Voice, Winter 2012

william f. connell school of nur sing Winter 2012

voice

on the spot Disaster simulation heightens community health training

From the Dean

Susan Gennaro

Dear Friends, I’ve been thinking lately about something I’ve appreciated and admired for some time: the behind-the-scenes work nurses do every day. Millions of people encounter nurses every day in hospitals, doctors’ offices, and community health settings. However, they may not understand all the preparation and scholarly investigation that go into designing, providing, and researching quality health care.

This issue of Voice magazine is abuzz with stories of new programs, projects, and research that take place outside the public’s eye. One feature looks at the groundbreaking research of Assistant Professor Allyssa Harris, who is studying whether a genre known as hip-hop literature encourages risky teenage behavior. The issue also reports on Associate Professor Pamela Grace, who—with colleagues at Massachusetts General and the Brigham— has developed a clinical ethical residency for nurses. And it covers how students in our community health courses train for the unthinkable in a new CSON disaster simulation.

I hope you enjoy reading the latest news from the Connell School campus— and that you take note of two exciting events coming up this spring: the Pinnacle lecture on Tuesday, April 10, and Reunion on Friday, June 1. You can read more about both on the back cover of this magazine and on our web site at www.bc.edu/cson.

I hope to see you at one of these events or in a continuing education course at CSON soon.

Best,

Susan Gennaro Dean

dean Susan Gennaro editor Maureen Dezell

contributors Elizabeth Dougherty Rachel Kossman Debra Bradley Ruder

managing editor Tracy Bienen

Photograph: Gary Wayne Gilbert

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photographers Caitlin Cunningham Rachel DiFazio Gary Wayne Gilbert Justin Knight Lee Pellegrini Frank Siteman

Voice is published by the William F. Connell School of Nursing and the Boston College Office of Marketing Communications.

Letters and comments are welcome: csonalum@bc.edu Communications Specialist William F. Connell School of Nursing, Boston College 140 Commonwealth Avenue Chestnut Hill, MA 02467

Winter 2012 news

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4 Recent AAN inductees, a CSON showcase at Sigma Theta Tau, a March of Dimes tribute to two of our own, a Pinnacle lecture, and a new Jonas Scholar

features 6 Urban lit: Do books change teens’ behavior?

Exploring the popularity and power of urban literature

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10 On the spot: Disaster simulation heightens community health training Bringing the human dimension to handson learning

14 Bedside matters: New residency helps nurses untangle ethical knots Navigating fraught scenarios in criticalcare settings

16 Dealing with ethical duties and dilemmas

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A nursing life lesson

achievements 17 Faculty Publications

14 Top left: Katherine Gregory. Photograph: Justin Knight Top right: Flyy Girl book jacket (detail), reprinted with the permission of Simon & Schuster, Inc. and Jody Hewgill from Flyy Girl, by Omar Tyree. Jacket illustration by Jody Hewgill. Jacket design by Jackie Seow (New York, 1996). Photograph: Gary Wayne Gilbert Middle: Ashley Thibodeau ’12, Jennifer Tomlich ’12, and Kathryn Daileader ’12 confer at the nurses’ station. Photograph: Gary Wayne Gilbert

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Bottom: Ellen Robinson, M.S. ’83, Ph.D. ’97 (right) at Massachusetts General Hospital’s Ethics Rounds. Photograph: Gary Wayne Gilbert

On the cover: CSON faculty and staff play the roles of patients and first responders during a simulated community health disaster (see page 10) in December 2011. Clockwise from left: Alanna Marciante ’12; Clinical Assistant Professor Donna Cullinan; Jennifer Tomlich ’12; Gabriella Sehne ’14; and Arlene Ross, administrative assistant, Nurse Anesthesia Program. Photograph: Gary Wayne Gilbert

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News from the Connell School alumni inducted into aan Moreen O. Donahue ’68, senior vice president and chief nursing officer of the Western Connecticut Health Network in Danbury, and Mairead Hickey ’72, executive vice president and chief operating officer at Boston’s Brigham and Women’s Hospital, were among 142 nurse leaders inducted into the American Academy of Nursing in October. Donahue is respon-

sible for the professional practice of nursing, nursing education, and research for the health network, which comprises Danbury Hospital, New Milford Hospital, and their affiliated network of providers and services. A former chief nurse and senior vice president for patient care at the Brigham, Hickey is the first nurse to hold her current position.

cson showcase at sigma theta tau Ten students, alumni, and faculty traveled to Grapevine, Texas, in late October to attend the 41st Biennial Convention of Sigma Theta Tau International, the Honor Society of Nursing, where they presented “Fostering the Development of Future Leaders in Global Health through the Keys to Inclusive Leadership in Nursing Program (KILN),” a three-panel program that showcased student experiences in South Africa, Switzerland, Ecuador, and Panama.

Siobhan Tellez ’13 described how a Siobhan Tellez ’13, Djerica Lamousnery ’11, Paulina Miklosz ’12, and Sabianca Delva ’12 at trip to Panama on a Boston College the Sigma Theta Tau convention. Photograph: Ph.D. candidate Rachel DiFazio, M.S. ’96 Advanced Study Grant helped increase her fluency in conversational Spanish University. Djerica Lamousnery ’11 recounted her experiand familiarity with Spanish medical terminology while ences volunteering at mobile clinics in underdeveloped she practiced basic clinical skills. Paulina Miklosz ’12 communities surrounding Cape Town, South Africa. recalled her semester abroad in Quito, Ecuador, where Faculty members Donna Cullinan, Allyssa Harris, she took all her classes in Spanish, completed a nursing Catherine Read, and Judith Vessey, and KILN project internship, and explored disparities in health care delivdirector Debra Pino also attended the symposium, along ery and the role of nursing in Latin America. Sabianca Delva ’12 talked about meeting and working with nurses with Dean Susan Gennaro, the editor of the honor socifrom the U.S., Singapore, India, Canada, and Switzerland ety’s Journal of Nursing Scholarship, who offered a workat the Switzerland Board of Higher Education’s Summer shop on writing for journals.

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march of dimes lauds faculty, alumni The Massachusetts chapter of the March of Dimes presented two of its ten 2011 Nurse of the Year awards to Connell School alumni in December. Connell School Assistant Professor Katherine Gregory was honored in the nurse researcher category. Heidi Fantasia, M.S. ’97, Ph.D. ’09, a nursing professor at the University of Massachusetts-Lowell, received the organization’s Nurse of the Year award in women’s health.

