Nursing Matters March 2015

March 2015 ■ Volume 26, Number 3

Nursingmatterswww.nursingmattersonline.com

InsIde:nurses, doctors offered

rural incentive

3nursing schools seek

cure for shortage of educators

4evidence: the ultimate

game changer

8

By ALICIA CHANGAP Science Writer

LOS ANGELES (AP) — A “super-bug” outbreak suspected in the deaths of two Los Angeles hospital patients is raising disturbing questions about the design of a hard-to-clean medical instrument used on more than half a million people in the U.S. every year.

At least seven people — two of whom died — have been infected with a potentially lethal, antibiot-ic-resistant strain of bacteria after undergoing endoscopic procedures at Ronald Reagan UCLA Medical Center between October and January. And more than 170 other patients may have been exposed as well, uni-versity officials said.

UCLA said the infections may have been transmitted through at least two contaminated endoscopes that were used to diagnose and treat pancreatic and bile-duct problems.

Hospital officials said they imme-diately removed contaminated medi-cal devices blamed for the outbreak and adopted more stringent steriliza-tion techniques.

At a news conference Thursday

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Scope is suspect in outbreak. This undated photo provided by the U.S. Food and Drug Administration shows the tip of an endoscopic retrograde cholangiopancrea-tography duodenoscope, attached to a long tube, which is not shown. A “superbug” outbreak suspected in the deaths of two Los Angeles hospital patients is raising dis-turbing questions about the design of a hard-to-clean medical instrument used on more than half a million people in the United States every year. At least seven people – two of whom died – have been infected with a potentially lethal, antibiotic-re-sistant strain of bacteria after undergoing endoscopic procedures at Ronald Reagan UCLA Medical Center between October and January. More than 170 other patients may also have been exposed, university officials said.

AP Photo/U.S. Food And drUg AdminiStrAtion

afternoon, health officials sought to reassure the public that there is no broad danger.

“This outbreak is not a threat to public health,” said Dr. Benjamin Schwartz, deputy director of acute

continued on page 2

communicable disease control and prevention for the LA County Department of Public Health.

Infections of carbapenem-resistant Enterobacteriaceae, or CRE, have been reported at hospitals around the country, and some have been linked to a type of endoscope that is used to diagnose and treat pancreatic and bile-duct problems. The duodeno-scope is a thin, flexible fiber-optic tube that is inserted down the throat to enable a doctor to examine an organ. It typically has a light and a miniature camera.

Doctors first discovered the prob-lem in mid-December when a patient underwent an endoscopic procedure and developed an infection that

This illustration released by the Cen-ters for Disease Control and Preven-tion depicts a three-dimensional (3D) computer-generated image of a group of carbapenem-resistant Enterobacte-riaceae bacteria. The artistic recreation was based upon scanning electron micrographic imagery. A potentially deadly “superbug” resistant to antibi-otics infected seven patients, including two who died, and more than 100 oth-ers were exposed at a Southern Cali-fornia hospital through contaminated medical instruments, UCLA reported Wednesday Feb. 18, 2015.

AP Photo/CenterS For diSeASe Control

March • 2015 NursingmattersPage 2www.nursingmattersonline.com

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Nursingmatters

couldn’t be treated with antibiotics.An investigation was launched

and doctors employed high-tech techniques to find other cases — a process that took several weeks, said Dr. Zachary Rubin, medical director of clinical epidemiology and infec-tion prevention.

It was determined that CRE infec-tions had been passed on from one “source case” patient to seven other patients between Oct. 3 and Jan. 28, Rubin said.

The two endoscopes were found to have “embedded” CRE infections even though they had been sterilized according to manufacturer instruc-tions, said Dr. Robert Cherry, UCLA Health System’s chief medical and quality officer. Five other devices were clear.

As a precaution, the two instru-ments were pulled from service, more stringent sterilization proce-dures were adopted and anyone who had undergone procedures with any of the seven endoscopic devices were notified that there was a potential risk that they may have been infected, officials said. The hospital has noti-fied them through letters and phone calls and is offering free testing and treatment options.

Health inspectors visited UCLA after being notified and found “no breaks and no breaches” in its disinfection process, said Dr. Benjamin Schwartz of

the county health department.“You can very easily do everything

right and still have some contamina-tion,” said Dr. Deverick Anderson, an infectious-disease expert at Duke University. “We’re finding this is a problem, but it’s probably one that we don’t have a very good solution to right now.”

Lawrence Muscarella, a Philadelphia infection-control expert, said the recent incidents point to a design flaw that needs to be addressed.

On Thursday, the U.S. Food and Drug Administration issued an advi-sory, warning doctors that even when

SUPERBUGcontinued from page 1

The Ronald Reagan UCLA Medical Center in Los Angeles building is seen in Los An-geles, Thursday, Feb. 19, 2015. A “superbug” outbreak suspected in the deaths of two patients at UCLA Medical Center in Los Angeles has raised questions about the adequacy of the procedures for disinfecting a medical instrument used on more than a half-million people in the United States every year. AP Photo/dAmiAn dovArgAneS

a manufacturer’s cleaning instruc-tions are followed, infectious germs may linger in the devices. Their complex design and tiny parts make complete disinfection extremely dif-ficult, the advisory said.

In a statement, the FDA said it is trying to determine what more can be done to reduce such infections. But it said that pulling the device from the market would deprive hundreds of thousands of patients of “this benefi-cial and often life-saving procedure.”

“The FDA believes at this time that the continued availability of these devices is in the best interest of the public health,” the agency said.

