Systems Improvement(theAmericanDieteticAssociation,2011).

Summary of Individual Studies

Study 1. Brancato, Church, and Stone (2008) studied2,827 healthy pregnant women from seven randomizedcontrol trials and found that women who delayed pushing for up to two hours once completely dilated significantly increased their risk of having a spontaneous vaginal birth (RR: 1.08;CI: 1.01-1.15), had a 23% significant decreasedriskofhavinganinstrumentaldelivery(RR:0.77;CI:0.71-0.85;p<0.0001),andexperiencedastatisticallysignificant

lower mean time spent pushing during second stage (mean difference:-0.19hours;95%CI:-0.27to-0.12).Thisstudyonly measured delayed pushing for up to two hours so the effectsofdelayedpushingforgreaterthan2hourscannotbedetermined. Also, there was no consistent pushing method across the studies. Epidural protocols were not described and variations in the epidural rate/type could potentiallyaffect the results. Also, the pooled effect from the seven RCTs was highly weighted by one study by Fraser et al.

Study 2. Fraser, Marcoux, Krauss, Douglas, Goulet and Bouvlain(2000)studied1862healthypregnantwomenandfound that women who delayed pushing for greater than or equal to two hours once completely dilated experienced a significantdecreaseindifficultdeliveries(RR0.79;95%CI0.66to0.95).Morespecificallythesewomenexperiencedasignificantdecreaseinmidpelvicprocedures(RR0.72;95%CI0.55to0.93),andanincreasedrisk(butnon-significant)for spontaneous vaginal delivery (RR 1.09 95% CI 1.00to1.18).Thisstudydidshowadecreaseinrateofdifficultdelivery; however, it was not without a likelihood of increased abnormal umbilical cord pH. More research needs to be done to see if the benefits of utilizing delayed pushing outweigh the risks of potential fetal compromise.

Study 3. Gillesby et al. (2010) studied 77 healthypregnant women and found that women who delayed pushing for up to two hours once completely dilated spent on average a 27% decrease in time actively pushing (68minutes in active pushing +/- 46; F(1,71) = 4.46 p=0.04).This study only evaluated nulliparous women and this study did not control the positions used by the participants during the second stage of labor or techniques used during active pushing which can affect the progress of fetal descent.

Study 4.Kellyetal.(2010)studied44healthypregnantwomenandfoundthatwomenwhodelayedpushingfor90minutes once completely dilated decreased the length of timeactivelypushing(min)(38.9+/-6.9t1,42=3.40p=.0015). This study only evaluated nulliparous women anddespite computer randomization the two treatment groups were not equal.

Study 5. Roberts, Torvaldsen, Cameron, and Olive (2004) studied 2953 healthy pregnant women and foundthat women who delayed pushing for at least 60 minutesand up to three hours experienced a significant decrease in rotational or mid-pelvic instrumental deliveries (RR 0.69;95%CI0.55 to0.87)anda significant increase invaginalbirths (RR1.22; 95%CI 1.05 to 1.42).Despite a decreasein mid-pelvic instrumental deliveries and an increased rate of spontaneous vaginal births, this study showed a clinically significant increase in the duration of second stage (58minutes) when laboring down is utilized. This results in increased time spent in a staff-intensive delivery suite.

Study 6.Simpsonand James (2005) studied45healthypregnant women. They report finding that delayed pushing decreased the rate of fetal desaturation (Mean=4.6; SD=8.5F (1,43)=12.24p=.001)and thatwomendecreased thetime spent activelypushing in the second stage (Mean=59minutes; SD 25.4 F(1,43)=10.4 p=.002). This study onlyapplies to nulliparous women with reassuring Fetal Heart Tone (FHT) tracings.

Study 7.Tuuli,Frey,Odibo,Macones,andCahill(2012)conducted a systematic review/meta-analysis and pooledresults from 12 RCTs (3115 healthy pregnant women).In these 12 studies, a total of 1584 women (51%) useddelayed pushing and 1531 (49%) pushed immediately.When pooling results from all 12 studies, the researchersfound that delayed pushing significantly increased the rate of spontaneous vaginal births (RR 1.09 95% CI 1.03 to1.15). Delayed pushing also decreased the mean time foractively pushing (WMD -21.98 minutes; 95% CI -31.29to -12.68). However, there was high heterogeneity amongthe 12 RCTs including variations in the duration of thedelay before pushing and the inclusion of both primiparous and multiparous women. When the high quality studies were analyzed separately and the low quality studies eliminated, the pooled effect for the delay of pushing did not significantly increase spontaneous vaginal delivery rates. The researchers recommended more clinical trials

with longer follow-up to determine how maternal pelvic morbidity is affected by delayed or immediate pushing.

ConclusionsOverall,delayedpushinghadavarietyofmaternal/fetal

outcomes from the seven keeper studies. Two major themes emerged: duration of the second stage of labor and the route of delivery.

In five of these seven studies, the most common emerging outcome from delayed pushing was a lower mean time (in minutes) actively pushing in the second stage after passive descent. One study did not measure this outcome; the systematic review/meta-analysis reported a neutraleffect.

Delayed pushing and second stage of labor. Across all seven studies, five studies examined the average time of the second stage of labor; findings were mixed. One of the studies found a decrease in average time of the second stage when delayed pushing was implemented. However, three studies found an increase in the average duration of the second stage when delayed pushing was utilized. One study found no effect.

Effect on route of delivery. Three out of seven studies found an increased rate of spontaneous vaginal births after delayed pushing. The other four studies did not measure this outcome. Two studies found that there was a decrease in operative vaginal births when delayed pushing was utilized and one study found no effect. Four studies did not specifically measure this outcome. More specifically, two studies examined the different types of operative vaginal births and found that there was a decrease in mid-pelvic procedures when delayed pushing was utilized. Two studies found no effect on low pelvic procedures. One study measured perineal third degree lacerations with delayed pushing and another study measured the rate of episiotomies. For both studies there was a neutral effect. There was also a neutral effect on second stage cesarean sections when delayed pushing was utilized.

Translation of Evidence into Practice Based upon this evidence evaluation and summary, more

research is needed in order to support an evidence-based practice change of delayed pushing to decrease the rate of assisted deliveries. Fortunately, as long as heightened fetal surveillance is executed, delayed pushing does not harm the mother or the fetus. Further research is warranted in part because assisted deliveries have a great potential to result in maternal and fetal morbidity, and at times, fetal mortality. It will be crucial to have multidisciplinary support and compliance in order to fully explore this topic and, in return, obtain the appropriate evidence.

ReferencesAmerican Dietetic Association. (2011). 2011 Academy of

Nutrition and Dietetics evidence analysis manual, page 70.Retrieved from http://www.adaevidencelibrary.com/topic.cfm?cat=1155&auth=1.

