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Nursingmatters August 2017 • Volume 28, Number 7


What if nurturing is critical?


Nurse brings community to doctor’s office Eric Hamilton University of Wisconsin‌

Native American program gains funds


Think diagnostic imagination






MADISON, Wis. – Nursing student Maichou Lor wanted to bring her fellow Hmong community members out of the shadows and into the doctor’s office. Lor, who recently received her Ph.D. from the University of Wisconsin-Madison School of Nursing, was born in a refugee camp in Thailand before her family immigrated to Madison. As she pursued nursing, starting in high school, Lor discovered that the Hmong immigrant community lacked access to major medical care because low rates of literacy and English proficiency kept their health status murky. In an interdisciplinary research program, Lor developed new survey tools that respond to the needs of the Hmong, which she hopes can help close gaps in access to care among her own community and other underserved populations. Along the way, she became the first Hmong-American nurse to earn a Ph.D. in the United States. “Throughout my whole life, I saw a lot of inequalities and injustice in issues surrounding health care,” Lor said, “not just among the Hmong population. It’s the Cambodian population, the Laotian population, a lot of Southeast Asian populations who have gone through the same kind of history that we have are also struggling.” Following the Vietnam War, Wisconsin became a hub for displaced Hmong from Southeast Asia immigrating to the United States. The Hmong community is the largest Asian population in Wisconsin, which has the third-largest Hmong population behind California and Minnesota. According to the U.S. Census Bureau, more than 54,000 Hmong lived in Wisconsin in 2015, nearly 20 percent of all Hmong in the country. As an undergraduate nursing student at UW, Lor partnered with three other Hmong students to try to survey the

Maichou Lor

local Hmong population about cancer screening. But the group found that written surveys, even if they only asked for true-false answers, resulted in mostly blank responses. “We ended up just reading the questions and having people raise their hands to respond, but we realized there’s contamination, because they just looked around at how others were responding,” Lor said. “That was an ‘aha’ moment for me, to realize we can’t collect data from this population, and I’m sure there are other populations experiencing the

same thing.” Lor saw that without an effective way to ask Hmong about their health, there was no way to fully integrate them into the health-care system. In graduate school she worked with an interdisciplinary group of mentors to create a data-collection tool that responded to the needs of the Hmong community. She adapted a survey system from sociology that combines prerecorded oral translations in the Hmong language,

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Nursingmatters is published monthly by Capital Newspapers. Editorial and business offices are located at 1901 Fish Hatchery Road, Madison, WI 53713 FAX 608-250-4155 Send change of address information to: Nursingmatters 1901 Fish Hatchery Rd. Madison, WI 53713 Editor........................................... Kaye Lillesand, MSN 608-222-4774 • Managing Editor................................... Julie Belschner 608-250-4320 • Advertising Representative.................... Teague Racine 608-252-6038 • Recruitment Sales Manager.......................Sheryl Barry 608-252-6379 • Art Director...........................................Wendy McClure 608-252-6267 • Publications Division Manager............Scott Zeinemann 608-252-6092 • Nursingmatters is dedicated to supporting and fostering the growth of professional nursing. Your comments are encouraged and appreciated. Email editorial submissions to Call 608-252-6264 for advertising rates. Every precaution is taken to ensure accuracy, but the publisher cannot accept responsibility for the correctness or accuracy of information herein or for any opinion expressed. The publisher will return material submitted when requested; however, we cannot guarantee the safety of artwork, photographs or manuscripts while in transit or while in our possession.

EDITORIAL BOARD Vivien DeBack, RN, Ph.D., Emeritus Nurse Consultant Empowering Change, Greenfield, WI Bonnie Allbaugh, RN, MSN Madison, WI Cathy Andrews, Ph.D., RN Associate Professor (Retired) Edgewood College, Madison, WI Kristin Baird, RN, BSN, MSH President Baird Consulting, Inc., Fort Atkinson, WI Joyce Berning, BSN Mineral Point, WI Mary Greeneway, BSN, RN-BC Clinical Education Coordinator Aurora Medical Center, Manitowoc County Mary LaBelle, RN Staff Nurse Froedtert Memorial Lutheran Hospital Milwaukee, WI Cynthia Wheeler Retired NURSINGmatters Advertising Executive, Madison, WI  Deanna Blanchard, MSN Nursing Education Specialist at UW Health Oregon, WI Claire Meisenheimer, RN, Ph.D. Professor, UW-Oshkosh College of Nursing Oshkosh, WI Steve Ohly, ANP Community Health Program Manager St. Lukes Madison Street Outreach Clinic Milwaukee, WI Joyce Smith, RN, CFNP Family Nurse Practitioner Marshfield Clinic, Riverview Center Eau Claire, WI Karen Witt, RN, MSN Associate Professor UW-Eau Claire School of Nursing, Eau Claire, WI © 2017 Capital Newspapers