More than 500,000 patients under-go procedures using duodenoscopes in the U.S. every year, according to the FDA.

CRE can cause infections of the bladder or lungs. Symptoms can include coughing, fever and chills. Healthy people usually don’t get CRE infections. The infections typi-cally occur in patients in hospitals, nursing homes and other health care settings. By one estimate, CRE can contribute to death in up to half of seriously infected patients, accord-ing to the U.S. Centers for Disease Control and Prevention.

National figures on the bacteria are not kept, but 47 states have seen cases, the CDC said.

AP Medical Writer Mike Stobbe in New York contributed to this report.

A research assistant with the David Geffen School of Medicine at UCLA carries a por-table cooler marked with a biohazard label past the Ronald Reagan UCLA Medical Center in Los Angeles, Thursday, Feb. 19, 2015. A “superbug” outbreak suspected in the deaths of two patients at UCLA Medical Center in Los Angeles has raised ques-tions about the adequacy of the procedures for disinfecting a medical instrument used on more than a half-million people in the United States every year.

AP Photo/dAmiAn dovArgAneS

March • 2015www.nursingmattersonline.com Page 3

nurses, doctors offered rural incentiveJeremy OlsonStar Tribune

There’s a bit of wanderlust in Dr. Michele Thieman, who worked in Washington, D.C., out of college, then spent a year outfitting canoeists in the Boundary Waters, then pur-sued an advanced degree — not in medicine — before finally applying to medical school.

So even though she liked the notion of practicing medicine in a rural area, locking Thieman in one place with a financial incentive prob-ably wasn’t a bad idea. She received state loan forgiveness on her stu-dent debt for two years in exchange for a commitment to practice in Park Rapids and Walker, near the Mississippi River headwaters.

“Knowing I had that money and that commitment made it a given,” she said. “I wasn’t leaving.”

A shortage of rural health care pro-viders, combined with the success of Minnesota’s current loan forgiveness program, is creating momentum at the Legislature for a plan to nearly triple the funding for these incentives — and perhaps extend them to other medical professionals.

Rural Minnesota is expected to face a shortage of at least 800 doc-tors in the next decade — a result of looming retirements and a lack of interest among medical students to do primary care — when at the same time the aging of its population will increase the need.

“We have a critical need for these providers,” said Steve Gottwalt of the Minnesota Rural Health Association.

The deal is that doctors, dentists, nurses and others agree to practice for three to four years in sections of Minnesota designated as health care shortage areas, and in exchange receive $5,000 to $30,000 per year to cut down their student loan debt.

Considering that doctors enter practice owing $170,000 or so for their medical education, and dentists have loan debts exceeding $200,000, the incentives have allure.

Rep. Deb Kiel, R-Crookston, wants to increase state funding from $740,000 per year to $3 million. That would fund an additional 50 loan forgiveness awards per year,

and more than replace state budget cuts from 2011.

The incentives seem to work. Of the 192 doctors who received loan forgive-ness in Minnesota since 1991, 75 percent are still in rural areas; among den-tists and nurses, more than half stayed in rural practic-es after their commitments ended.

“The intent is not just to have them plant them-selves for five years,” Kiel said, “but to actually build a career … in an area that needs medical help.”

Friends and neighborsThe loan forgiveness

concept was immortalized by the TV show “Northern Exposure,” in which a true New Yorker took the money to practice in remote Alaska. But just how much it changes doc-tors’ decisions isn’t entirely clear. Thieman, for instance, already want-ed to practice in rural Minnesota; her residency had been in Park Rapids.

Dr. Andrea Westby has received awards for three years to practice in Perham and in her hometown of Pelican Rapids. She is thrilled, even though her friends and relatives had varied reactions.

“Some absolutely can’t wait to have me as their doctor, just because they know I know them,” said Westby, 33. “Then there are some who go, ‘You know, I just know a little bit too much about you, and you know a little bit too much about me to have that relationship.’?”

Even if loan forgiveness attracts doctors to locations in which they already intend to practice, that doesn’t bother Mark Schoenbaum, director of the Minnesota Department of Health’s Office of Rural Health and Primary Care. As they near the end of training, doctors are intensely recruited by clinics nationwide, and could be tempted to change plans, he said.

“Loan forgiveness can be the tie-breaker,” he said.

Thieman, 40, is settled in Park Rapids, where she raises a child with

her husband, also a doctor. But there were times when she might have bolted if it wasn’t for the loan sup-port. A takeover of her clinic group resulted in changes and stresses, and colleagues departed — some for urban practices — and left the group shorthanded.

“There were days when I was like, ‘Ugh, God, really?!’?” she said.

But who will qualify?Westby said the allure of rural

primary care is the variety. She recalled a recent day when she treated a woman going through a divorce for stress-induced heart problems, then a 90-year-old woman with dizziness, then deliv-ered a baby. She once thought she’d never practice in a rural area, but now she can have lunch with her grandma each week and treat “my farmers and my bankers” and oth-ers she knows well.

“It’s fun to take care of people when you know them as people,” she said.

Many rural areas lack dentists, nursing-home nurses and pharma-cists, who are already eligible for loan forgiveness. Some lawmakers want to add chiropractors, physical therapists, mental health providers, dental hygienists and public-health

nurses to the list. Doctors and den-tists would be eligible for larger indi-vidual awards, because their student-loan debts are higher, but the money would be tailored each year to the professions with the greatest needs.

The changes seem likely to pass.