Brancato, R., Church, S., & Stone, P. (2008). A meta-analysis of passive descent versus immediate pushing in nulliparous women with epidural analgesia in the second stage of labor. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing,37(1),4-12.

Fraser, W., Marcoux, S., Krauss, I., Douglas,J. Goulet, C., and Bouvlain. M. (2000). Multicenter, randomized, controlledtrial of delayed pushing for nulliparous women in the second stage of labor with continuous epidural analgesia. American Journal of Obstetrics and Gynecology,182(5),1165-1172.

Gillesby, E., Burns, S., Dempsey, A., Kirby, S., Mogensen, K.,Naylor,K.,& ...Whelan,B. (2010).Comparisonofdelayedversus immediate pushing during second stage of labor for nulliparous women with epidural anesthesia. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing, 39(6),635-64.

Kelly, M., Johnson, E., Lee, V., Massey, L, Purser, D., Ring, K.,&…Wood,D.(2010).Delayedversusimmediatepushinginsecond stage of labor. The American Journal of Maternal/Child Nursing, 35(2).81-88.

Roberts, C., Torvaldsen, S., Cameron, C., and Olive, E. (2004). Delayed versus early pushing in women with epiduralanalgesia: A systematic review and meta-analysis. BJOB: An International Journal of Obstetrics & Gynaecology, 111(12),1333-1340.

Simpson, K., & James, D. (2005). Effects of immediateversus delayed pushing during second-stage labor on fetal well-being: A randomized control trial. Nursing Research, 54(3),149-157.

Tuuli, M., Frey,H., Odibo, A., Macones, G., Cahill, A., (2012).Immediatecomparedwithdelayedpushinginthesecondstage of labor: A systematic review and meta-analysis. Obstetrics and Gynecology, 120(3),660-668.

How Does Delayed Versus Early Pushing Affect Vacuum and Forceps-Assisted Deliveries?

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May, June, July 2013 RN Idaho • Page 9

by Linda Zvonar, R.N., FNP Track, MSN Program, Gonzaga University, Spokane, WA

E-mail: lzvonar@zagmail.gonzaga.edu

The author reports no potential conflicts of interest.

IntroductionThis evidence review sought to identify which insulin

therapy, continuous subcutaneous insulin infusion or multiple daily injections, achieved better glycemic control in insulin-dependent adult patients. This inquiry sought to answer the following research question: In adult patients with insulin-dependent diabetes mellitus, how does continuous subcutaneous insulin infusion (CSII) compared to multiple daily injections (MDI) affect glycemic control over at least three months?

Search StrategyDatabases searched: Several electronic databases were

utilizedforthisresearch:Medline/PubMed,CINAHL,andthe Cochrane Library.

Search terms included: “CSII;” “MDI;” “A1C

;” “insulin infusion;” “glyc* control;” “review.”

Study selection criteria. The following pre-specified eligibility criteria were used to select studies would be acceptable for further review and consideration as “keeper studies.”

Population:Adultpatients(age18orolder)withinsulindependent diabetes, type I or type II but excluding gestational diabetics.Intervention: Intensive insulin therapy via continuous subcutaneous insulin injection (insulin pump). Insulin of any type or any amount. Any type of insulin pump.Comparison: Multiple daily insulin injection therapy. Insulin of any type or any amount.Outcome: Glycemic control as measured by HbA

1c.

Time Factors: A minimum of three months.

Results of the ReviewTypes of studies. Seven articles were obtained, analyzed

and then summarized in order to reach conclusions for this inquiry. One article was a systematic review and two additional studies were meta-analyses. The four remaining studies were randomized controlled trials (RCTs).

Study quality and/or sources of bias. The overall grade for the strength of this body of evidence was rated as Grade Level II (Fair) based upon five elements (overall quality, consistency, quantity, clinical impact, and generalizability of the studies) proposed by the Institute of Clinical Systems Improvement(AmericanDieteticAssociation,2011).

Summary of Individual StudiesStudy 1. Bolli, et al. (2009) conducted a trial of 50

adults with type I diabetes (age ranges 18-70 years) thatfound essentially no difference in the Hemoglobin A1c

(HbA1c) percentage reduction in patients using continuous

subcutaneous insulin infusion (CSII) versus patients using multiple daily injections (MDI) as a form of intensive insulin therapy. The six month trial utilized Lispro as the principal insulin. Results showed a -0.1% differencebetween the two forms of treatment (95%CI -0.5 to 0.3)which was not statistically significant. This sample size was relatively small and the trial used an older insulin pump model which had less effective bolus-management capabilities than newer pumps on the market currently. Newer pumps could positively impact HbA

1c levels when

compared to the older models.

Study 2. DeRosa, et al. (2009) followed 64 adultpatients with insulin-dependent diabetes for one year while comparing the changes in HbA

1c with CSII versus MDI. The

study found that CSII results in a statistically significant (pvalue=<0.05) reduction inHbA

1c levels at the one year

mark,aswellasallothertimeintervals(3,6,&9months)used in the study.

While such results are encouraging for proponents of CSII as an intensive insulin therapy, this particular trial had limitationsincludingitslackofdescriptionforconcealment/randomization/funding. The authors state the study wasrandomized and that the protocol was institutionally approved, but they fail to disclose these methods to the reader leaving validity of results at risk.

A Review Comparing Glycemic Effect of Insulin Therapies: Continuous Subcutaneous Insulin Infusion Versus Multiple Daily Injections

Study 3.Hoogma,etal.(2006)conductedarandomizedcontrolled,crossover trialutilizing11Europeancenters.Atotalof272adultpatients(aged18-65)withtypeIdiabeteswere studied. Results indicated that patients randomly assigned to the CSII group for intensive insulin therapy had improved HbA

1c results compared to those assigned

to the MDI group for their insulin therapy. The study collected data for a two month run-in period and a six month treatment period and reported a reduced HbA

1cmean

endoftreatmentperioddifferenceof0.23%(CSII=7.45%andMDI=7.67%,pvalue<0.001)favoringtheCSIIgroupcompared to the MDI group. These results are statistically significant and are worthy of noting. The trial failed to address issues of allocation concealment and the specifics for randomization.

Study 4. Missor, Egberts, Page, O’Connor, and Shaw (2010) performed a systematic review comparing CSII toMDI in 23 studies (976 patientswith type I diabetes) andfound that in a subgroup analysis of adult patients, HbA

1c

was reducedby0.30% (95%CI -0.5 to -0.1, pvalue0.01)in favor of CSII across a wide range of studies examining effects from six days to four years. The authors state there is an unclear risk of bias in the results of this systematic review (SR) and that a greater body of research is required before widespread changes can be recommended. While the results favored CSII, they are modest in size and clinical significance has yet to be shown.