The March of Dimes mission is to improve the health of babies by preventing birth defects, premature birth, and infant mortality through research, community service, education, and advocacy.

Assistant Professor Kate Gregory examines a patient in Beth Israel Deaconess Medical Center’s neonatal intensive care unit.

Photograph: Lee Pellegrini

fall pinnacle lecture Nurses should prepare to take on leadership roles in global health care, Karen H. Morin, president of the Honor Society of Nursing, Sigma Theta Tau International, told an audience of more than 80 people who turned out for her fall Pinnacle lecture, “Lessons Learned: Leadership in a Global World.” A professor and director of graduate programs at the University of WisconsinMilwaukee School of Nursing and an accomplished author, investigator, and presenter, Morin highlighted the distinct skills and abilities required of nursing leaders in the global arena.

ph.d. candidate named jonas scholar The National League for Nursing named Brian French, M.S. ’09, one of its five 2011–2012 Jonas Scholars.

French is writing the dissertation Caregivers’ Perceptions of Nurse-led Discharge Interventions: Knowledge Needed for Adequate Care of a Technology-dependent Infant in the Home Setting.

Established with a $75,000 grant from the Jonas Center for Nursing Excellence, which supports doctoral research in nursing education, the program selected its first group of scholars in 2010. Lisa Wolf, Ph.D. ’11, was among the inaugural group.

Karen H. Morin delivers the November talk in the Pinnacle Lecture Series, which brings a nursing leader to campus each semester.

Photograph: Caitlin Cunningham

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URBAN LIT Do books change teens’ behavior?

BY ELIZABETH DOUGHERTY

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Urban fiction bestsellers: The Coldest Winter Ever reprinted with the permission of Atria Books, a division of Simon & Schuster, Inc. and Michel Legrou, PMG, from The Coldest Winter Ever, by Sister Souljah. Front cover photo by Michel Legrou. Art and design by Lisa Litwack (New York, 1999). Flyy Girl reprinted with the permission of Simon & Schuster, Inc. and Jody Hewgill from Flyy Girl,

by Omar Tyree. Jacket illustration by Jody Hewgill. Jacket design by Jackie Seow (New York, 1996). Photograph: Gary Wayne Gilbert

ive years ago, in the waiting room of

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Roxbury Comprehensive Community Health Center, women’s health nurse Allyssa Harris ’94, M.S. ’99, Ph.D. ’08, noticed a number of young female patients reading novels like Flyy Girl, by Omar Tyree, and Sister Souljah’s The Coldest Winter Ever. Gritty comingof-age stories set in the contemporary urban ’hood and packed with vivid details of sexual promiscuity, abusive boyfriends, drug dealing, and other criminal behavior, the books are classics of urban fiction, a wildly popular if controversial genre sometimes called hip-hop lit, street lit, or gangsta lit.

A certified women’s health nurse practitioner and Connell School assistant professor, Harris at the time had just started work on her doctoral dissertation examining factors that influence African American women’s contraceptive choices. She began to wonder if the books—which frequently feature teen protagonists and plots packed with illicit activity, explicit sex, and violence—might influence young adolescents’ birth control decisions.

Like any good scholar, Harris did her background research. She reviewed literature on media influence on adolescents and asked patients and staff at the clinic what books they liked to read. She visited African American bookstores and went to the Harlem Book Festival. She learned that urban lit’s widespread appeal to young, mostly female readers is a source of some debate among African American educators, librarians, writers, and artists. (See sidebar, page 9.) But she found no studies exploring connections between reading choices and health; no clues to information that might link books to risky behaviors.

In 2008, Harris undertook a small qualitative research study that suggested that some of the themes in urban lit might indeed affect sexual health decisions among young African American women. She published her findings in the July issue of the Journal of the National Black Nurses Association and wrote a column summarizing her research for the Huffington Post.

Harris plans soon to undertake a more rigorous study that will survey hundreds of adolescent African American women about their reading choices and sexual behaviors. Ultimately, she hopes to use what she learns to find ways of communicating more effectively with young girls about their sexual habits and health.

True to life in the ’hood Whether and to what extent media depictions of sex, violence, and crime influence children’s behavior has been a subject of public inquiry and extensive study since at least the early 1950s, when Congress held its first hearings on violence on radio and television.

Evidence overall suggests that media exposure to risky behavior, such as violence or unprotected sex, makes that behavior seem normal, says Michael Rich, associate professor of pediatrics at Harvard Medical School and director of the Center on Media and Child Health at Children’s Hospital Boston. “Media exposure to risky behavior makes it appear less risky.”

But the influence of books on sexual behavior? “This is a new area of exploration,” says Joellen Hawkins, professor emeritus of maternal and child health at Boston College and Harris’s thesis advisor, who calls her former student a “gifted” nurse, particularly in her work with adolescents.

As Hawkins sees it, Harris has made a signal contribution to nursing simply by raising awareness that urban lit exists. It is an area of critical importance for nurses, says Hawkins. “We’re the ones who care for adolescents as they are emerging in their sexuality.” Often, nurses don’t know what their patients are reading, she observes. “It’s important to know where the adolescents are getting their information—or misinformation, as the case may be.”

That is especially important when caring for African American adolescents, according to Harris.

A Washington University School of Medicine study in 2009 found that 74 percent of African American girls under 17 were sexually active, nearly three times more than Asian girls (28 percent) and significantly higher than whites (58 percent) and Latinos (59 percent). According to the Centers for Disease Control and Prevention, African American adolescents also have higher rates of sexually transmitted infections, including HIV/AIDS. “I’m looking for ways to change those numbers,” says Harris. In her nursing practice, she counsels young women to use condoms, to use birth control, to stop having sex with men who have multiple partners. But the young women don’t always listen. “I couldn’t understand what was driving my patients,” she said. Urban fiction gave her a glimpse, if perhaps exaggerated, into their worlds.

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Harris picked up her first urban lit title, B-More Careful,

by Shannon Holmes, in a Barnes & Noble in 2005. It took her six months to get through it; the story was so graphic, she kept putting the book down. “Pardon my language,” she says before distilling the plot: “It’s about four girls known in the ’hood as the Pussy Pound. They trade sex for goods. So they dress all fly and have nice bags and cars.”

Harris says, “It’s not my world at all. I had a middle class upbringing,” and she adds with a laugh, “While I was at BC, I lived in Bedford”—a picture-postcard New England town north of Boston.