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March • 2015 NursingmattersPage 4

nursing schools seek cure for shortage of educators

Lenore Sobota The Pantograph

BLOOMINGTON, Illinois – With her advanced degrees, Amanda Hopkins could make a lot more money as a practicing nurse rather than as an assistant professor of nurs-ing at Illinois Wesleyan University.

But Hopkins, in her second year at the university, said, “For right now, this fits for me… because my passion fits it. I love being able to see that translation of theory into practice. To me, it’s immediate grati-fication. Did it make sense for them? Did my teaching strategy connect with their learning strategy?”

With a looming nationwide nurs-ing shortage, the challenge for nurs-ing schools is to find more people with Hopkins’ passion to teach the next generation of nurses.

A faculty shortage was cited by more than two-thirds of nurs-ing schools responding to a recent American Association of Colleges of Nursing survey as a reason why all qualified applicants were not accept-ed into their baccalaureate pro-grams. The Illinois Board of Higher Education awards Nurse Educator Fellowships each year as a way to retain well-qualified nursing faculty.

Hopkins and Ed Reitz, an assistant professor of nursing at Illinois State University, were among 22 recipi-ents this year. Hopkins already had looked into professional develop-ment opportunities and a potential research project when she received a letter telling her the $10,000 sal-ary supplement that is supposed to be part of the fellowship would not be awarded this year for budgetary reasons.

The money has been frozen as “non-essential spending” under an executive order from the governor, according to a board spokesman.

Even without the money, the rec-ognition is nice, said Reitz, but he also was pleased to see ISU’s online nursing program – which he teaches – listed among the top 100 Best Online Nursing Programs by U.S. News and World Report earlier this

year.Both Hopkins and Reitz are

the first people in their families to graduate from college. Reitz grew up on Bloomington’s west side and graduated from ISU in 1982 – with a criminal jus-tice degree. Reitz took what he describes as a “zig-zag” path that led to nursing, then teach-ing, after earlier positions as a social worker and detoxification counselor.

He considers teaching a “dream job.” He said he likes the educational stimu-lation and the students.

“They’re young and they keep me young being around them,” he said.

Catherine Miller, interim dean of ISU’s Mennonite College of Nursing, said although the number of doctoral graduates in nursing is increasing, so are the opportunities. Full, associate and assistant professors at ISU are required to have doc-toral degrees; instructional profes-sors, who teach the bulk of under-graduate classes must have master’s degrees, Miller said.

IWU requires its full-time nurs-ing faculty to have doctoral degrees. But filling positions is difficult, said Vickie Folse, director of IWU’s School of Nursing.

An opening in the sociology department, for example, might attract hundreds of qualified appli-cants, she said.

“With nursing, we get fewer than 10 who meet the qualifications,” Folse said.

Nursing salariesThe problem is nationwide. The

limited pool of doctoral-prepared faculty was cited by 31.4 percent of schools responding to the American Association of Colleges of Nursing survey on the difficulty in finding nursing faculty. Noncompetitive sal-

aries, compared to those in nursing practice, were cited by 28.4 percent.

At ISU, the starting salary for an assistant professor ranges from $70,000 to $74,000, depending on experience, expertise and years of teaching, according to Miller. By comparison, a nurse practitioner can make $85,000 to $90,000 a year.

Salaries at Heartland Community College are governed by a collec-tive bargaining agreement and vary according to experience and teaching load, said Becky LaMont, Heartland’s dean of health and human services. A nine-month faculty position can range from about $45,000 to near-ly $50,000, she said, with summer teaching assignments putting it into the $50,000 range.

But salaries and a shortage of doc-torally prepared nurses are only part of the problem.

Nationally, the average age of

nursing professors is 61 and the aver-age age of associate professors in nearly 58, Miller said.

“Within the next 5 to 10 years, we’re going to see a huge turnover due to retirement,” she said.

A shortage of clinical sites also limits the ability of programs to grow. The Twin City schools use clinical sites in Peoria, Springfield and else-where in addition to Bloomington-Normal. The three nursing programs work well together, particularly in sharing clinical sites, according to the heads of the programs. But LaMont said in her travels to other parts of the state, she has not always seen the same collaborative, support-ive relationship among schools.

“We trust each other,” Miller said. “We’re focused on the health out-come of the patients and the educat-ing the best nurses that we can.”

Illinois Wesleyan University assistant professor of nursing Amanda Hopkins teaches a nursing class. She could make a lot more as a practicing nurse, but has a passion for teaching.

AP/Steve Smedley/PAntAgrAPh


school nurses work toward positive outcomes Bette Carr, MSN, RN, NCSN

School nurs-es are an integral part of healthcare teams that strive to improve health out-comes for children

with chronic conditions. Traditionally these teams have included only mem-bers from the clinical or healthcare setting, but that reality is changing.

According to the Child and Adolescent Health Measurement Initiative, 15 percent to 20 percent of children and adolescents in schools have chronic health conditions. This includes asthma, seizures, diabetes and severe allergic reactions, as well as unusual and complex health condi-tions requiring complex nursing care.

As more emphasis is placed on quality-care measures and “patient-centeredness healthcare” due to the Patient Protection and Affordable Care Act, healthcare providers out-side the school setting will want to become more involved in communi-cating with school nurses about treat-ment and care plans for their pediat-ric and adolescent patients. Children are usually at school for at least seven to eight hours a day, and coor-dinated and consistent-quality care is important for improved health out-comes, student safety and decreased absences.

The perception of the school nurse being someone who just places ban-dages on cuts or checks heads for lice must be abandoned. The school nurse must now be viewed as an extension of the professional team of caregivers. School nurses provide care coordination within the school environment for students with health conditions. This can sometimes be challenging.