Study 5. Pickup and Sutton (2008) performed ameta-analysis of 22 studies. Studies were included thatinvestigated HbA

1c (glycemic control) for patients with type

I diabetes mellitus who received either CSII or MDI for at least sixmonths to4years.Using thepooleddata fromsix RCTs (402 patients), the authors reported a modestreduction in HbA

1cof0.21%infavorofCSII(95%CI,0.13

to 0.30%).When all 22 studies in thismeta-analysiswerecombined for a pooled effect, the mean difference was 0.62%(95%CIof0.47%to0.76%)infavorofCSII.Clinicalsignificance remains unknown, but these results appear valid and worthy of consideration. One caution noted by the researchers is the high level of heterogeneity among the studies (I2 = 84.1%). The authors concluded that thereappears to be “a greater reduction in HbA

1c with the most

poorlycontrolled.”(page773).

Study 6. Retnakaran, et al. (2004) performed a meta-analysis of three RCT studies totaling 139 adult patients(aged 18-70 years) with type I diabetes. In this meta-analysis, the effect of CSII versus MDI on HbA

1c levels

over a four month to nine month period was examined. The researchers found that when data from individual studies were pooled, CSII resulted in a mean reduction in HbA

1c

levelof0.35%(95%CI,-0.10to0.80andpvalue0.08)butthe effect did not reach statistical significance. This finding, combined with the lack of reporting of how methodically sound each study was, leads the reader to conclude that further rigorous research is required before clear insulin treatment recommendations should be made.

Study 7. Tsui,Barnie,Ross, Parkes andZinman (2001)studied 27 adult patients with type I diabetes over a ninemonth period to determine whether CSII is more effective in controlling HbA

1clevels than MDI. They found there

was no statistically significant difference among the interventions for mean reduction in HbA

1c percentages

(0.08%,95%CI,-0.23to0.39andp>0.10).Thiswasaverysmalltrialandwasconductedmorethan10yearsago.Sincethat time, insulin pump technology has improved greatly and new insulin analogs continue to be added to patient regimens.

ConclusionsThe evidence from seven studies indicates that for

many diabetic patients the use of continuous subcutaneous insulin infusion can achieve improved glycemic control, as measured by HbA

1c, Continuous subcutaneous insulin

infusion may be useful intensive therapy option for patients with a history of poor glycemic control who are using traditional multiple daily injection therapy. Additionally, patients who are seeking increased independence from multiple injection therapy may find lifestyle improvements while using a continuous form of insulin infusion.

Translation of Evidence Into Practice - Recommendations

Although the evidence considered for this review was from only seven published studies on this topic, the review suggests that better glycemic control can be achieved with continuous subcutaneous insulin infusion versus traditional multiple injection therapy. In these studies, the improvement in glycemic control was modest and did not always reach statistical significance. Further, the clinical significance of reported reductions in HbA

1c was not addressed in any study

and underscores the importance of avoiding a sweeping change in practice at this time. It is clear that more research studies are needed to definitively answer the researcher’s research question, especially as newer pump technologies and real-time blood glucose monitoring become more commonplace in the treatment of insulin-dependent diabetes.

What was clear from the evidence synthesis is that many patients may benefit greatly from CSII, including patients with consistently poor glycemic control and patients who desire a greater level of freedom from glucose testing and injections. In the author’s view and experience, the patients who are adept at using technology seem to do very well with CSII and achieve a more normalized lifestyle compared to traditional therapy. The choice of which intensive insulin therapy to use remains an individual one, achieved through shared-decision-making between a patient and his or her healthcare provider.

ReferencesAmerican Dietetic Association. (2011). 2011 Academy of

Nutrition and Dietetics evidence analysis manual, page 70.Retrieved from http://www.adaevidencelibrary.com/topic.cfm?cat=1155&auth=1.

Bolli, G.B, Kerr, D., Thomas, R., Torlone, E., Sola-Gazagnes, A., Vitacolonna, E., et al. (2009). Comparison of a multipledaily insulin injection regimen (basal once-daily glargine plus mealtime lispro) and continuous subcutaneous insulin infusion (lispro) in type I diabetes. Diabetes Care, 32(7),1170-1176.

Derosa, G., Maffioli, P., D’Angelo, A., At Salvadeo, S., Ferrari, I., Fogari, E., et al. (2009). Effects of insulin therapywith continuous subcutaneous insulin infusion (CSII) in diabetic patients: Comparison with multi-daily insulin injections therapy (MDI). Endocrine Journal, 56(4),571-578.

Hoogma, R. P., Hammond, P. J., Gomist, R., Kerr, D., Bruttomesso,D.,Bouter,K.P., et al. (2006).Comparisonof theeffects of continuous subcutaneous insulin infusion (CSII) and NPH-based multiple daily insulin injections (MDI) on glycaemic control and quality of life: Results of the 5-Nations Trial.Diabetic Medicine, 23(2),141-147.

Misso, M. L., Egberts, K. J., Page, M., O’Connor, D., Shaw, J. Continuous subcutaneous insulin infusion (CSII) versus multipleinsulininjectionsfortype1diabetesmellitus. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.:CD005103.DOI:10.1002/14651858.CD005103.pub2.\

Pickup,J.C.&Sutton,A.J.(2008).Severehypoglycemiaandglycaemic control in Type I diabetes: meta-analysis of multiple daily insulin injections compared with continuous subcutaneous insulin infusion. Diabetic Medicine, 25(7),765-774.

Retnakaran, R., Hochman, J., DeVries, J. H., Hanaire-Broutin, H., Heine, R. J., Melki, V., et al. (2004). Continuoussubcutaneous insulin infusion versus multiple daily injections. Diabetes Care, 27(11),2590-2596.

Tsui, E., Barnie, A., Ross, S., Parkes, R. & Zinman, B. (2001). Intensive insulin therapy with insulin lispro. Diabetes Care, 24(10),1722-1727.

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By Chelsea Dallman, R.N., BSN, MSN Program, Gonzaga University, Spokane, WAcdallman@zagmail.gonzaga.edu

The author reports no potential conflicts of interest.

IntroductionThis is a summary of seven studies examining the

evidence of family involvement as a predictor of decreased relapse in symptoms of schizophrenia. This evidence was discovered, summarized and translated over an eight week period.

Research Question

In people with schizophrenia (Population), does family involvement and education (Intervention), compared

to no family involvement and education (Comparison), predict a decreased risk of relapse (Outcome)?

Search Strategy Databases searched: The Cochrane Library, PubMed,

CINAHL and Proquest. Search terms. “Schizophrenia AND Family

involvement;” “Schizophrenia AND Family AND Therapy.”Study selection criteria. For studies published from

2007to2012, thefollowinginclusioncriteriawereusedtoselect “keeper studies” for this evidence summary.