We all need reinforcement that we are valuable, loved and important. Those in pain need it even more.

Nurturing is that important Brenda Zarth

How do we learn to cope, how do we learn how to nurture the next generation, if we didn’t learn it ourselves through experience? Clinic nurses receive calls every day from people in pain, who are trapped inside the injustices that have been done to them. They want to be healthy; they want to feel whole, but they are stuck in the memories that they never resolved. A couple of years ago I Brenda Zarth‌ receive a call from a woman wanting her pain medications increased. She told me why she needed them and repeated her life story every time she called. She was abused as a child, she was abused as a wife, she was abandoned and she was in car accidents. She listed her medical diagnoses to explain

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At least 60 percent of my time is spent dealing with issues related to chronic mental and psychological health. Painful memories often present as physical pain; they are easier to deal with that way.


“Throughout my whole life, I saw a lot of inequalities and injustice in issues surrounding health care, not just among the Hmong population. It’s the Cambodian population, the Laotian population, a lot of Southeast Asian populations who have gone through the same kind of history that we have are also struggling.”

continued from page 1 written text in English and color-coded responses to facilitate communication and to accommodate any level of language proficiency. In addition, a family helper was included to assist with the survey-completion process. The tool allowed Lor to successfully survey all her study participants on their health status, without missing responses. One concern was that respondents might be reluctant to answer a question that may be sensitive or potentially embarrassing in the presence of family members. To test this, Lor included a question about frequent urination. “What I realized is because I translated the question in a culturally sensitive way, people were fine answering it, and they didn’t see any question as being too sensitive or embarrassing to answer,” Lor said. Barbara Bowers is the associate dean for research at the School of Nursing and Lor’s adviser. “She’s just tenacious,” Bowers said. “She’s the most curious student I’ve ever had. She ends up being a cultural broker for a lot of people in the Hmong community. “I’m hoping she comes back here and establishes her own center for Hmong health at the university.” Lor is leaving Madison this month to train in informatics and data visualization

What if?

continued from page 2 why she had so much pain. I thought if I let her talk as long as she wanted maybe she would finally have some relief from her painful memories. She finally stopped and said, “Thank you for listening to me. I know you don’t want to hear me. You probably wish I were dead; I wish I were dead, but I’m still here.” She made me think about how we deal with our mental health and pain patients. As a triage nurse almost all my calls are related to lack of coping. People are tired of being sick and are ready to seek help. At least 60 percent of my time concerns dealing with issues related to chronic mental and psychological health. Painful memories often present as physical pain; they are easier to deal with that way. I worked with a couple of children who were cutters in high school. They grew up with parents yelling at each other; they couldn’t feel anything anymore because they were emotionally exhausted trying to figure out the discord. So they cut. It made the emotional pain physical so they could look at it outside of their heads and deal with it. The cutting helped them to cope; it provided some relief. What if our chronic-pain patients have physical pain because it allows them to pull

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August • 2017

Maichou Lor

Barbara Bowers

at Columbia University. She wants to find ways to communicate with her patients about their health that bypass linguistic and cultural barriers. But Wisconsin remains her home. “My family threw me a graduation party back in May, and I had some of my research participants come; they were sad I’m leaving,” Lor said. “They’re often forgotten in research, in health, in everything, and they felt like I was a voice for them. “I told people I will come back; I just have to go get another kind of tool to help me develop as a researcher and make a greater impact.” Visit or visit and search for “Maichou Lor” to see Lor’s video.