School nurses are key to pro-viding valuable feedback to parents and medical providers on a child’s medication efficacy and treatment-plan progress. Completing health assessments and patient education on chronic health conditions is also an important role of the professional school nurse. School nurses advocate for quality care for their students and are resources for families as they

Bette Car

maneuver through the intertwined systems of healthcare and education.

In Wisconsin, there are more than 500 school nurses, and yet more than 100 of 426 school districts are without a district-hired school nurse. Funding for school nurses is difficult due to schools being strapped with other teaching and academic needs. It is almost impossible, however, to teach children who are not ready to learn due to a compromising health condition. A student with asthma or diabetes who does not receive appro-priate care will find it difficult to con-centrate on math and reading.

School nurses have their own stan-dards of practice they are required to follow. These 17 standards were developed by the American Nurses Association in collaboration with the National Association of School Nurses. A school nurse is held accountable for his or her practice and must be giving care that is acceptable and evidence-based. Professional development, professional learning plans, and keeping up with not only changes in the education system, but the healthcare system, too, are expected of a school nurse.

School nurses are leaders in schools; they collaborate with their pupil service colleagues; they con-nect with the teaching and adminis-trative staff; and they must be able to communicate well with parents, school staff and students when facili-tating care for children. School nurses must be knowledgeable about a wide variety of local resources and how to access them.

The Wisconsin Department of Public Instruction works with school nurses and districts to provide guid-ance regarding healthcare in the school setting. Visit http://sspw.dpi.wi.gov/sspw_schlnurse for extensive resources. In collaboration with sev-eral other agencies, there are also projects that have been developed to expand and enhance school-nurse resources for working with children with healthcare needs. The Wellness Improves Learning for Youth proj-ect is a collaboration between the Department of Public Instruction, the Wisconsin Department of Health Services and the Centers for Disease Control and Prevention, focused on improved care and decreased absences for students with chronic

healthcare conditions. Visit http://sspw.dpi.wi.gov/sspw_schoolhealth-project for more information. The Wisconsin Improving School Health Services project – visit http://www.wishesproject.org – developed by the Wisconsin Public Health Association, offers school nurses training resourc-es and best-practice policies and pro-tocols. Another resource that many Wisconsin school nurses are using is eSchoolCare, through the University of Wisconsin, School of Nursing.

Although some say schools should not be burdened with needing to provide health services for children, one would argue that children can’t learn if they can’t breathe well, or if their blood sugar is too low or if they are having frequent seizures. School nurses, in partnership with families, students, and medical pro-viders, work tirelessly to implement plans to reduce the barriers for chil-dren to learn and to improve health outcomes.

Contact the author at [email protected] for more information.

Wisconsin Department of Public Instruction School Nurse and Health Services Consultant

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nurse by day, writer by night

Jeanne KolkerThe Wisconsin State Journal

“I’m surprised by how much the inside of a dead body smells like the inside of a live one.”

So begins “Working Stiff,” the first in a series of mysteries starring deputy coroner Mattie Winston.

Mattie’s creator Beth Amos – writ-ing under the pseudonym Annelise Ryan – came up with that first sentence while witnessing an autopsy during her years of schooling to become a nurse.

“The first autopsy I saw was on a teenager who had fallen into the James River (in Virginia, where she was living) several months before and had finally surfaced a few months later,” said Amos, who now lives in Stoughton.

She admits she was nervous about witnessing her first autopsy.

“I didn’t want to embarrass myself by throwing up or passing out or any-thing,” she said.

When the doctors cut into the body, it was the smell – a smell just like sur-gery – that surprised her.

“The first thought I had was the smell of the inside of a dead body isn’t all that different from the inside of a live one,” she explained. “As soon as I thought that, my brain went, ‘What a great first line for a book.’”

Her character of Mattie Winston was born.

Amos has been charting Mattie’s exploits in a series of books begin-ning with “Working Stiff,” followed by “Scared Stiff,” “Frozen Stiff,” “Lucky Stiff,” “Board Stiff” and most recently “Stiff Penalty,” just out from Kensington Books.

While blood and guts certainly play a part in her mysteries, her wry writing style also manages to tickle the funny bone for readers.

“Humor has always been a big part of my life, and it’s an important coping mechanism for people in the medical field, for those people who work in the fields of death and dying,” she said.

Today, she’s an emergency room nurse, but she has worked the gamut from birth to death, spending time in obstetrics and hospice.

Her heroine, Mattie Winston, is a deputy coroner in the fictional town of Sorenson, Wisconsin, which her cre-ator admits looks a lot like Stoughton. In “Stiff Penalty,” Mattie investigates the case of a high school math teacher who turns up dead with a barbecue fork to the heart.

Amos also writes mysteries as Allyson K. Abbott, a pseudonym that doubles as a tongue-in-cheek acronym. She jokes she uses two fake names for her books.

“I’m an E.R. nurse, and I figure my patients don’t want to know that I spend my spare time thinking up fun ways to kill people,” she said.

Truth be told, she writes under dif-ferent names for marketing reasons. Annelise Ryan writes about Mattie Winston, and Allyson K. Abbott writes about a synesthetic bar owner named Mack Dalton. But before those two personas were published, Amos was writing under her real name back in the 1990s. For a fresh start, she assumed the noms de plume.

The thrillers Amos concocts tend to have an equal mixture of suspense, laughter and romance.

“Any good story has a little bit of all of those things in it,” she said.

Life, after all, holds a blend of emo-tions and challenges any run-of-the-mill working stiff needs to contend with.