Populations included: Any person diagnosed with schizophrenia.Interventions included:Anytypeoffamilyeducation/therapy for treatment of schizophrenia.Comparison Groups included:Nofamilyeducation/therapy, standard therapy, use of medications only.Outcomes included: Decreased risk in relapse, increased compliance, decreased disease symptoms.

Search Results Types of Studies. Of seven articles that were analyzed,

the highest level of evidence was found in one systematic review (Pharoah et al). Two studies were randomized controlled trials (RCTs), two were cohort studies (one provided evidence for answering the clinical question and the other provided useful background information). Two remaining articles were classified as expert opinion or a literature review; both considered as lower levels of evidence.

Summary of Keeper StudiesStudy 1. Fischer et al. (2008) studied a cohort of 258

schizophrenic patients discharged from the Arkansas State Hospital and Central Arkansas Veterans Healthcare System to determine how family interaction and substance abuse status affected treatment service utilization. In subgroup analyses, findings indicated ongoing family support was associated with a statistically significant decrease in the negative effects of substance abuse on service use patterns in patients with schizophrenia and co-morbid substance abuse. This study had a relatively small sample size, conducted subgroup analyses and examined patients with schizophrenia and substance abuse.

Study 2. Giron, Fernandez-Yanez, Mana-Alvarenga, Molina-Habas,NolascoandGomez-Beneyto(2010)studied50 patients with schizophrenia who were registered tomental health centers in Alicante, Spain (a district with 121,024 inhabitants). This randomized controlled trialsought to measure how family interaction (consisting of education, active listening, expressing emotions, etc.) reduced clinical relapse and increased social functioning and Global Outcome scores. The main findings of the study indicated that clinical relapse was significantly less frequent (p=0.024) in the family intervention group (12%)comparedtothestandardcaregroup(40%).Majorincidentswere statistically higher (p=0.002) 32% in the standardcare group compared to 0% in the family interactiongroup. For patientswith improvement of 10 points on theGlobal Assessment of Functioning Scale and Diagnostic and Statistical Manual of Mental Disorders-IVa (GAF-DSM-IVa), a statistically greater number (p=0.045) werein thefamily interactiongroup(56%)compared to48%in

the control group. Global outcome scores for those in the familyinteractiongroupwerestatisticallyhigher(p<0.001)indicating lower clinical relapse and overall better social functioning in the family interaction group. A limitation of this study was small sample size.

Study 3. Jewell, Downing, and McFarlane (2009)reviewed the literature on family psychoeducation (specifically multiple family group (MFG) education about mental illness, family support, crisis intervention, effective communication strategies, and problem-solving training). The researchers concluded that this type of family psychoeducation, MFG, can help educate the family on the illness and provide coping strategies that in turn prevent relapse of the patient. The authors indicated that family psychoeducation is evidence-based practice for this topic. This literature review provided valuable information and overview of this topic.

Study 4. Levene, Lancee, Seeman, Skinner and Freeman (2009) conducted a cohort study involving 38male schizophrenic patients referred from the inpatient psychiatric units of 12 hospitals in downtown Torontoand surrounding suburban/outlying areas. The purposeof this study was to determine how patient characteristics (psychotic symptoms) and family characteristics (e.g., expressed emotion, family burden, and family functioning) at one month post discharge (T1) and at follow-up (T2)predict patient relapse. Researchers found that at T1 thePerceived Family Burden Scale score and T1 psychoticsymptoms predicted psychotic symptoms at T2. Thiscombination of patients’ and relatives’ characteristics predicted a variance of 19% in the level of psychoticsymptoms at follow-up (p.4). These results indicated thatpatient and family interactions may influence patient relapse. This study was different from the other studies in that it was measuring the effects of a very different intervention for schizophrenic patients. Study limitations were small sample size, testing of male schizophrenics only, and no direct comparison of how family interaction versus no family interaction affected patient relapse.

Study 5. Pharoah et al. (2010) completed a systematicreview/meta-analysis of randomized controlled trials todetermine if family intervention decreases the risk of relapse and other outcomes. The review examined 53studies of schizophrenic patients between the ages of 16-80yearsandfromAustralia,Canada,Europe,ThePeople’sRepublic of China and the U.S.A. The studies indicated thatfamilyinterventionfor7-12months,13-18monthsand19-24 months significantly decreased the risk of relapse.Family intervention for less than seven months, for 25-36 months, for 5 years, and 8 years did not significantlydecrease the risk of relapse but did show an association. Significant positive effects were detected for family intervention and hospital admissions. The researchers noted that some small negative studies may have been missed in their search.

Study 6. Tas, Danaci, Cubukcuoglu and Brune (2012)studied 45 schizophrenia patients discharged from CelalBayer University Psychosis Unit in a randomized controlled trial on the usefulness of family- assisted social cognitive and interaction training (F-SCIT) versus social stimulation (SS) training in the improvement of quality of life, social functioning and social cognition. The study indicates that F-SCIT resulted in statistically significant improvement in all subscales compared to the control group receiving SS. Family social cognitive interactive training resulted in greater improvements in symptoms, quality of life and all areas of social cognition and social functioning in comparison to social stimulation. Study limitations included a small sample size, the groups were not completely matched in size or number of sessions, and the F-SCIT was led by an experienced psychiatrist, the SS group was not.

Study 7. Wilk, West, Marcus, Countis, Regier and Olfson(2008)surveyed771psychiatristsrandomlyselectedfrom the American Medical Association Masterfile of Physicians about interventions to manage anti-psychotic medication non-adherence in their schizophrenic patients.

Dataforatotalof310schizophrenicpatientswhometstudycriteria were examined. Patients were rated as either at a high level of family contact (daily family contact or living with spouse or parents) or a low level of family contact (all others).

Patients with high family contact were significantly less likely than those with low family contact to: have a history ofananxietydisorder(49%vs62%,p=.03),injuresomeone(20%vs40%,p<.01),useasecondgenerationantipsychotic(88% vs 94%, p=.05), and have severe positive symptomsofschizophreniapriortomedicationnon-adherence(5%vs12%,p=.03).

Patients with high family contact were significantly more likely than those with low family contact to use family interventions in managing medication non-adherence (74% vs 43%, p<.0001). The authors indicated that formedication non-adherence, family interventions seem to be useful for patients with high levels of family contact, but more testing needs to be done on this subject. High family contact correlated positively with better overall outcomes such as prior anxiety, injuring someone, second generation antipsychotic use, and positive schizophrenic symptoms prior to non-adherence. This study was limited by data reporting from psychiatrists rather than directly from patients or families. Further trials are needed to address medication non-adherence in this population.