She would learn, though, that the plot lines were readily recognizable to her patients at Roxbury Comprehensive Community Health Center, an urban community health clinic that serves patients from Roxbury and North Dorchester, two of Boston’s most impoverished neighborhoods.

Harris conducted extensive interviews with six young black women between the ages of 18 and 21, inner-city residents who had been sexually active for at least two

Assistant Professor Allyssa Harris at Roxbury Comprehensive Community Health Center. Photograph: Lee Pellegrini

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years. The women were all longtime, avid readers of urban lit, who pass and trade the books among friends and family members. Part of the books’ appeal, they told Harris, is that they reflect real life. “The same things that happen in the books happens in the streets,” one said.

Strikingly, some of the more popular street lit titles are cautionary tales that make clear there are consequences to living the fast life. Reading The Coldest Winter Ever, in which wealthy, savvy, and sexy protagonist Winter Santiaga ends up with a 15-year prison sentence, had a profound effect on one participant, who describes her younger self as “fast,” “wearing makeup and tight pants,” “skipping school.” She told Harris, “I changed my life a lot because of that book. I was just like, I don’t want to be like that.”

Keeping it real “From a health view, I want to know if the risky sexual behaviors in these books will turn into sexual scripts that become social norms,” says Harris. “Will young girls think this behavior”—such as having sex at a young age, selling sex, or tolerating sexual abuse (even rape)—“is what they are supposed to be doing?”

They might, she suspects, if they don’t have anyone to talk to about the books.

At age 18 or older, the study participants had no difficulty distinguishing fiction that resembles real life from life itself, according to Harris. But several expressed concern that younger readers might not be able to do the same. “They read these books and they don’t ask their parents any questions,” one interviewee said of younger family members and friends. “Or they might not even have parents to talk to or anyone to talk to. So they just go off and do what they read and hear and see.”

In the clinic, Harris has helped many an adolescent girl tell her parents about a pregnancy and coached many a young woman to tell her boyfriends about STDs. “I have to deal with the consequences of their high-risk behavior along with them,” she says. She is particularly concerned about the youngest adolescents. “They’re just developing their identities and thinking about their lives,” she says.

Harris’s aim is not to demonize urban literature, she says, but rather to identify opportunities for nurses to intervene. Indeed, she is encouraging nurses as well as parents to pick up the books and read them. “If this work

can help nurses think about what their younger patients might be doing and help guide their patients and their patients’ parents,” she says, “maybe we’ll be able to change some behaviors and have better outcomes.”

Looking ahead, she is beginning to think about interventions that use the books as a way in. By talking with patients about what happens to characters in these books,

either informally or as part of a discussion group, she and other nurses might open up opportunities to encourage condom use and other safer sex choices.

“My patients always think, ‘It won’t happen to me,’” says Harris. But one thing the hyper-reality portrayed in urban literature makes clear is that everybody gets caught sooner or later. ✹

Learning from examples Urban literature has been around since the mid-20th century, when authors such as Donald Goines and Iceberg Slim first published semi-autobiographical stories of drug use, gang life, and crime in low-income black and Latino neighborhoods, says Amy Pattee, associate professor of library and information science at Simmons College and an expert on young adult and urban fiction.

Teri Woods, who self-published her first novel, True to the Game, in 1999, is now a publisher. Vickie Stringer wrote her first, autobiographical novel, Let That Be the Reason, while serving time in a federal prison for dealing drugs, using her life story “as an example to warn others of the dangers of the drug game,” she has said.

She published and distributed that book,

Like hip-hop musicians before them, many street-lit authors print their own work and sell it out of car trunks, on street tables, and at mom-and-pop stores.

However, she says, “Its popularity has definitely picked up” since the mid-1990s, driven by a generation of younger writers who came of age in the hip-hop music era, as well as by the runaway success of books such as Sister Souljah’s The Coldest Winter Ever, one of the first titles picked up by a mainstream publisher (Simon & Schuster), and Push, by Sapphire (Knopf), the novel that inspired the movie Precious.

It is difficult to gauge the success of urban fiction by conventional measures, according to Pattee. Nielsen BookScan does not track it as a separate genre, and, even if it did, it would miss a significant segment of the market. Like hip-hop musicians before them, many street-lit authors print their own work and sell it out of car trunks, on street tables, and at mom-andpop stores. Some are extremely successful.

which eventually sold more than 100,000 copies, and parlayed its success into Triple Crown Publications, which now boasts close to 100 titles by some four dozen other hip-hop authors.

Some established African American writers, authors, and artists look askance at the quality and marketing of street literature. Often lightly edited and filled with errors, and bearing suggestive titles and lurid covers showing men who look like drug lords and women dressed like prostitutes, street-lit bestsellers fill several shelves at many black bookstores. And they sit side-by-side with fiction by Toni Morrison and classics like W.E.B. DuBois’s The Souls of Black Folk in the African American literature sections of Barnes & Noble stores, crowding the limited retail space dedicated to works by black

authors, some say. (Bestselling street-lit author Omar Tyree [Flyy Girl] announced in 2008 that he was retiring from writing urban classics because public appetite for “gold-digging, ghetto girl, gangster-love, drug dealing stories” had diminished publishers’ interest in “positive, progressive” African American literature.)

While none of the widely available streetlit titles are specifically aimed at the young adult market, there is no question that girls as young as 12 and 13 of all races and backgrounds read books written to appeal to their mothers and older siblings, according to Pattee. And that presents teachers and librarians with a quandary: Should they encourage young African American female readers, who as a group lag behind Asian and Caucasian female peers in reading assessments, to read the books they want to read, even if they are books of uneven quality and unsavory content?

In “Critical Readings: African American Girls and Urban Fiction,” published in the April 2010 Journal of Adolescent and Adult Literacy, author and literacy expert Simone Gibson argued that, if students want to read books like Sister Souljah’s The Coldest Winter Ever, which has sold more than a million copies, they may be more open to engaging with texts they would otherwise rebuff, and possibly would become better readers as a result.

Like Allyssa Harris, Gibson envisions a new role for hip-hop lit: teaching tool.

—maureen dezell

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on the spot Disaster simulation heightens community health training

BY RACHEL KOSSMAN PHOTOGRAPHS BY GARY WAYNE GILBERT

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ilary Von Glahn ’12 scans a chart in a black binder before she approaches a patient who is huddled under a blanket in her bed. “Mrs. Canton? How are you feeling today?” she asks.