And, despite her assertion that she’s always been obsessed with death, all of Amos’ books have a fairly strong romantic underlying plot.

Because?“I’m a romantic at heart,” she

admitted.

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neumueller to Provide Medical services at Aspirus FastCare in

Abbotsford Abbotsford – Family Nurse

Practitioner Caroline Neumueller, MSN, RN, FNP-BC, CEN, is set to provide expert medical care at Aspirus FastCare in Abbotsford. Located in Abbotsford’s East Town Mall, Aspirus FastCare is a retail health clinic offering basic health-care services.

Neumueller said she decid-ed to join the Aspirus FastCare-Abbotsford staff because she enjoys caring for people in a small com-munity. She said she loves work-ing with children and anticipates treating a large number of pediatric patients at the clinic.

“Aspirus Medford Hospital and Clinics is an excellent leader in central Wisconsin for accessible, efficient healthcare,” Neumueller said. “It is only appropriate to con-tinue expanding our area of service by including the community mem-bers of Abbotsford. They deserve to have high-quality healthcare that is located at their doorstep and I am excited to be involved in providing that service to them. I feel like a pioneer who is homesteading on a new frontier.”

FastCare clinics offer convenient and economical healthcare for minor conditions and symptoms, includ-ing allergies, rashes, earaches, sinus infections, sore throats, flu or cold symptoms, bladder infections, pink eye and more.

FastCare accepts most insurance coverage; office-visit co-pays apply. For those with a high-deductible plan or no insurance, a FastCare visit is $54 including lab. FastCare takes walk-in patients only.

Neumueller began her career in 1999 with Aspirus Medford Hospital, as an emergency-department techni-cian. In 2005 she began providing care as a registered nurse in the department. In 2014, she became a

Family Nurse Practitioner. She also has experience as a nursing instructor at Northcentral Technical College.

Neumueller earned her associate degree in nursing from Northcentral Technical College, and her bach-elor’s and master’s degrees in nurs-ing from the University of Phoenix. She earned her certification as a Nurse Practitioner from Concordia University. She is a member of the American Association of Nurse Practitioners, the Wisconsin and American Nurses Associations, and the Emergency Nurses Association.

In her free time, Neumueller said she enjoys hunting, fishing, reading, scrapbooking and doing needlework. She and her husband, Randy, have six grown children and four grandsons, with a granddaughter arriving in late January.

Aspirus is a non-profit health-care system with a broad network of clinics and hospitals throughout central and northern Wisconsin and the Upper Peninsula of Michigan. Visit www.aspirus.org for more information.

Contact Kaye Lillesand,editor of

Nursingmatterswith news or events youwould like to submit at

608-222-4774

or

email [email protected]

Assistant Professor of Nursing

The Henry Predolin School of Nursing at Edgewood College announces the opening fortwo full-time tenure track faculty positions beginning with the academic year 2014-2015.Responsibilities include teaching at the undergraduate and graduate (MSN and DNP) levels.Graduate concentrations include Nursing Administration and Leadership.

Qualifications:• Earned PhD in Nursing (preferred), or doctorate in related field with a Master’s degreein Nursing; DNP may be considered

• Eligible for RN licensure in the State of Wisconsin• Evidence of teaching, scholarly and community services potential• Knowledge and skills in contemporary practice issues related to the AACN Essentials• Demonstrated commitment to promoting diversity, inclusion, and multiculturalcompetence

To Apply: Send a letter of application, resume, and references to:Edgewood CollegeHuman Resources – APN11000 Edgewood College DriveMadison, WI 53711www.edgewood.eduE-mail: [email protected] Equal Opportunity Employer


evidence: the ultimate game changerStandard for excellence in nurse staffing is set

By Joan Ellis Beglinger, MSN, RN, MBA, FACHE, FAAN

The nursing profession is com-prised of the larg-est group of clini-cians participating

in the delivery of healthcare in this country. Numbering more than 3 million, nurses are the largest sector of the health professions. Nursing is practiced in virtually every setting in which healthcare is delivered, from the home to hospitals, clin-ics, nursing homes and hospices. Though nursing care has been, or will be, experienced by everyone at some stage of life, it is ironic that the work of the profession is often poorly understood by those who are recipients of its services, by col-leagues in other clinical disciplines and by those who administer health-care organizations.

Nursing has not clearly commu-nicated the nature of its work to its public. It has also been less effec-tive than it must be in assuming ownership of all the accountabilities

that comprise any clinical profession – defining practice, managing qual-ity, assuring competence, generating and validating the knowledge base of the discipline, and managing the resources essential to the work. The result has been detrimental to the care of patients across the country in many settings, but nowhere more acutely than in hospitals. Since the early 1980s, the pressure of declin-ing reimbursement to hospitals has resulted in decisions related to nurse staffing that have at times created unworkable and even unsafe prac-tice environments. The Institute of Medicine Report on the Future of Nursing identifies that high turnover rates among new nurses continues to be a concern. Nurses, disenchanted with practice environments that do not support excellence and may even pose risks to patient safety, have left those settings.

Nurses are knowledge workers. While much of what nurses do in the form of tasks is observable – such as administering medication, teaching a patient, or changing a dressing on a wound – the essence of nursing practice is not. Nurses, in caring for

patients, are engaged in a continuous process of interpreting a broad array of objective and subjective informa-tion. The information is gathered through a variety of means including observation, physical examination, conversing with the patient and/or family, and review of diagnostic-test results. Nurses interpret and assign meaning to the information by draw-ing on a vast knowledge base from physical and social sciences, lib-eral arts, practice wisdom and intu-ition. They make judgments about the significance of the information and decisions concerning appropriate intervention. Continuous evaluation of practice interventions for desired outcomes rounds out what has come to be known as “nursing process.”