ConclusionsFamily involvement has been shown to decrease the

risk of relapse and improve patient functioning associated with symptoms of schizophrenia. All studies in this evidence summary provided support for family involvement as one factor in improving symptoms associated with schizophrenia. Not all studies examined the same outcomes. Evidence indicated a correlation between family burden and relapse. Overall, these seven studies support the fact that family involvement is very important for individuals with schizophrenia.

Translation of Evidence into Practice RecommendationsOverall, this author would recommend that involvement

of family members be encouraged in the treatment of schizophrenia. Further research studies focusing on analysis of similar interventions and outcomes are necessary. Studies should be of longer duration and provide more detailed follow up information. The current seven studies, although containing variable and sparse evidence, does show a pattern of family involvement impacting patients with schizophrenia in a positive way, whether through decreased relapse, increased social function, or better quality of life.

As a future Psychiatric/Mental Health NursePractitioner, this author will recommend and support family involvement for patients with schizophrenia. This author will continue to examine studies that explore the impact of family on schizophrenia as well as treatments for schizophrenia that result in the best outcomes.

ReferencesFischer, E.P., McSweeney, J.C., Pyne, J.M., Williams, D.K.,

Naylor, A.J., Blow, F.C., & Owen, R.R. (2008). Influence offamily involvement and substance use on sustained utilization of services for schizophrenia. Psychiatric Services, 59(8),902-8.

Girón, M., Fernández-Yañez, A., Mañá-Alvarenga, S., Molina-Habas,A.,Nolasco,A.,&Gómez-Beneyto,M. (2010). Efficacyand effectiveness of individual family intervention on social and clinical functioning and family burden in severe schizophrenia: A 2-year randomized controlled study.Psychological Medicine, 40(1),73-84.

Jewell, T. R., Downing, D., McFarlane, W.R. (2009).Partnering with families: Multiple family group psychoeducation for schizophrenia. Journal of Clinical Psychology, 65(8),868-878.

Levene, J., Lancee, W., Seeman, M., Skinner, H., & Freeman, S.(2009).Familyandpatientpredictorsofsymptomaticstatusinschizophrenia. Canadian Journal of Psychiatry, 54(7),446-451.

Pharoah, F., Mari, J. J., Rathbone, J., & Wong, W. (2010).Family intervention for schizophrenia. Cochrane Database of Systematic Reviews 2010, Issue 12. Art. No.: CD000088.DOI:10.1002/14651858.CD000088.pub3.

Tas,C.,Danaci,A.E.,Cubukcuoglu,Z.,&Brune,M.(2012).Impact of family involvement on social cognition training in clinically stable outpatients with schizophrenia: A randomized pilot study. Psychiatry research, 195(1),32-38.

Wilk, J., West, J., Marcus, S., Countis, L., Regier, D., & Olfson, M. (2008). Family contact and the management ofmedication non-adherence in schizophrenia. Community Mental Health Journal, 44(5),377-380.

The Effectiveness of Family Involvement in Treatment of Schizophrenia: A Review

May, June, July 2013 RN Idaho • Page 11

Page 12 • RN Idaho May, June, July 2013

Chelsea M. Collins, B.A., College of Western Idaho student nurse and

ISNA President

Note: Ms. Collins would like to thank the following individuals:

• Dr.BarbaraMcNeil,R.N.-BC,Co-editorofRN Idaho for her input and careful editing of this manuscript and

• ProfessorElizabethCartwrightfromIdahoStateUniversity who teaches medical anthropology and global heath for her inspiration and guidance on this subject.

IntroductionRefugees are a distinct population of individuals who

have been forced to leave their country by various means because of war or persecution. In Idaho alone, there were 775 refugees in 2011 from 17 different countries(Idaho Office of Refugees). Often, these refugees begin with a cultural influence within their family, experience another culture that is ultimately creating the upheaval that identifies them as needing asylum, and then enter into a whole new culture when they are granted asylum in another country. Refugees do not have to seek out cultural differences, as cultural differences dictate the daily life of refugees.

Aydingun, Harding, Hoover, Kuznetsov and Swerdlow (2006) noted that the Meskhetian Turks continue toemigrate and resettle in the United States. The population is also spread throughout the former Soviet Union, Turkey, Ukraine, and Uzbekistan.

For the purpose of this paper, the authors examine the Meskhetian Turk history and culture and how these influence health care needs. Finally, the authors explore the nurse’s role in caring for this unique refugee population and implications for culturally-based healthcare for a Muslim population.

Meskhetian Turks OriginMeskhetian Turks are a population of Turkish-speaking

people who are originally from a region called Meskhetia (now known as Samtskhe-Javakheti) in southern Georgia on the border of Turkey. They identify themselves as Muslim. According to a cultural profile of this population writtenbyAydingunet al. (2006), therehasbeendebateover their ethnic origins: “Are Meskhetian Turks in fact ethnic Turks, or are they ethnic Georgians who have in somestageinhistoryconvertedtoIslam?”(p.2)

The name, “Meskhetian,” is controversial, as it identifies with the thought that this population is composed of ethnic Georgians who learned to speak Turkish and converted to Islam. Another name for this population is Ahıska Turks, which highlights the Turkish part of their identity. There are other identifiers for this

population. For the purposes of this paper, this population will be identified as the Meskhetian Turks, a term “most widely used today by officials, scholars and the media.” (Aydingunetal.2006,p.3)

HistoryThe history and ethnic identity of the Meskhetian

Turks are intertwined and disputed by those favoring either the Georgian view or the Turkish view. From the perspectiveofGeorgiansources,startingasearlyas1578,under Ottoman rule, the Meskhetian Turks were placed into Meskhetia. According to Aydingun et al. (2006),the original individuals there were in fact a part of the Georgian tribe, Meskhs, who were converted to “Islam andtheirgradualTurkicizationunderOttomanrule”(p.4).The Turkish view differs.

With the end of World War I and the demise of the Ottoman Empire, historians cite the origin of the roots of strife and lack of acceptance of the Meskhetian Turks into the Georgian population. According to Aydingun et al. (2006), theOttomanEmpire, aMuslimpopulation,invaded this region and a dispute between the treatment of Muslims by Christians, and vice versa, was “one of the main official justifications for keeping Meskhetian Turks from returning to Georgia in the post-Stalin and post-Soviet periods” (p. 5).As a result, theMeskhetianTurkshave been without a home for some time.

In 1921, when the Soviets took control of Georgia,Lenin and Atatürk signed a peace agreement that split the region of Meskhetia into two parts. Through governmental policy changes, the Meskhetian Turks, who were then a part of the Soviet region, went through many ethnic identity changes.