“Oh, just okay,” sighs Mrs. Canton. “Where’s José?” she asks, repeating the question for the fifth time since Von Glahn arrived for her shift.

“José isn’t here right now, Mrs. Canton. He’ll be here soon, though,” Von Glahn responds.

“Can I take you out in your chair for a walk?”

Kristen Yurewicz ’12, meanwhile, stands beside a nearby bed, listening to an animated conversation between Mrs. Hernandez, an elderly patient, and her granddaughter, Becca.

“What a great story!” says Yurewicz, dressed for duty in maroon scrubs and sneakers, her long hair pulled back in a ponytail. Slowly and gently, with the granddaughter’s help, she helps the older woman sit up and move her legs to the edge of the bed.

Then the room goes pitch black. An alarm blares. A red siren flashes. Flames lick the walls in a corner, and smoke fills the room. Several residents of St. Ignatius Long-Term Care facility scream. “What’s going on? Are we in Kansas?” cries a woman named Mrs. Johnson, who was traumatized as a child during a tornado. Another resident, curled in the fetal position, moans, her body shaking.

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This “emergency scenario” is a fabrication—the centerpiece of a disaster simulation that unfolded in the main lab of the Connell School’s Learning Resource Center on the fourth floor of Cushing Hall. The flames glowed in an artificial fireplace, dry ice passed for smoke, and nursing school faculty and staff played the roles of incapacitated patients and frightened family members who were cared for by a small team of Connell School seniors taking part in the simulation.

The “disaster sim,” as it is most often called, is a pilot teaching and learning exercise introduced last year in the Community Health Theory and Community Nursing Clinical Laboratory, a capstone course required of all CSON seniors. It is designed to help students understand how to handle critical emergencies in community settings such as long-term care facilities, where patients may be too ill or scared

to take care of themselves, according to Amy Smith, clinical assistant professor and interim director of the Connell School’s clinical learning labs and simulation center. The simulation’s goals, said Smith, are to teach students how to prepare for and respond in an emergency, to make tough decisions on the spot, and to learn something about themselves.

Sitting in a classroom hearing about an earthquake or tornado and what a responsible nurse should do, or working with computer-programmable mannequins during patient simulation exercises in a learning resource lab, are essential elements of contemporary nursing education, observed Smith. But confronting an unexpected, high-stakes simulated disaster is a vital learning experience as well, she said.

Told only to wear scrubs, bring their stethoscopes, and be prepared for a community simulation, Victoria

Nguyet Chau ’12 attempts to move her patient, Mrs. Roy, after fire breaks out during a simulated disaster.

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Weiss ’12 and her classmates were shocked when they entered the resource lab (where they frequently work with mannequins) and saw real faces in the beds. “To be honest, my heart started to race a little when I saw [the real people],” she said. “At first I was thrown off, but then I was ready to play my role.”

That role—and the field of community nursing— has become increasingly complex in recent years, as patients are discharged earlier from hospitals than they were in the past, and child and family health care moves away from traditional clinical settings into schools and communities, said Donna Cullinan, a clinical assistant professor and community health practitioner for more than 30 years. Nurses are more likely to confront—and be expected to handle—emergencies and other chaotic events.

That is among the reasons the National Council Licensure Examination for registered nurses (NCLEX) now includes global health and disaster questions. The exam also focuses on two skills that are essential to disaster response—critical thinking and prioritizing care— both of which are learning goals of the disaster sim.

In a real emergency, everybody reacts differently, said Smith. Some cry, some laugh, others shake. Some patients shut down, while others experience intense panic. “We really wanted to design a sim that had [patients with] all those responses, to give students the exposure,” she said. Ultimately, she added, “We hope to provide exposure to a chaotic event where the students are not only managing an emergency situation but also organizing a team (even if they’ve never met some members of the team) and communicating with their colleagues.”

Recognizing that “disaster really touches different aspects of nursing,” Smith enlisted the help of a diverse group of faculty whose specialties include community health, psychology, and adult health to design a course component that meets contemporary students’ needs.

“The disaster scenario experience is really a springboard for the learning,” Smith said, much of which takes place during a debriefing session that follows the 10-minute simulation. “You really have to be activated or stressed and put in that situation to open yourself up to embrace the learning. I think that’s why it’s so powerful.”

Participating in the sim helps students realize not only whether they did or didn’t know how to respond, but

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how important it is that they learn the right way to react, she added. “It’s so chaotic and it’s so stressful that it’s an important experience for students to have in a controlled environment. To be sensitized to it, to have some tools to use if they experience it again—that’s crucial.”

“As soon as we were put in a state of emergency, I panicked a little,” Weiss recalled during her debriefing session. “My patient became unresponsive, and I realized I needed to prioritize everything that I wanted to get done. Do I try to calm down her granddaughter first? Do I enlist her help? Should I stop trying to wake up the patient and just get her in a wheelchair and out of the unit?”

What she learned during the debriefing session was invaluable, Weiss said.

“We all realized that none of us called 911, a pretty important thing to do when there is a fire,” she explained, and added, “That will now be forever ingrained in my head!” ✹ View video at www.bc.edu/disastersim

Alanna Marciante ’12 (right) assists her patient, Mrs. Canton (center, Arlene Ross, administrative assistant, Nurse Anesthesia Program), and Canton’s daughter (Gabriella Sehne ’14) before the disaster occurs.

Top: After the lights go out, students prepare to evacuate patients. Clockwise from left: Allison Sandler ’12, Hilary Von Glahn ’12, Nguyet Chau ’12, and Kristen Yurewicz ’12 help Mrs. Canton. Janet Yu ’12 prepares to move Mrs. Hernandez (Clinical Instructor Maureen Connolly) from her bed. Margaret Flynn ’12 helps Mrs. Johnson (Jeanie Foley, assistant director, Simulation Center) into a wheelchair. Bottom: Ashley Thibodeau ’12 (center) seeks help from Mrs. Hernandez’s granddaughter.

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Bedside matters New residency helps nurses untangle ethical knots

BY DEBRA BRADLEY RUDER

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assachusetts General Hospital (MGH) is a place of daily life and death decisions, and nurses witness them all.

Take the man in his 40s, a father of young children, who was admitted after suffering a massive stroke.