Effective nursing practice is dependent upon the nurse’s ability to know the patient’s “story,” includ-ing pertinent history, co-morbidities, present illness, culture or beliefs, family support, education and any compounding variables that might impact his or her interpretation of the patient situation. Subtle changes in a patient, which may precede a signifi-cant change in condition, can only be noted if the nurse has the oppor-tunity to remain in adequate contact with the patient. Research has dem-onstrated that an expert nurse can often intuitively detect deterioration in a patient’s condition before there are any objective findings to sup-port that conclusion. Further, stud-ies have shown that an assignment of too great a number of patients to a nurse may result in “failure to rescue,” that is, impending signs of patient deterioration are missed because of inadequate opportunity to observe the patient first-hand. Research continues to contribute to the growing, and irrefutable, body of evidence that patient outcomes are improved with increased RN staff-ing, positive practice environments and greater percentages of BSN-prepared nurses. The Principles and Elements of a Healthful Practice/Work Environment, developed by the American Organization of Nurse Executives in 2004, supports the

presence of adequate numbers of qualified nurses as important to the provision of quality care to meet the patient’s needs. In the absence of research-based evidence to guide us, decisions about “adequate numbers of qualified nurses” have historically been largely opinion-based. As we move forward, these methods must be replaced by decisions based on best-available evidence.

In 2005, the Wisconsin Organization of Nurse Executives published its first evidence-based position paper on nurse staff-ing entitled, “Guiding Principles in Determining Appropriate Nurse Staffing: Standards of Practice for Acute Care in the State of Wisconsin.” The standards were developed to reflect the best-available evidence and the process involved, eliciting input on the draft document from all organization members, as well as support from the Wisconsin Nurses Association.

In 2014, one of the strategic prior-ities identified by the organization’s Board of Directors was to “broadly disseminate the evidence that links nurse staffing, practice environments and education levels to patient out-comes.” There has been significant research conducted and published in recent years that has provided the much-needed evidence to take us from opinion-based to evidence-based staffing decisions. The 2010 report from the Institute of Medicine on the Future of Nursing creates additional urgency to ensure nurses are well positioned to “lead change to advance health.” The staffing standards, first published in 2005, have been revised to reflect contem-porary understandings of the rela-tionships of nurse staffing, practice environments and BSN preparation to patient outcomes. Current evi-dence requires we expand our under-standing of excellence in staffing to a holistic and systemic approach that encompasses the downstream out-comes and sustainability of staffing decisions. The title of the document has been changed to both “raise the

Joan Ellis Beglinger

continued on page 12

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Publishing honored with eight awardsINDIANAPOLIS – Eight books

published by the Honor Society of Nursing, Sigma Theta Tau International, were honored in January.

The annual awards from the American Journal of Nursing rec-ognized six of the books with a first place, which gave the honor society more first-place awards than any other publisher honored.

The award recipients are as follows:Re-Entry: A

Guide for Nurses Dealing with Substance Use Disorder received a first-place award in both the History

and Public Policy, and Professional Development and Issues catego-ries. Focused on helping the one in 10 nurses who have struggled with substance abuse, authors Karolyn Crowley and Carrie Morgan provide practical advice through case studies and first-person narratives for nurses to overcome addiction and return to the nursing profession.

Population-Based Public Health Clinical Manual: The Henry Street Model for Nurses, Second Edition received first place in Community/Public

Health. Authors Carolyn Garcia, Marjorie A. Schaffer and Patricia M. Schoon build on the Henry Street Consortium’s framework of 11 competencies for population-based entry-level public-health nursing in a variety of settings.

The Nerdy Nurse’s Guide to Technology received first place in Information Technology/Social Media. In a tone

that is entertaining and easy to understand, author Brittney Wilson shares practical tools to help nurses embrace technology in the work-place.

Staff Educator’s Guide to Clinical Orientation: Onboarding Solutions for Nurses received first place in Nursing Education/

C o n t i n u i n g E d u c a t i o n . Authors Alvin Dean Jeffery and Robin L. Jarvis help nurses create and sustain a qual-ity orientation pro-cess to meet the

needs of the organization and the patient while setting up new nurses for success.

Person and Family Centered Care received first place in the Nursing M a n a g e m e n t /Leadership catego-ry. The book offers

new and practical advice for taking a different approach to the traditional model of patient-centered care. Jane Barnsteiner, Joanne Disch and Mary K. Walton take the approach that care begins with the person while embracing family and encompassing all care-delivery locations.

M a s t e r i n g Simulation: A Handbook for Success received a third-place award in the Information Technology/Social

Media category, and Transforming Interprofessional Partnerships: A New Framework for Nursing and Partnership-Based Health Care received a second-place award in the Professional Development and Issues category.

“To receive eight of these awards, covering such a wide range of top-ics, is truly amazing,” said Honor Society Publisher Dustin Sullivan. “We are extraordinarily fortunate to work with authors who demonstrate such a broad expanse of expertise and quality of knowledge. These awards also reflect positively on the members of our editorial and pro-

duction teams, who show a similarly high level of skill in working with the initial ideas and bringing them to market in such a successful fashion.”

Nurses regard the Book of the Year Awards as the most important designation of excellence in book publishing. These honors are espe-cially meaningful for the honor soci-ety publishing group because it had 14 books published in the eligibility period, meaning that more than half of the books published in this time were recognized with a Book of the Year award.