Despite the recognition of Meskhetian Turks as Georgianbetween1938andWorldWarII,“Stalin’sright-hand man, Lavrenti Beria, passed an executive resolution declaring the Meskhetian Turks and other smaller groups in the area to be ‘untrustworthy populations’ that should be immediately deported from the Georgian Soviet republic to Central Asia” (Aydıngün et al., 2006, p. 6).During this period, approximately 100,000 MeskhetianTurks were “forcibly” deported from the region; the populationsufferedalossofapproximately15%to20%ofthe total Meskhetian population; many died from typhoid aswell as cold and hunger (Aydingun et al., 2006, p. 6).Those who survived were dispersed across Kazakhstan, Kyrgyzstan and Uzbekistan to live in “special settlement regimes” (Aydingun et al., 2006, p. 7) and toworked aslaborers in agriculture.

AfterStalin’sdeathin1956,theMeskhetianpopulationwas not allowed to return to their original homeland in Georgia. This situation and not marrying outside of their group served to strengthen their identity as a distinct group of people. Although their identity is considered as distinct, there continues to be multiple debates as to what exactly

that identity is: Turks, Georgians who speak Turkish, or Meskhetians.

One country that the Meskhetian Turks resided in during this time was Uzbekistan. In 1989 they wereuprooted again from the territory where they were beginning to make their home. They were evacuated to Russia by the Soviet army and then emigrated to other areas of the former Soviet Union such as Azerbaijan, Ukraine, Kyrgystan and Kazakhstan.

During the 15 years following 1989, the MeskhetianTurks in Krasnodar in southern Russia experienced further extreme discrimination, persecution, and violence against them. They were identified as “illegal migrants” and were not allowed to work; own property; attend higher education institutions; or obtain legal documents such as birth certificates, passports, or marriage certificates. They were also not able to access social security or health care benefits. Because of these restrictions, they truly were “stateless” with no legal trail or form of identification, and no way to provide for their family through education, work, or health (Aydıngün et al., 2006, p. 9).This statuscontinued for many years. Because of harassment, inability to lease/own land, anddemands for bribes fromthe local police force, the Meskhetian Turks were unable to provide proper documentation and claim citizen status.

With the collapse of the Soviet Union and the growing international attention on the Meskhetian crisis, in 2004, the U.S. government “proposed the option of U.S.resettlement” (Aydingun et al., 2006, p. 12) and joinedin the resettlement efforts of the Meskhetian Turks. Although Americans are still sheltered from much of the information about this cultural group, greater awareness of the human rights issues is being brought forward.

On a local level, Americans living in the United States can begin to address the global healthcare issues facing this refugee population. Once these refugees have gone through the process of being accepted into the U.S., their transition follows. Being uprooted from a society that is only somewhat theirs, the Meskhetian Turks along with other refugees from across the world, are being transplanted into new societies that are often unlike their own and are well-established.

The refugee’s role in society is uncertain, but they now have access to such things as education and health care that were previously denied to them. Transplantation into a new society creates not only physiological health needs for these individuals, but also the potential for psycho-social issues. It is imperative that we in the U.S. work as a global society to support the basic human rights that have been denied to this population, regardless of their physical location.

The Meskhetian Turk Refugees: Their History, Cultural Practices and Nursing’s Role

The Meskhetian Turk Refugees continued on page 13

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Nursing’s Role in Facilitating Refugee ResettlementApplication of the nursing process to all refugee

populations can help facilitate their sense of belonging and “having a home.” Although the nursing process is difficult to master in the short time as a nursing student, it is even more challenging for nurses to apply it to refugee populations. Through assessment and understanding, however, nurses can apply what is learned from these populations to these and similar populations that are minorities are misunderstood and have experienced discrimination and persecution.

When the Meskhetian Turks were denied health care despite the availability of modern medicine, it underscored the need for nurses and others to understand this population’s healthcare challenges. The following are areas of nursing assessment that we should focus on with this particular population. We as health care professionals need to keep in mind that assessment of the Meshketian Turks cultural beliefs and practices is important. However, it is also imperative to know the basic premises for their cultural practices.

Assessment of Cultural PracticesThe following is a basic discussion of selected

cultural practices that may apply to Meskhetian Turks and all individuals who identify themselves as Muslim. Health professionals should take into consideration this information as well as other unique practices specific to the various individual Muslim populations including the Meskhetian Turks.

Nutrition. The observance of Ramadan occurs in the ninth month of the Islamic calendar, which does not coincide with the calendar used in the United States. Therefore Ramadan can occur at any time during the year. Ramadan is a time of contemplation and reflection alongside prayer, where Muslims fast from sunrise to sunset. Fasting begins for those beyond puberty and while fasting, they abstain from eating, drinking, and smoking (Maloof, Ross-Sheriff and Asani, 2003).Fasting can potentially interfere with medical care such as administration of medications. Depending on the individual’s beliefs, this cultural practice may also affect administration of intravenous (I.V.) fluids and medications. The practice of worshiping Allah and fasting during Ramadan could cause much strife in the life of an individual who has medications that need to be taken during the day. Non-compliance with medication may result especially in the case of a hospitalized patient whose health may be compromised from the lack of fluids or nutrition from sunrise to sunset.

Islamic tradition forbids the consumption of pork and other meat that is not prepared in accordance with their customs. Certain medications, for example insulin, may be derived from animal sources as opposed to human insulin. In an examination of various types of insulin, insulin detemir (Levemir), insulin glargine (Lantus), and insulin lispro (Humalog) are the only identified “human insulins” while others use pork in some aspect or another, or are not identified at all (Wilson, Shannon & Shields, 2012).By consuming pork, Muslim individuals may experience spiritual distress and not comply with medical therapy. This could lead to more severe issues such as diabetic ketoacidosis. It is important for nurses and all healthcare professionals to consider dietary restrictions not just the physical food source, but the ingredients of medications and how they are prepared.

Gender. Not entirely unique to the Muslim population, women are often chosen as the health care providers for other women. In some instances, male health care providers are not utilized at all. It is important to assess this preference because a family’s belief may place limits on who can provide care. It is important to also assess these gender preferences in relation to selection of interpreters and various other clinicians that may impact theoverallcareofthepatient(Maloofetal.,2003).

Circumcision. According to Maloof et al., (2003),Muslim male children are circumcised at birth or within the first seven days of life. There is not a requirement of a comparable procedure for females.

Female circumcision is more based on tradition and not rooted in religious beliefs (Kristof, 2011). Althoughthis belief is considered to be a tradition and some may consider it to be a requirement of their religion, according

to the Federal Prohibition of Female Genital Mutilation Act of 1995, female circumcision is not allowed in the United States (Maloof et al., 2003). Despite femalecircumcision not being legally allowed in the United States, there is still pressure for it to occur based on tradition,asitisapartofawoman’sidentity(Chen,2010).