their emotional or psychological pain out of their heads and give it a physical presence? What if they had someone to help them look at that pain and the memories attached to it, from a safe place? Someone to help them understand that life isn’t always correct. It isn’t reasonable or logical that some events happen. Sometimes “good” people do “bad” things. Sometimes there is no answer. Buddhists say, “It is what it is.” We can acknowledge that something was wrong, understand that we did the best that we could with the tools that we had at the time. We all need reinforcement that we are valuable, loved and important. People in pain need it even more. I have a chronic-pain patient who is weaning off morphine. He said he doesn’t want to let go of all his pain because he wants to be able to know if he’s in danger. He needs to know he has the ability to feel. I said, “I don’t have pain, and I can still feel.” He looked confused. He realized he was using his pain as a tool or a benchmark for being alive. I wonder if it’s logical to expect him to let go of all his pain unless we help him find a different benchmark. We need to replace the pain with purpose, and a reason for living life more fully. Hopefully he will see value in something he created, or can do – something to help him get outside of himself.

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Native American students to see support Jennifer Garrett University of Wisconsin‌

Two faculty members at the University of Wisconsin-Madison School of Nursing have received a $1.3 million federal grant to develop a comprehensive system of support services that will help admit, retain and graduate 30 Native American nursing students through the next four years. Audrey Tluczek, an associate professor of nursing, and Mel Freitag, the school’s director of diversity initiatives, will lead the project, Linda Scott called “Success Through Recruitment/Retention, Engagement, and Mentorship (STREAM) for American Indian Students Pursuing Nursing Careers.” The project aligns with a Wisconsin Center for Nursing goal of expanding the diversity of the nursing workforce to mirror the diversity of the population it serves. The goal is based on evidence showing that increasing diversity in the nursing workforce improves access to health care and leads to better health outcomes for underrepresented groups, including Native Americans. Currently the Wisconsin nursing workforce is 94 percent white, while the Wisconsin population is only 79 percent white. About 90 percent of nurses who provide services in Wisconsin tribal health facilities are white; the vast majority of patients are American Indian. “This project is vital for the state, as we believe it can make a real difference in improving health outcomes within American Indian populations by increasing the number of Native nurses in these communities,” said Linda D. Scott, dean of the School of Nursing. “This grant validates the important relationships already forged by Dr. Tluczek and Dr. Freitag with Wisconsin American Indian communities. It reflects the UW-Madison School of Nursing’s commitment to admitting, educating and graduating students from diverse backgrounds in an effort to better serve


Signe Skott Cooper Hall is the home of the University of Wisconsin–Madison School of Nursing.

all Wisconsin residents and eliminate the health disparities that many populations experience.” All 12 Wisconsin tribes – 11 federally recognized and one state-recognized – are federally designated Health Professional Shortage Areas. The grant, awarded by the U.S. Health Resources and Services Administration, builds on a previous community-academic partnership project among the Great Lakes Inter-Tribal Council, the UW-Madison School of Nursing, and UW-Population Health Institute, which was funded by the Wisconsin Partnership Program. One of the objectives of that project, “Increasing

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All 12 Wisconsin tribes – 11 federally recognized and one state-recognized – are federally designated Health Professional Shortage Areas.

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Diagnostic imagination important to clinician Mary Ellen Wurzbach, RN, BSN, MSN, FNP, PhD John McNaughton Rosebush Professor Emerita University of Wisconsin-Oshkosh‌

I am a nurse practitioner. I’ve developed diagnostic imagination over time – first as a nurse, then as a public-health nurse. Diagnostic imagination is necessary for the skilled clinician. Its roots lie in sensory information, which provides the foundation for Mary Ellen Wurzbach intervention and treatment. Sensory information entails all the senses – visualization, hearing, taste, smell and touch.

Native American

continued from page 4 Cultural Congruence Among Nurses in Wisconsin,” was to increase the number of American Indian nurses in the state. “This new grant will help us do just that,” Tluczek said. Additionally the new project offers greater opportunities for the School of Nursing to collaborate with the Native American Center for Health Professional, which is based in the UW-Madison School of Medicine and Public Health. The center has been instrumental in helping the School of Nursing to promote nursing careers within American Indian communities by featuring two Native nurses on the website, We Are Healers. The Native American Center for Health Professional partners will have a central role in STREAM to help identify and address the unique needs of American Indian students pursuing nursing careers at UW-Madison. “It’s been a privilege to be able to collaborate with and learn from tribal communities,” Tluczek said. “Working closely with our American Indian partners provided us valuable insights about the need for more Native nurses who can help develop models of health care that combine traditional American Indian healing with western medicine. Doing so holds great potential for improving the health and well-being of tribal communities. That experience also taught us much about the challenges that American Indian students and communities face and the role the University of Wisconsin-Madison can play in supporting these students interested in nursing careers.” Freitag said, “In partnership with (the Great Lakes Inter-Tribal Council) and