Although his eyes remained open, he had significant brain damage and couldn’t talk. His family wanted to try a feeding tube, but his wife—his health care proxy—felt that would go against his wishes to live an independent life.

“It was challenging for everybody,” recalls Yassaman Khalili, a clinical nurse specialist on the unit who, with MGH staff nurse Linda

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Gorham Ryan ’78, helped family members and clinicians resolve their differences over the feeding tube, fluid levels, and other treatment choices. While providing the patient with comfort care, they supported his disconsolate relatives by encouraging them to pray and listen to music, soothing their way as they said goodbye. The man died comfortably a few weeks later with his wife beside him.

“His wife stayed true to the wishes he had expressed months earlier,” says Ryan. “And our team delivered dignified patient care, as he would have wanted.”

Fraught scenarios in criticalcare settings are part and parcel

of 21st century medicine, as rapid advances allow people to live longer, and patients, families, and health care providers confront ethical questions about life-sustaining treatment, quality of life, informed consent, and surrogate decision making. From their vantage point at the bedside, nurses often witness contentious family dynamics and high-intensity disputes between patients (or their surrogates) and clinicians. At large urban teaching hospitals like Mass General that serve a diverse and critically ill population, linguistic, religious, or cultural differences can exacerbate discord and dilemmas over morally complex issues.

Tricia Gordon ’06, M.S. ’14, with a patient at Massachusetts General Hospital. Photograph: Gary Wayne Gilbert

Unlike Ryan and Khalili in this case, not all nurses feel they are in a position to intervene as easily on behalf of their patients. And that can cause considerable ethical and moral distress. “Nurses, on the whole, have a good sense of what’s right for a patient, but not necessarily the confidence or language to say, ‘Here’s what we need to do about it,’ or ‘Here’s who we need to talk to,’’’ says Connell School Associate Professor Pamela Grace. That is why Grace, along with colleagues at the Connell School, MGH, and Brigham and Women’s Hospital (both Harvard teaching hospitals), has developed the Clinical Ethics Residency for Nurses (CERN), a nine-month program of classes, role-plays, and on-the-job mentoring that aims to strengthen RNs’ ability to help anticipate, identify, and resolve ethical dilemmas.

CERN was established partly in response to results of a 2009 survey of 750-plus registered nurses at Mass General, 64 percent of whom said they had encountered a disturbing, ethically charged situation for which they felt they lacked skills and training during the previous year. The study revealed four sets of circumstances that frequently cause nurses distress: disagreements among health care team members about end-of-life decisions; conflicts between families and providers over courses of treatment; angry and distraught relatives; and family members (typically adult children) who ask nurses to withhold pain medication from patients.

Most of the problems nurses confront are not new, says Grace.

But today’s high-stakes, fast-paced

health care environments have made them more complicated.

Even experienced, well-trained nurses sometimes don’t feel comfortable—or don’t have a platform from which to speak up. Or they may not know where to get the help and support they need to untangle ethical knots, she notes.

Ryan and Khalili, who took the brand-new course last year, say they’ve become better arbiters and advocates in situations like that of the stroke patient. Ryan, a staff nurse for more than 30 years, says she is now more likely to assert her expertise when she believes, for example, that a patient already on pain meds for a chronic condition needs more pain relief while recovering from surgery.

Project director Ellen Robinson, M.S. ’83, Ph.D. ’97, clinical nurse specialist in ethics at MGH, says nurses who are frustrated with their ability to solve problems run the risk of distancing themselves from patients or leaving the field. And with the country facing a looming nursing shortage, retention is a major concern. CERN’s developers hope the program will benefit not just individual nurses, patients, and families, but the profession as a whole.

Acting out CERN grew out of collaboration between Robinson, Grace, and Martha Jurchak, Ph.D. ’96, who overlapped with Robinson at the Connell School and is now executive director of the Ethics Service at BWH. With then-Dana-Farber Cancer Institute nurse Elizabeth Tracy, they launched a series of oneday clinical ethics conferences that

ran for five years—during which time they realized nurses were hungry for more in-depth training. (The 2007 conference was held at Boston College.) Supported by a grant to MGH from the U.S. Department of Health and Human Services Division of Nursing, they inaugurated CERN in October 2010.

Over three years, the CERN team—which also includes MGH Clinical Pastoral Education Director Rev. Angelika Zollfrank and MGH nurse scientist Susan Lee, Ph.D. ’05—plans to train more than 50 staff and advance-practice nurses at MGH and BWH. This year’s group has 23 RNs (another dozen were turned away because the course was full). Three doctorally prepared nursing educators will also go through CERN training.

Simulations are a mainstay of the 98-hour residency. Held in a special observation lab at Mass General, they allow participants to enact roles of the health care team and family members, to get a sense of others’ motivations and interests, and to sharpen their own communication and empathy skills. CERN is also building a cadre of ethics-savvy nurses including Ryan and Khalili, who now lead regular Ethics Rounds on their unit. (See related story, page 16.)

During her 25 years as a critical care nurse, Grace felt she had no one to talk to about ethical problems.

“Nurses were not allowed to request ethics consults, and many physicians didn’t want to,” she remembers. “I know many nurses would like to improve their ability to speak up on behalf of patient-care needs, but the resources remain inconsistent.”

CERN offers a remedy. ✹

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Nursing rounds Dealing with ethical duties and dilemmas

BY MAUREEN DEZELL Sue M. (center) presents a case during nursing rounds. Photograph: Gary Wayne Gilbert

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n a Monday evening in December, Linda Ryan, Ellen Robinson, and interfaith chaplain Patricia Keeler joined seven other MGH nurses for Ethics Rounds, a regular roundtable presentation and discussion of ethically challenging decisions and cases nurses on the medical-surgical unit have encountered.

Staff nurse Sue M. (patient, family, and staff names are always kept confidential) read from her notes as she described her experience caring for Mr. K, an 84-year-old man who “suffered unnecessarily for 24 hours,” she said, because a covering physician disregarded recommendations made by doctors in the MGH intensive care unit, as well as the man’s own end-of-life wishes.

Barely alert, in “excruciating pain,” and receiving morphine through an intravenous drip, Mr. K was surrounded by family, Sue said. They had accepted the fact that doctors could do nothing to change the course of his illness, and decided, with the patient, that he should receive only comfort care. A Catholic chaplain visited and prayed with the family, who sat quietly for much of the day, talking occasionally about what should be included in Mr. K’s obituary.