Female circumcision leads to infections and urinary difficulties and scar tissue can make child birth more dangerous, increasing maternal mortality and injuries such asfistulas(Kristof,2011).Althoughthepracticeoffemalecircumcision may not apply to every Muslim group, nurses should consider it as a possibility when assessing a patient from these populations.

Mental health. When assessing the mental health of these refugees, the nurse should remember that traumatic events have occurred in the lives of these people. Some individuals may have had a more difficult time than others. They experienced something so threatening that they sought emigration and asylum elsewhere.

Weissman, Morris, Ng, Pozzessere, Scott and Altshuler (2012) noted that there are greater numbers of refugeeswith Post Traumatic Stress (PTS) compared to the U.S. population and that refugees go through an adjustment disorder upon arrival to their new home which can sometimes be misdiagnosed as PTS. It is important for nurses to understand that there are multiple mental health issues that a refugee can face. In assessing the patient, the nurse should engage in more than a basic discussion of issues. Nurses must be aware of the potential for mental health issues and must understand how mental health issues will affect the refugee’s physical and overall well-being.

Resources. Despite having access to medical health care in the U.S., refugees face many difficulties including a lack of understanding of the health care system and of the language needed to ask for and get the help needed to provide for their family in multiple ways, including health care(Weissmanetal.,2012).Inane-mailcorrespondence,KaraFink (personalcommunication,December17,2012)of the Idaho Office of Refugees explained that refugees are guaranteed Medicaid for eight months after arrival. She explained how those who meet certain requirements might be able to access Medicaid after that period of time. She noted that money, language, transportation, cultural differences, work schedules and others may interfere with the refugee’s means of seeking health care.

Conclusions and Implications for NursingAlthough not being able to meet every care need of a

refugee population, we as health care professionals have an ethical duty to provide healthcare services and to refer this population to other resources for additional help. In a health care world where the reach of one society is global, it is important that nurses step back and consider how cultural practices influence the care of patients. The willingness to try to understand the care needs and the effort to help these individuals are essential actions.

When it comes to the care of refugees, it is critical that nurses and all healthcare providers respect (within legal limits) the traditions and religious beliefs of the refugee population. Healthcare providers need to consider the various factors impacting the lives of these individuals and their families. As nurses, we must assess the impact of current and past factors on the refugee’s current physical and emotional well-being. All healthcare professionals should be aware of the cultural preferences and background of refugees in order to effectively advocate for them. The sharing of knowledge with colleagues about cultural practices will assist other families that may not have received culturally-sensitive care. When religious and personal beliefs coincide with the provision of healthcare, any individual will be more likely to participate in care and achieve greater health benefits.

ReferencesAydıngün, A., Harding, Ç. B., Hoover, M., Kuznetsov, I., &

Swerdlow,S.(2006).MeskhetianTurks:Anintroductiontotheirhistory, culture and resettlement experiences, Retrieved from http://www.culturalorientation.net/learning/backgrounders

Chen, S. (2010, May). Pressure for female genital cuttinglingers in the U.S. Retrieved from http://www.cnn.com/2010/HEALTH/05/21/america.female.genital.cutting/index.html

Idaho Office of Refugees. (n.d.). Retrieved from http://www.idahorefugees.org/Refugees_in_Idaho/

Kristof, N. (2011, May 11). A rite of torture for girls. Retr ieved from http://www.nytimes.com/2011/05/12/opinion/12kristof.html?_r=0

Maloof,P.S.,Ross-Sheriff,F.,Asani,A.S. (2003).Muslimrefugees in the United States: A guide for service providers. Cultural Orientation Resource Center, Retrieved from http://www.culturalorientation.net/learning/backgrounders

U.S. Census Bureau. (2012, September 18). Retrieved fromhttp://quickfacts.census.gov/qfd/states/16000.html

Weissman, G., Morris, R., Ng, C., Pozzessere, A., Scott, K., & Altshuler, M. (2012). Global health at home: A student-runcommunity health initiative for refugees. Journal of Health Care for the Poor and Underserved, 23(3),942-948.

Wilson, B. A., Shannon, M. T., & Shields, K. M. (2012).Nurse’s drug guide 2012. Boston, MA: Pearson.

The Meskhetian Turk Refugees continued from page 12

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Idaho Student Nurses Association:

Progress and Updates

by Elise Russell-Manicke, Boise State University, ISNA Communications Chair & Chelsea Collins,

College of Western Idaho, ISNA President

Student nurses often struggle to learn how to be leaders and to find ways to network outside of the clinical setting. These opportunities are offered to members of the National Student Nurses Association at the national, state, and school levels. The Idaho Student Nurses Association (ISNA) facilitates this development by sponsoring an annual conference, giving student nurses the opportunity to serve as elected board members, and participating in the House of Delegates at the NSNA convention each spring.

This year, the ISNA has instituted several major changes. The organization appointed a new advisor, Dr. Sandie Nadelson of the College of Western Idaho (CWI), went live with a new and vastly improved Website, and will, for the first time, feature online voting for the next board. The latter will allow additional members beyond the ones able to attend the NSNA convention to let their voices be heard.

Changes aren’t the only thing ISNA has implemented this year. President Chelsea Collins and Secretary Nicole Benskin authored a resolution about autism education to be presented and voted on at the NSNA convention. NSNA has reached out to programs not traditionally active at the state level; board members from North Idaho College and CWI have been added. The organization is also working on gaining non-profit status at the federal level.

Most of the projects ISNA has taken on aren’t without financial costs. Members are in the midst of a fundraising drive to raise money to help secure the organization’s non-profit status, pay for its 2013 state convention, andhelp send members to the NSNA convention. If you are interested in helping out students who will soon be your professional colleagues, please check out our Website, www.idahostudentnurses.org and click on contact us, or email presisna@gmail.com.

In addition to creating better communication among the students, ISNA would also like to increase the support and communication with nursing faculty. Please use the contact information above for any questions or concerns or for any suggestions for ISNA. Although each school may have a State Nurses Association (SNA) chapter, ISNA believes that representation on the state level is paramount in creating a better student nurse population in Idaho. Equally important is membership in NSNA in order to bring issues important to Idaho forward on a national level. If you are a faculty member, please support and encourage membership in SNA at all levels to help create a better future for Idaho nurses through initiatives to promote learning and leadership development opportunities that enable nursing students to be more well-rounded.

Our Internal Compass: Guiding Self-Reflection to

Ensure Quality and Safe Care by Lynda Heise R.N.-BC,

Kootenai Health, Coeur d’ Alene, Idaho lsheise56@yahoo.com

I do not represent any commercial affiliation or have interest in any financial way with this submission.