In the past those sensory methods would have been seen as auscultation, palpation and percussion. Today we know those maneuvers are the basis for diagnosis, but much can be told from the other senses as well. Traditionally, touch, hearing, taste and smell were diagnostic means. Today we know sight is also essential. Sight is the most non-intrusive and in many ways can lead to equally valid conclusions. Visual imagination allows one to imagine what the sound, smell, touch or taste of a visualized sign or symptom might be. If I can see an injury to a trapezius I can, by extension, logically conclude what the outcome may be, how severe the injury is, and what decision ought to be made about

treatment and post-treatment care. The same is true of a flank injury or a forearm injury. One can tell by the anatomical visualization what to expect for treatment and recovery. Minor acute injuries can be discerned. More severe injuries may be ruled out – not necessarily ignored – and not given as much salience in determining what ought to be instituted as an optional intervention. Diagnostic visualization replaces older methods of auscultation, palpation and percussion, and can be performed at a distance – giving validity to tele-medicine. If one can visualize a concern and logically extend what one sees into the future, one can determine what outcome to expect

or can come to a conclusion about what further diagnostic measures are necessary, if any. Nurse practitioners are taught to diagnose and treat minor acute injuries of all types and can be very beneficial in directing care to the most cost-effective and simplest solution. If more serious problems arise, the person can be directed to a physician. For example, flank pain with urinary-tract bleeding would be referable whereas flank pain that resolves without blood in the urine might not necessarily be referred. Other injuries can be addressed in a collaborative manner. Diagnostic visualization is the assessment phase of the “nursing

(the Native American Center for Health Professional), we have visited tribal communities throughout the state to develop relationships and identify ways the School of Nursing can help expand the Native nursing workforce and access to culturally

congruent health care for Native populations. We designed this program with our Wisconsin tribal partners to educate Wisconsin students to serve Wisconsin populations. We’ve been saying all along that this is the Wisconsin Idea in action,

and it is. It really is.” The STREAM grant specifically calls for recruiting more students with the help of a nursing-specific online recruitment tool, and yet recruitment is only part of the challenge, Freitag said. The STREAM program will also focus on retention and graduation. That involves providing structured support designed to address the specific challenges and barriers Native students encounter when attending UW-Madison. Freitag said Native Americans, like many students from underrepresented populations, are more likely to face barriers and challenges on a large predominantly white campus. Geographic factors also come into play for Native students because Madison can seem like an isolating place to them. “The desire for a sense of belonging, or the lack of a sense of belonging, comes up with our Native students as it does for other underrepresented groups,” Freitag said. “Underrepresented groups are small groups in Madison, and Native Americans are the smallest of the small. It can be difficult for them to find and forge peer groups on campus and certainly within the school.” To foster community within the school and on campus, STREAM will use traditional American Indian talking circles to provide student peer support. The program will also work to foster confidence by connecting American Indian students with mentors who are Native nurses currently practicing in Wisconsin. The grant proposal also calls for continued efforts to strengthen relationships with tribal communities through yearly Native Nations Nursing Summits, which Tluczek and Freitag have organized since 2015. The grant also provides financial support to American Indian students through monthly stipends.

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continued from page 5 process.” In the 1960s it was called “the problem-solving process.” Diagnostic visualization requires imagination to understand, explain to others and predict future outcomes. It also may be proscriptive. All of these are the purposes of science – to understand, explain, predict and control. Thus diagnostic visualization or imagination may be seen as a scientific method for determining the outcomes of health care – minor or some major emergencies. Nurse practitioners are an integral part of the health-care team. They learn as nurses to assess visually – because traditionally in their history more “hands-on” methods were denied to them. They were not to auscultate, percuss or palpate. Those were medicine’s methods. Therefore, nurses – not exclusively nurse practitioners – who now practice these methods have already in the past learned to use their ability to visualize. Public-health nurses especially needed to do a visual assessment because physical methods were seen as practicing medicine. Today all the professions work together for the benefit of the patient. All members of the team with developed visualization skills and imagination add to positive outcomes of health care.