Visit www.nursingknowledge.org for more information.

The Honor Society of Nursing, Sigma Theta Tau International is a nonprofit organization whose mission is to support the learning, knowledge, and professional devel-opment of nurses committed to mak-ing a difference in health worldwide. Visit www.nursingsociety.org for more information.

Why do you think you’re here?Brenda Zarth RN BSN

The art of listen-ing keeps resurfac-ing in my career as I transition from hospital, to home health and to clinic

nursing. I was a staff nurse 28 years ago

in a hospital on a medical/surgical unit. I liked to talk to my patients in the evening as I passed their bed-time meds and they lingered on the edge of sleep. Initially, lingering with them seemed almost selfish because my focus was on being an accu-rate and diligent nurse. Back then, I assumed the most important role of nursing was to interpret lab val-ues correctly, always being observant for signs and symptoms of infection or complications, to be diligent in gathering data and vital signs, and in charting everything.

The diligent part of nursing was more than a full-time job by itself.

Brenda Zarth

Often my patients were angry at the inconvenience of being laid up. They were trying to manage their lives from their hospital beds, shouting orders and trying to carry on their tasks by phone. I found it interesting that as evening wore on and business hours ended, these business people would often become reflective and say that maybe they needed this stop in their lives to reflect on who they were and where they were going. They were so busy managing the tasks of their daily lives and keeping all the balls in action that they had totally forgotten about any relation-ships with their families and friends. They were running in the fast lane, high on adrenaline, and they thought they would catch up with relation-ships later. But now they had the time to take stock of where they were, and analyze who cared whether they lived or died. Often they didn’t like what they saw.

After 10 years I went into Home Health, and my focus switched from

analyzing everything about Jane Doe’s pneumonia to looking at the big picture of everything she is and everything around her. For about two years I alternated daily between hospital and home-health nursing. I felt like I was asking my brain to swell and shrink every other day. I literally had headaches, because of the switching back and forth. The phrase “you can’t see the forest for the trees” had new meaning. It took me about 12 months to really learn how to see the forest. I had to learn the importance of the world as Jane perceived it – her overall health, her physical environment and the rela-tionships within her environment. I had more flexibility and focus in home health, and was able to look more deeply for the reason for her individual health problems.

I enjoyed the luxury of fully read-ing her history and physicals, and reviewing her chart as far back as available. But I was still under the



The 29th-annual Wisconsin Nurses Association’s Advanced Practice Registered Nurse confer-ence will be held April 30 through May 2 at the Monona Terrace and Convention Center, 1 John Nolan Drive, Madison. Conference reg-istration is now open. During registering for enrollment-limited Thursday-afternoon Preconference Sessions, priority will be given to practicing APRNs. If register-ing as a student and wish to be on the waiting list for any of the enrollment-limited sessions, contact Megan at the association office at [email protected] or 608-221-0383, ext. 203. Registration deadline is April 22.

Exhibitor registrations are also

open. Learn about opportunities to support this conference and reach nearly 600 attendees. Be a pro-gram patron, exhibit at the confer-ence or advertise in the conference program.

Overnight accommodations are available at the Hilton Madison Monona Terrace, at the Best Western Plus Inn on the Park or at the Sheraton Madison Hotel, all at special rates.

Mary Barker APRN scholar-ships will be awarded May 1 at the conference.

Visit www.wisconsinnurses.org or contact the WNA office at 800-362-3959 for schedules and regis-tration.

Mark the date now

Kim LamoreauxBaraboo News Register

After 14 years in offices on North Street in Prairie du Sac, the Good Neighbor Clinic has moved to what staff members say is a much bigger and better space in the emergency room of the former Sauk Prairie Memorial Hospital.

The entrance to the new clinic is at 95 Lincoln Avenue, on the north side, just around the corner of the building from the former emergency room entrance on 1st Street. The new clinic began seeing patients Feb. 2.

When the new Sauk Prairie Hospital opened last April, it left what would be a perfect space for pri-vately funded, free medical services under the auspices of St. Vincent de Paul of Sauk Prairie. With the move of the Good Neighbor Clinic, addi-tional space opens up for the dental

Good neighbor offers moreclinic also located on North Street.

Mary Ann O’Brien is a registered nurse and former nursing director for Sauk Prairie Memorial Hospital who has worked with the clinic since it opened in 1999.

“We love the space,” O’Brien said. “It’s much more private and it’s a more clinical setting.”

The new setting is about 3,000 square feet, several hundred more than on North Street.

O’Brien said there are still three treatment rooms, but extra space for staff needs. The clinic’s prescription nurse and office manager no longer need to share an office, and doctors have their own dictating room.

The patients’ waiting room is twice the size as the old one, as is the reception area. Good Neighbor Clinic board president Todd Pieper said the clinic might add one more

day per month to see patients.“I’m really proud of what this is

going to provide to the community,” Pieper said. “The biggest thing is we have much better privacy for patients. This is a group effort by a lot of really good volunteers.”

There are more than 30 volun-teers staffing the clinic, including up to 25 local doctors who find time to see patients there. The Good Neighbor Clinic medical services are

for those who have no state or fed-eral assistance or private insurance, and to those whose income is below 200 percent of Federal Poverty Guidelines. In 2012, $55,000 was donated to the clinic. It also receives funding from donations made through Sauk Prairie United Way.

“Our donors’ money goes directly to services for the patients,” O’Brien said. “All of our income is donated through the community.”

impression that my most important function was connecting the lab and diagnostic tests to her health prob-lems, assessing the medications she was taking and her response to them. Teaching her about her medications and how to take them correctly and filling out medication administration and teaching sheets. Assessing her diet, teaching her ways to improve her health and prevent re-hospital-izations. I case-managed her care and added physical therapy, occupational therapy, social work and community services as needed to improve the ability to fully achieve her optimal health.