But when a young physician arrived for her shift in the early evening, she removed the morphine drip and substituted fluids and an antibiotic. Sue questioned the change,

16 Voice

pointing out that the medical team in the ICU had tried without success to treat the man with antibiotics, and noting the documented wishes of the patient and his family. But the doctor was adamant. “She said she didn’t like morphine drips and wanted the patient alert,” said Sue. The decision confused and disturbed the family. “They got that he was dying,” Sue recalled. “What they didn’t get is why the physician did that. The son asked, ‘Is the antibiotic going to get my father back to the nursing home?’”

The following day, after a difficult and painful night, Mr. K’s skin was gray and his blood pressure was low.

Sue helped the patient and his family “focus again on comfort care.” She spent time at the patient bedside as they played recorded classical music, and joined them when they asked her to form a circle, hold hands, and pray while Mr. K died.

“You made this work for the family and the patient,” Robinson told Sue, and other nurses nodded. A few recounted similar situations that did not go well. Disagreements over morphine drips and other interventions are among challenges that occur in hospital units, according to veteran nurses who attended the Ethics Rounds. Some doctors may discount the assessments of others; younger, less experienced doctors and nurses sometimes order interventions out of trepidation that

a patient might die of dehydration or an overdose of a painkiller. In this case, because of a difference of opinion, the patient suffered, and “the family was given false hope,” said Ryan.

Health care providers have ethical and legal responsibilities to terminally ill patients and their surrogates, Robinson observed. “Case law has affirmed the legal right and ethical principle that patients (and patient surrogates) have a right to refuse life-sustaining treatment,” she told the group. In a 1997 Supreme Court ruling on assisted suicide, Sandra Day O’Connor wrote that patients approaching the end of life have a right to pain control. Many consider that decision a fundamental tenet of case law.

Sue wondered, in retrospect, why her patient hadn’t been offered palliative care or hospice services. It may be difficult for a non-physician to refer a patient to another unit. But a nurse confronting an ethical conundrum she doesn’t have the authority to resolve might consider consulting palliative specialists and ethics resources at MGH, said Ryan.

Robinson agreed. “They might help you intercede with the physician, or coach you if the physician is hesitant to order pain medications,” diminishing obstacles to a paramount goal of nursing ethics: devising an effective, ethical strategy that meets a patient’s needs. ✹

Faculty Publications nancy allen Welch, G., N. Allen, S.E. Zagarins, K.D. Stamp, “Comprehensive Diabetes Management Program for Poorly Controlled Hispanic Type 2 Patients at a Community Health Center,” The Diabetes Educator 37, no. 5 (2011): 680–688.

Allen, N., G.D. Melkus, D.A. Chyun, “Physiological and Behavioral Factors Related to Physical Activity in Black Women with Type 2 Diabetes Mellitus,” Journal of Transcultural Nursing 22, no. 4 (2011): 376–385.

Leyva, B., S.E. Zagarins, N. Allen, G. Welch, “The Relative Impact of Distress vs. Depression on Glycemic Control in Hispanic Patients Following a Diabetes Self-Management Education Intervention,” Ethnicity & Disease 21, no. 3 (2011): 322–327.

Zagarins, S.E., N. Allen, J.L. Garb, G. Welch, “Improvement in Glycemic Control Following a Diabetes Education Intervention Is Associated with Change in Diabetes Distress but Not Change in Depressive Symptoms,” Journal of Behavioral Medicine (2011). DOI: 10.1007/ s10865-011-9359-z.

Zagarins, S.E., N. Allen, S. Skinner, G. Welch, “Improved Exercise Behaviors Associated with a Comprehensive Structured Exercise Program Following Bariatric Surgery,” Bariatric Nursing and Surgical Patient Care 6, no. 2 (2011): 85–90.

ann wolbert burgess Burgess, A.W., G. Pasqualone, M. Piatelli, Basic Laboratory Manual for Forensic Science (Sudbury, Mass.: Jones & Bartlett, 2012).

Dowdell, E.B., A.W. Burgess, J.R. Flores, “Online Social Networking Patterns Among Adolescents, Young Adults, and Sexual Offenders,” American Journal of Nursing 111, no. 7 (2011): 28–36.

Burgess, A.W., G. Pasqualone, M. Piatelli, “Criminalistics and the Forensic Nursing Process,” Journal of Forensic Nursing 7, no.

2 (2011): 97–104.

rosanna f. demarco Simons, S., R. Starks, R.F. DeMarco, “A New Four-Item Instrument to Measure Workplace Bullying,” Research in Nursing and Health 34, no. 2 (2011): 132–140.

Vessey, J.A., R.F. DeMarco, R.L. DiFazio, “Bullying, Harassment, and Horizontal Violence in the Nursing Workforce: The State of the Science,” in Annual Review of Nursing Research, vol. 28, eds. A. Debisette and J. Vessey (New York, N.Y.: Springer Publishing Co., 2011).

Transmission of HIV,” policy brief for the American Academy of Nursing (2011).

DeMarco, R.F., L.B. Springer, D. Gallagher, S.G. Jones, J. Visk, “Recommendations and Reality: Perceived Patient, Provider, and Policy Barriers to Implementing Routine HIV Screening and Proposed Solutions,” Nursing Outlook (2011). DOI: 10.1016/j.outlook.2011.06.002.

jane m. flanagan

DeMarco, R.F., “Foreword,” Treatment Strategies AIDS 2, no. 1 (2011): 9.

Jones, D.A., J.M. Flanagan, “Functional Health Patterns” and “Nursing Practice Models,” in The Encyclopedia of Nursing Research, 3rd ed., eds. J. Fitzpatrick and M. Katzer (New York, N.Y.: Springer Publishing Co., 2011), 195–197 and 342–345.

DeMarco, R.F., L.B. Springer, “Routine Screening for HIV to Decrease Personal Disease Burden, Health Costs, and

DeMarco, R.F., “Women Living with HIV: The Power and Complexity of Voice,” HIV, AIDS, and Religion Collaborative forum, www.harc-network.org (2011).

Jones, D.A., M.E. Duffy, J.M. Flanagan, “Randomized Clinical Trial Testing Efficacy of a Nurse-Coached Intervention in Arthroscopy Patients,” Nursing Research 60, no. 2 (2011): 92–99.

abstract

Nurse-coached intervention in arthroscopy patients Patients appreciate the convenience of ambulatory surgery. But many also report “feeling left on their own to manage care, sometimes under difficult circumstances,” while they are recuperating at home, according to Dorothy Jones (see page 18), Mary E. Duffy, and Jane Flanagan, whose study showing the benefits of postoperative nursing coaching interventions with arthroscopic surgery patients appeared recently in Nursing Research.