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Project BEYOND-2, one of Marquette University’s student-support programs, aims to improve nursing-workforce diversity.


Terrie Garcia, M.Ed., R.N., left, is the project coordinator and Dr. Leona VandeVusse, R.N., C.N.M., F.A.C.N.M., is the project director of Project BEYOND-2.

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College project receives grant MILWAUKEE – Marquette University’s College of Nursing has received nearly $2 million to continue one of the college’s student-support programs, Project BEYOND-2. The program, initially launched in 2007, is supported by the Health Resources and Services Administration of the U.S. Department of Health and Human Services. The funding will provide support for the program during the next four years. Project BEYOND-2 aims to improve nursing-workforce diversity by increasing the numbers of students and graduates from economically and educationally disadvantaged backgrounds, including underrepresented minorities, graduating with bachelor of science in nursing degrees. Students in Project BEYOND-2 participate in a variety of academic and informal sessions as well as professional and

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Kim Litwack has been named dean of the College of Nursing at the University of Wisconsin-Milwaukee. She began in the position effective June 1. A professor of nursing, Litwack joined the University of Wisconsin-Milwaukee in 2004. She has been serving as the interim dean of the college since July 2016, and has served as associate dean for academic affairs. Prior to coming to the University Kim Litwack of Wisconsin-Milwaukee, she taught at Grand Valley State University in Grand Rapids, Michigan, the University of New Mexico and at Rush University in Chicago. Litwack earned her PhD in educational administration from Kent State University. Litwack’s nursing background has been in the areas of critical care, perianesthesia care and, more recently, ambulatory care and pain management. A fellow of the American Academy of Nursing, she has written on nursing education, pain management in military trauma and chronic pain. Litwack was instrumental in creating the community paramedics program with Milwaukee Fire Department Capt. Michael Wright. The program is coordinated by the College of Nursing, Medical College of Wisconsin and Milwaukee County Emergency Medical Services. “I look forward to working closely with the college faculty to grow and strengthen our excellence in nursing education across all academic programs,” Litwack said. “It is my expectation that we can also enhance our research and scholarship among students and faculty scholars, and continue to deepen and expand our community partnerships.” Litwack succeeds Sally Lundeen, who served as dean of the College of Nursing from 2003 to 2016.

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Lifesaving training travels to Tanzania Karen Klemp

A nine-person team on a Sun Prairie-based “Hope 2 Others” trip to Tanzania has been providing training to birth attendants in the communities they visit. “Helping Mothers Survive” and “Helping Babies Breathe” trainings were held in Dar es Salaam, Tanzania, and Zanzibar Island. “I thank you so much for coming again this year,” said Beate Kiwinda, RN, the nurse-midwife in charge. “Yesterday we had a pre-term baby who was grey and did not breathe. So thanks to your teaching I was so confident to help and bag the baby. It is breathing and just a bit slow to feed but otherwise is fine. Thank you again. Oh yes and the moms are so proud when they walk with their baby in a most beautiful blanket and even clothes for the baby! And the hats too … God is great!” This is why we go, because one more baby lived because many donated, supported, sacrificed and prayed so we could go. Zanzibar Island is 98 percent Muslim. We had the opportunity to teach a class of 10 nurse-midwives, nine who were Muslim and one Christian. A local pastor set this up; we had the classes at one of the small health centers. We were received with open hearts and they were thrilled to have the training. They asked us to come back so more can be trained and for them to become “Helping Mothers Survive” and “Helping Babies Breathe” master trainers. We had fun learning and they loved the training equipment. They invited us to visit their Muslim birthing center at the end of the week. As we went through the center I asked if there were any births taking place that we could attend. They said a baby had just been born. The baby was nine weeks early; they said we could see the baby. She was tiny and precious, about 3 pounds. There were no isolettes, clothes, hats, blankets … nothing for the baby. Dawn Morales, RN – a UnityPoint Health-Meriter labor, delivery and postpartum nurse –helped the mother breastfeed her tiny newborn. I helped the mother do skin-to-skin Kangaroo care following her nursing the baby. We shared with the mother,


Karen Klemp helps with the Helping Mothers Survive training, using the Mama Natalie simulation uterus.