Then I met Viola. Viola had chronic pain due to

Cauda Equina syndrome and should not have been able to walk. She couldn’t feel her feet on the floor and her legs were purple from her toes to half way up her thighs. She was able to walk with a walker or by holding onto the walls. She walked stiffly, using her legs like boards. It was my job to evaluate her pain, instruct in medications and pain management, and case-manage other services. But Viola didn’t like talking about her pain, and had a rule that the only way she would talk to me was if I sat down and had a cup of coffee and a donut with her first. After our cof-fee and donut, she was cooperative in discussing pain levels, reviewing medications and diet, assessing what she had tried before and working at adjusting pain meds based on the type of pain she was having. After about six weeks and several medica-tion-dose adjustments and different

YOU’RE HEREcontinued from page 9

drugs, I finally admitted to Viola that I didn’t have any more ideas and I was going to recommend that she be transferred to a different case manager.

She was livid. I had never seen her angry before, but she yelled at me and said, “How dare you think you’re God!”

I was totally confused. She said I had done more for her by talking to her, caring about her and shar-ing ideas with her than any other healthcare provider she had ever known. She said, “This is my pain, between me and God, and it isn’t yours to take away!” She had been told several years previously that she would not be able to walk; the pain would be unbearable. She had managed to mentally block the pain. She transferred her pain to thinking about other people’s families and lives, which gave her images and ideas to fill her mind. She would suck up the intricacies of our lives like a sponge. She didn’t like talking about her pain, because it caused her to let it in and think about it.

From that time forward, I decided to alter my practice and ask, “What do you want from Home Health? What are your goals; what would you like to work on? Why do you think you are sick?”

I focused on communicating to my patients that they are my primary focus; we are going to work toward meeting their needs and wants, and achieving their goals. My popularity rating grew. I received many “Thank You” notes from my patients, and my patients frequently asked for me by name. I was able to convince many of my Medicare patients that they


DEPARTMENT CHAIR,NURSING PROGRAM

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Office: 641-683-5200Monday thru Thursday

Fax: 641-683-5184Email: [email protected]

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they were too young to be old, and needed to go back to their hobbies or reasons for living. Our outcomes improved. They had hope, felt valued and had renewed purpose.

I’ve been a clinic nurse for almost two years now. I’m doing care coordi-nation and phone triage. I was curious what health concerns cause people to call in for advice or appointments. I discovered the most important reason seems to be the need to be heard, to know someone cares, and to know that someone will follow through with a request.

Sometimes they are chronically ill. I spoke with a gentleman with arm numbness. He walked in to report he was still having arm numbness that went from one arm to the other, never both, and only at night when he is lying down.

I asked, “What do you think is wrong?”

He said, “Hmm, no one has asked me that before. But I have been think-ing about that. When I forget my water pill and my legs hurt, my arms

YOU’RE HEREcontinued from page 10

don’t hurt. When I take my water pill, my legs feel fine and then one of my arms will hurt.”

We found out he always sleeps on his side, and he turns from side to side. I asked if it was the arm up in the air or the arm that he is lying on that hurts. He said he didn’t know; he would investigate and let me know. I guessed he might lack blood pressure in the arm that was higher than his heart. It’s

March • 2015 Nursingmatters

resources to assist nurse leaders who are charged with managing staffing budgets and in advancing evidence-based staffing decisions within their organizations. In order for healthcare organizations to be positioned to produce exceptional outcomes and experience for those who are served, it is critical they make the shift from opinion to evidence in management decision-making.

Note: Portions of this article were excerpted from the “Guiding Principles for Achieving Excellence in Nurse Staffing: Standards of Practice for the State of Wisconsin” with permission from the Wisconsin Organization of Nurse Executives.

EVIDENCEcontinued from page 8

Joan Ellis Beglinger has prac-ticed for 28 years as a tertiary medical center vice-president/ CNO, building expertise in transforming the professional practice environ-ment from traditional hierarchy to shared decision making through shared governance. She is a cham-pion of advancing the profession of nursing through investment in the direct-care nurse, enabling owner-ship of practice at the point of care. She is a Fellow in the American College of Healthcare Executives and in the American Academy of Nursing and is the 2015 President-Elect of the Wisconsin Organization of Nurse Executives.

possible our questions could save this gentleman from having an ultrasound to check for an obstruction, or a CT or MRI to look for other points of pres-sure or constriction.

My patients need to know they are my main focus. They have my undivided attention. I really want to hear and understand what they are saying. They often have spent a lot of time analyzing what is happening to

them and often have valuable insight. Listening can’t be rushed; pain and frustration is often born of unrealis-tic fear. I’m encouraged that the Art of Nursing and listening seem to be gaining ground in the role and focus of Case Management.

Nurse training encompasses the whole of a person, so who better to focus on all that a patient brings to the table than a nurse?

bar” by articulating “excellence” as the desired outcome – as opposed to “appropriate” – and expand the use of the standards beyond acute care to every setting in which nurs-ing is practiced. The title of the 2015 revision is “Guiding Principles in Achieving Excellence in Nurse Staffing: Standards of Practice for the State of Wisconsin.”

The standards have now been finalized and are available at w-one.org – located under Publications/ WONE Positions. In 2015, the Wisconsin Organization of Nurse Executives is developing a tool kit of

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Nursing Matters March 2015