Most patients have little or no postoperative contact with health care providers and no ready access to people who might be able to answer their questions, the authors observe. As a result, patients and their families are frequently unprepared for the significant postoperative symptoms many suffer, including pain, nausea and vomiting, and sleep disruption. Many arthroscopic surgery patients, told they will be back to work in 24 hours, find they have limited mobility that requires them to use assistive devices they don’t know how to use, sometimes for several days, the authors note. That raises patient and family anxiety and increases suffering.

Jones, Duffy, and Flanagan tested the hypothesis that nurse coaching interventions—in which nurses made phone calls to patients the evening after surgery, 24 hours later, and 72 hours after that—would reduce symptom distress and lead to improved functional physical and mental health. Their findings suggest that patients who received interventions had significantly less symptom distress and were in significantly better overall physical and mental health a week after surgery than patient participants who recuperated without interventions.

Winter 2012 17

Faculty Publications holly b. fontenot

susan s. kelly-weeder

Haggerty, L., J. Hawkins, H.B. Fontenot, A. Lewis-O’Connor, “Tools for Screening for Interpersonal Violence: State of the Science,” Violence & Victims 26, no. 6 (2011): 725–737.

Kelly-Weeder, S.S., “Impaired Fertility in African-American Women: An Investigation of Behavioral Risks,” Journal of National Black Nurses Association 21, no.

2 (2010): 9–15.

Fantasia, H.C., H.B. Fontenot, “Do Women in Abusive Relationships Have Contraceptive Control?” Nursing for Women’s Health 15, no. 3 (2011): 239–243.

Kelly-Weeder, S.S., “Binge Drinking and Disordered Eating in College Students,” Journal of the American Academy of Nurse Practitioners 23, no. 1 (2011): 33–41.

susan gennaro

ellen k. mahoney

Gennaro, S., “The Author’s Authentic Voice,” Journal of Nursing Scholarship 43, no. 3 (2011): 221–222.

Jablonski, R.A., B. Therrien, E.K. Mahoney, A. Kolanowski, M. Gabelo, A. Brock, “An Intervention to Reduce Care-Resistant Behavior in Persons with Dementia During Oral Hygiene: A Pilot Study,” Special Care in Dentistry 31, no. 3 (2011): 77–87.

Gennaro, S., “If You Can Differentiate Your Apostrophe from Your Elbow, Should You?” Journal of Nursing Scholarship 43, no. 2 (2011): 105–106.

allyssa l. harris Harris, A.L., “A Second Look: Examining the Link Between Vitamin D Deficiency and Bacterial Vaginosis in Pregnancy,” Nursing for Women’s Health 15, no. 5 (2011): 423–430.

Harris, A.L., “The Influence of Urban Literature on African-American Adolescent Girls’ Sexual Behaviors,” Journal of National Black Nurses Association 22, no. 1 (2011): 36–42.

june a. horowitz Horowitz, J.A., “Interventions to Promote Maternal Responsiveness and Sensitivity,” in Maternal Sensitivity: A Scientific Foundation for Practice, eds. D.W. Davis and M.C. Logsdon (Hauppauge, N.Y.: Nova Science Publishers, 2011), 285–294.

dorothy a. jones Jones, D.A., J.M. Flanagan, “Functional Health Patterns” and “Nursing Practice Models,” in The Encyclopedia of Nursing Research, 3rd ed., eds. J. Fitzpatrick and M. Katzer (New York, N.Y.: Springer Publishing Co., 2011), 195–197 and 342–345.

Jones, D.A., M.E. Duffy, J.M. Flanagan, “Randomized Clinical Trial Testing Efficacy of a Nurse-Coached Intervention in Arthroscopy Patients,” Nursing Research 60, no. 2 (2011): 92–99. see abstract on page 17.

18 Voice

natalie mcclain Sutherland, M.A., H.C. Fantasia, N. McClain, “Abuse Experiences, Substance Use, and Reproductive Health in Women Seeking Care at an Emergency Department,” Journal of Emergency Nursing (2012). DOI: 10.1016/j. jen.2011.09.11.

Pulcini, J.A., M. DeSisto, P. Dowd, L. McIntyre, “School Nurses and Primary Care Providers: Collaborating to Improve Asthma Self-Management in School-Aged Children,” Journal of Pediatric Health Care 25, no. 5 (2011): e20–e21.

catherine read Read, C., “Semester Abroad Opportunities in Baccalaureate Nursing Programs,” Journal of Professional Nursing 27, no. 4 (2011): 221–226.

Lea, D.H., H. Skirton, C. Read, J.K. Williams, “Implications for Educating the Next Generation of Nurses on Genetics and Genomics in the 21st Century,” Journal of Nursing Scholarship 43, no. 1 (2011): 3–12.

sr. callista roy Roy, S.C., “Extending the Roy Adaptation Model to Meet Changing Global Needs,” Nursing Science Quarterly 24, no. 4 (2011): 345–351.

Roy, S.C., “Research Based on the Roy Adaptation Model: Last 25 Years,” Nursing Science Quarterly 24, no. 4 (2011): 312–320.

joyce a. pulcini

mary c. simonelli

Pulcini, J.A., L.T. Viola, “Health and the Global Environment,” in Community and Public Health Nursing: Evidence for Practice, eds. G. Harkness and R. DeMarco (Philadelphia, Pa.: Lippincott, Williams & Wilkins, 2012), 45–62.

Simonelli, M.C., W.F. Velicer, “Cluster Subtypes Appropriate for Preventing Postpartum Smoking Relapse,” Addictive Behaviors (2011). DOI: 10.1016/j. addbeh.2011.11.001.

Pulcini, J.A., M.A. Hart, “Health Care Financing,” in Policy and Politics for Nursing and Health Care, 6th ed., eds.

D. Mason, M. Chaffe, and J. Leavitt (Philadelphia, Pa: Lippincott, Williams & Wilkins, 2011), 135–146.

Pulcini, J.A., A. Sheetz, D. Crowe, “School Nurse Research Networks: A Win-Win for Nurse Educators,” NASN School Nurse 26, no. 1 (2011): 11–14.