Nursing professionals need, more than ever, to be focused in the delivery of care for patients. It is vital to know what is best practice for quality care and for patient outcomes. As a result, nurses at the bedside need to be in touch with their “internal compass” which includes the values, morals, and instincts that help guide nurses in their practice.

With the current widespread economic constraints in our country, the need for health insurance, increasing number of patient comorbidities, and the challenges patients and families face in meeting financial responsibilities, consumers and health professionals face many unanswered questions about the efficient and financially-responsible delivery of healthcare in the future. Concurrently, the professional nurse at the bedside observes and directly deals with many fast-paced organizational changes and challenges including the growth in technology, medical insurance needs and pharmaceutical shortages. These factors stimulate grave concerns about the provision of healthcare.

In order to find strength to cope with these issues and use our inner compass to stay focused and positive, the professional nurse must self-reflect which involves taking inventory of one’s own emotions, values, and experiences. This reflection can provide insight and open up a vision for clear decision making. Through self-reflection, one can increase awareness of what drives our actions.

Assisting with this clarity and direction for the future of nursing care, leaders in nursing play an increasingly important role. Leaders can foresee the unexpected and through guidance, communication, and collaboration can effectively enable staff to keep a clear focus. It is vital that leadership inspire, praise, and encourage the professional work of nurses as a means of helping nurses progress forward in a positive way. By example of our leaders, the professional at the bedside can gain answers to questions about providing quality care that is greatly needed by our patients. Leaders can supply the nurse at the bedside with resources to help address the needs of the future care delivery system. Through this guidance from nurse leaders, our individual compass can be genuinely renewed.

Overall, nursing’s accountability for patient safety, major concerns about hospital acquired infections and reimbursement of costs result in a search for answers. We are all asking, “How do we provide quality safe care and maintain costs?” Through a combination of self-reflection, insights into one’s own compass, and effective leadership, we can find answers to restore and maintain a clear and steady direction in healthcare delivery. We are all seeking confidence in making the best decisions for our patients. We must continue to navigate with our internal compass to build the path for our decision making processes that offer high quality, safe care for our patients.

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May, June, July 2013 RN Idaho • Page 15

Boise State is a progressive learning-oriented, student focused university dedicated to academic excellence. At Boise State you will find an academic community that values diversity and prepares students to become leaders in nursing.

For over 55 years, the School of Nursing has been recognized as the largest Nursing program in Idaho promoting excellence in teaching, research, and service.

A variety of courses and program options are available to fit your needs:

• Astudent-friendlyRN-BSprogramtaughtentirelyonlinefornurseswhowanttocompletetheirBSdegreeinnursing.

• UniqueMastersprogramtaughtentirelyonline.Focusedonnursingcareofpopulations.Nursesmanageandcoordinate;yetfewprogramspreparedustolookataggregatesofpopulationstomakedatabaseddecisions.

We invite you to contact us to determine if Boise State’s School of Nursing is the right fit for you.

Becky White, Student Recruiter208-426-4632Beckywhite1@boisestate.edu

D I S C O V E R B O I S E S TAT E U N I V E R S I T Y

Page 16 • RN Idaho May, June, July 2013

Kootenai Health is a Joint Commission-accredited, Magnet designated, 246-bed hospital offering complete clinical services.

Employee Benefits • TuitionReimbursement•On-siteDayCare• Fullypaidmedical,dentalandvisioninsurance.•Generouscompensationandbenefitpackage.• Extensiveon-siteprofessionaldevelopmentopportunities.

To review full job descriptions visit:www.kootenaihealth.org/careers

Human Resources 2003 Kootenai Health Way, Coeur d’Alene, ID 83814208.666.2050 tel

* Subjects that consumed the BOLD diet experienced a 10.1% decrease in LDL cholesterol compared to baseline. In comparison to the Healthy American Diet, subjects experienced a 4.7% decrease in LDL cholesterol on the BOLD diet.1 Roussell MA, Hill AM, Gaugler TL, West SG, Vanden Heuvel JP, Alaupovic P, Gillies PJ, and Kris-Etherton PM. Beef in an Optimal Lean Diet study: effects on lipids, lipoproteins, and apolipoproteins. Am J Clin Nutr 2012; 95(1):9-16.2 USDA, ARS. 2011. USDA National Nutrient Database for Standard Reference, Release 24. Nutrient Data Laboratory Home Page, http://www.nal.usda.gov/fnic/foodcomp/search/

CouncilIdaho BEEF

idbeef.org • 208-376-6004

Heard the good news about lean beef? The latest research presents a new way of thinking: lean beef can be part of a solution to one of America’s greatest health challenges—eating for a healthy heart. A study published in the American Journal of Clinical Nutrition found that participants in the BOLD (Beef in an Optimal Lean Diet) study experienced a 10% decrease in LDL cholesterol from baseline when they ate lean beef daily as part of a heart-healthy diet and lifestyle containing less than 7% of calories from saturated fat.*1

SETTING THE RECORD STRAIGHTThis ground-breaking clinical study substituted lean beef for white meat as part of an overall heart-healthy diet and found the improvements in LDL cholesterol seen on the beef-containing diets were just as effective as DASH (Dietary Approaches to Stop Hypertension).

MANY LEAN CUTSLean beef is easily served with vegetables,whole grains and low-fat dairy—improving taste, satisfaction and providing essential nutrients. And many of the most popular cuts of beef—like Top Sirloin steak, Tenderloin and 95% lean Ground Beef—meet the government guidelines for lean.

TEN ESSENTIAL NUTRIENTSPacked with high-quality protein, lean beef provides a satisfying, nutrient-rich experience. A 3-ounce serving of lean beef contains 150 calories on average and is a good or excellent source of ten essential nutrients, including iron, zinc and B-vitamins.2

PART OF A HEART-HEALTHY PLAN PATIENTS WILL LOVELean beef can be a deliciously welcome and satisfying choice in a heart-healthy diet. Help your patients increase meal flexibility by including lean beef among other heart-healthy choices on their shopping lists.

BE BOLDWITH LEAN BEEF

Learn more about the many nutritional benefits of lean beef at BeefNutrition.org

Program for Recovering Nurses

Addiction Intervention and Recovery Services for Nursing Professionals

There are two different treatment tracks into our recovery program:

Self-Referral: A nurse, or agent of the nurse (colleague, family member, friend, or employer) may contact the PRN if the nurse has not been reported to the Idaho State Board of Nursing.

Nursing Board Referral: The Idaho State Board of Nursing will refer a nurse, if a formal complaint has been filed or if the nurse has voluntarily surrendered his/her license to the Board of Nursing.

For immediate assistance, please call us at 866-460-9014

www.southworthassociates.net