Dawn Morales, RN BSN, a labor-delivery-postpartum nurse at UnityPoint Health-Meriter, assists a Tanzania nurse with Helping Babies Breathe skills.


A baby who was born the last day of a Hope 2 Others trip, on Zanzibar Island, is now 31 weeks old and doing well — praise God for answered prayers!

nurse-midwives and doctor about breast-milk hand expression and how to do skin-to-skin care to keep the baby warm. All the mother had was a thin cotton cloth and the baby was cool to touch. We had nothing left to give this precious tiny baby and mother. There wasn’t even a hat. My heart broke; if I could only have one hat for the little one. She was breathing, nursing fairly well, but just needed to

stay warm – such a simple thing that was out of our reach. So I asked the mother and the nursing staff if I could pray for this baby and mother. It was all I had to offer, and they said yes. I prayed and asked God to keep this baby warm, safe, healthy and protected as He is the Great Physician who is all about families. I often ask myself as we are nearing the end of our journey – does God want us to keep doing

this mission of Hope 2 Others and are we making a difference? I felt in my heart that God was saying, “Yes do it for the one, do it for the littlest of them and you are doing it for me. Don’t worry about how, just do it for the ONE.” Karen Klemp, MA, BSN, RN, is the founder of Hope 2 Others; she is a neonatal intensive-care-unit nurse at UnityPoint Health-Meriter. Meghan Chua contributed to this story.


Kathy Gerhardt, RN BSN, helps a nurse-midwife learn how to use the upright ambu bag and mask with the Helping Babies Breathe program.

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Writing and publishing tips offered INDIANAPOLIS – Nursing is more than just patient care. Whether turning a dissertation into a published article or contributing a chapter to a book, writing can be a core necessity and tool for nurses. While nurses spend years learning about human anatomy, deciphering the anatomy of writing can seem much more difficult. “Anatomy of Writing for Publication for Nurses,” Third Edition, is a practical and useful guide for nurses who need to bridge the gap from incomplete sentences to a published manuscript. Award-winning lead author and editor Cynthia Saver, MS, RN, removes the fear and confusion most nurses have about the writing and publishing process. In this new edition, published by the Honor Society of Nursing, Sigma Theta Tau International, Saver walks readers through each step and provides the tools


continued from page 6 peer-mentoring opportunities. Project BEYOND-2 students are encouraged to ask questions, request discussion

necessary for effective and successful writing. Equipped with nearly three decades of publishing experience and with more than 40 years in the nursing field, Saver, along with 25 of nursing’s top writing experts and decision makers, shares important insights to increase the likelihood that an academic manuscript is accepted for publication, whether the author is a nursing student or an established nurse. Instead of adhering to the rigid style of

traditional textbooks, Saver presents an easy-to-understand guidebook that covers topics ranging from dissertation, clinical and peer-review writing to tips for properly documenting sources, how to effectively utilize illustrations and advice for marketing a finished work. The fully revised third edition includes an expanded exploration of topics. • How to collaborate and coauthor with professionals in other health-care disciplines • How to avoid being the victim of predatory publishing • How to navigate Interprofessional Continuing Education • How to write qualitative studies and report the different instruments used • “Our goal is to show you that although it takes some work to write effectively, it is within every nurse’s reach to do so – and

you can even have some fun while doing it,” Saver said.

topics and become actively involved in study groups. “The continuation of this grant reflects a vital need for diversity in the nursing workforce,” said Dr. Janet Krejci, dean of the College of Nursing.

“I am continually amazed by the dedication (that) faculty, staff and community partners provide to our Project BEYOND-2 students.” Terrie Garcia, Project BEYOND-2 coordinator, said, “There is a pressing

need to increase diversity in the nursing workforce. Marquette (University) and the project team are pleased to contribute to these important efforts. This funding also includes scholarships and stipends to assist students with financial need.”

Anatomy of Writing for Publication for Nurses, Third Edition By Cynthia Saver, MS, RN ISBN-13: 9781945157219 Published by STTI, May 2017 Price: U.S. $54.95; soft cover, 488 pages. Available at

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