Spina, J., L. McIntyre, J.A. Pulcini, “An Intervention to Increase High School Students’ Compliance with Carrying Auto-Injectable Epinephrine: A MASNRN Study,” Journal of School Nursing (2012).

DOI: 10.1177/1059840511431459.

Simonelli, M.C., A.L. Paskausky, “Simulation Stimulates Learning in Childbearing Clinical Course,” Journal of Nursing Education (2012). DOI: 10.3928/01484834-20111230-03.

lori r. solon Solon, L.R., “Building Collaboration Between Nursing Students and Nursing Staff,” Nursing Network 35, no. 1 (2011): 1–7.

Faculty Publications judith a. vessey

abstract

Nursing Science Quarterly honors Sr. Callista Roy A professor and nurse theorist best known for her pioneering work on the Roy Adaptation Model of nursing, Sr. Callista Roy pioneered the nursing strategy—which identifies a patient’s physiological and psychosocial needs and provides care that integrates the needs of the “whole person”—in the 1960s. In October, a special issue of Nursing Science Quarterly was dedicated to Roy’s work.

Today, the model is “entrenched in nursing practice, and is adaptable, demonstrating the ability to respond to the dynamic health needs of persons or groups such as families, communities, or societies,” according to Stacey Barone, an associate clinical professor who is one of three nursing scholars interviewed about the Roy Adaptation Model in the nursing journal. Barone lauded the model’s widespread adoption, and its success in improving nursing care and patient outcomes among a wide variety of patient populations, in different settings, and across cultures. “Hundreds of scholarly nursing research studies have been influenced by Roy’s work, and each has contributed knowledge to nursing science,” Barone observed.

kelly d. stamp

melissa a. sutherland

Welch, G., N. Allen, S.E. Zagarins, K.D. Stamp, “Comprehensive Diabetes Management Program for Poorly Controlled Hispanic Type 2 Patients at a Community Health Center,” The Diabetes Educator 37, no. 5 (2011): 680–688.

Laughon, K., M.A. Sutherland, B. Parker, “A Brief Intervention for the Prevention of Sexually Transmitted Infection among Battered Women,” Journal of Obstetric, Gynecologic & Neonatal Nursing 40, no. 6 (2011): 702–708.

Stamp, K.D., “How Nurse Practitioners Make Decisions Regarding Coronary Heart Disease Risk: A Social Judgment Analysis,” International Journal of Nursing Terminologies and Classifications (2011).

DOI: 10.1111/j.1744-618X.2011.01196.x.

Stamp, K.D., “Self-Care in Women with Heart Failure and the Effectiveness of Nurse-Led Educational Interventions: A Review of the Literature,” Journal of Nursing and Healthcare of Chronic Illness 3, no. 4 (2011): 339–351.

mary e. thompson Thompson, M.E., “Nurses’ Role in Prevention of Infant Mortality in 1884– 1925: Health Disparities Then and Now,” Journal of Pediatric Nursing (2011). DOI: 10.1016/j.pedn.2011.05.011.

Steeves, R., B. Parker, K. Laughon, A. Knopp, M.E. Thompson, “Adolescents’ Experiences with Uxoricide,” Journal of the American Psychiatric Nurses Association 17, no. 2 (2011): 115–123.

Vessey, J.A., R.F. DeMarco, R.L. DiFazio, “Bullying, Harassment, and Horizontal Violence in the Nursing Workforce: The State of the Science,” in Annual Review of Nursing Research, vol. 28, eds. A. Debisette and J. Vessey (New York, N.Y.: Springer Publishing Co., 2011).

DiFazio, R.L., J.A. Vessey, D. Zurakowski, M.T. Hresko, T. Matheney, “Incidence of Skin Complications and Associated Charges in Children Treated with Hip Spica Casts for Femur Fractures,” Journal of Pediatric Orthopedics 31, no. 1 (2011): 17–22.

Larson, J., Interview for “School Nurses Positioned to Address Bullying,” Nursezone.com (2011).

barbara e. wolfe Wolfe, B.E., D.C. Jimerson, A.T. Smith, P.K. Keel, “Serum Amylase in Bulimia Nervosa and Purging Disorder: Differentiating the Association with Binge Eating Versus Purging Behavior,” Physiology & Behavior 104, no. 5 (2011): 684–686.

robin y. wood Wood, R.Y., N. Della-Monica, “Psychosocial Factors Influencing Breast Cancer Risk Appraisal among Older Women,” Qualitative Health Research 21, no. 6 (2011): 783–795.

lichuan ye Ye, L., A.I. Pack, G. Maislin, D. Dinges, S. Hurley, S. McCloskey, T.E. Weaver, “Predictors of Continuous Positive Airway Pressure Use During the First Week of Treatment,” Journal of Sleep Research (2011). DOI: 10.1111/j.13652869.2011.00969.x.

Ulrich, C.M., Q. Zhou, S.J. Ratcliffe, L. Ye, C. Grady, D. Watkins-Bruner, “Nurse Practitioners’ Attitudes about Cancer Clinical Trials and Willingness to Recommend Research Participation,” Contemporary Clinical Trials 33, no 1.

(2012): 76–84.

Winter 2012 19

william f. connell

non-profit org. u.s. postage paid boston, ma permit #55294

school of nur sing 140 commonwealth avenue chestnut hill, ma 02467 www.bc.edu/cson

voice Save the dates tuesday, april 10, 2012, 5:00 p.m. corcoran commons, heights room Karen Daley, M.S. ’04, Ph.D. ’10, president of the American Nurses Association, will present the spring Pinnacle lecture, “Leading the charge: A nursing agenda in the age of health care reform.”

Read more and register at www.bc.edu/pinnacle.

friday, june 1, 2012, 2:00 p.m. higgins hall, room 300 At this year’s Connell School of Nursing Reunion, Dean Susan Gennaro will present the fourth annual Dean Rita P. Kelleher Award to Mairead Hickey ’72, executive vice president and chief operating officer of Brigham and Women’s Hospital. The Alumni Association will honor Terry Fulmer, M.S. ’77, Ph.D. ’83, dean of Northeastern University’s Bouvé College of Health Sciences, with its McInnes Professional Excellence Award. Immediately after the presentation, there will be a panel discussion on nursing leadership, followed by a reception in the Higgins Hall atrium. All alumni are welcome.

Mairead Hickey ’72

Read more and register at www.bc.edu/csonreunion.

Photograph: Frank Siteman