The Journal of the New York State Nurses Association, Vol. 47, Number 1

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JOURNAL of the New York State Nurses Association

Volume 47, Number 1

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Editorial: Emotional Flexibility, Adaptability, Positive Outlook, and Collegiality: The Right Mix for Resiliency in Nursing

by Anne Bové, MS, RN-BC, CCRN, ANP; Dana Deravin Carr, DrPH, MS, MPH, RN-BC, CCM; Seth Dressekie, MSN, RN, NP; Audrey Graham-O’Gilvie, DNP, ACNS-BC; Meredith King-Jensen, PhD, RN; Caroline Mosca, PhD, RN; and Coreen Simmons, PhD-c, DNP, MSN, MPH, RN

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Growth Through the Storm: Perinatal Nurses’ Experiences of Hurricane Sandy

by Karen Mancini, PhD, RN

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A Literature Review and Opinion Article on the Nurse Practitioner’s Role in Certification and Management of Medical Marijuana

by Joseph J. Brennan, MS, AGNP, RN-BC, CCRN-CMC; and Maureen C. Roller, DNP, RN, ANP-BC

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Nurses’ Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue

by Lucille Contreras Sollazzo, MSN, RN-BC, NPD; and Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD

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In the Aftermath of Maria: An Ethnographic Review of Rescue, Recovery, Climate, and Social Justice in Puerto Rico

by Carole Ann Moleti, DNP, FNP-BC, CNM; Lucille Contreras Sollazzo, MSN, RN-BC, NPD; Marc Minick, PhD, LMSW; and Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD

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What’s New in Healthcare Literature

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E Activities: Growth Through the Storm; A Literature Review and Opinion Article; C Nurses’ Unions Can Help Reduce Stress; In the Aftermath of Maria

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JOURNAL of the New York State Nurses Association

Volume 47, Number 1

n E ditorial: Emotional Flexibility, Adaptability, Positive Outlook, and Collegiality:

The Right Mix for Resiliency in Nursing..................................................................................................... 3

by Anne Bové, MS, RN-BC, CCRN, ANP; Dana Deravin Carr, DrPH, MS, MPH, RNBC, CCM; Seth Dressekie, MSN, RN, NP; Audrey Graham-O’Gilvie, DNP, ACNS-BC; Meredith King-Jensen, PhD, RN; Caroline Mosca, PhD, RN; and Coreen Simmons, PhD-c, DNP, MSN, MPH, RN

n Growth Through the Storm: Perinatal Nurses’ Experiences of

Hurricane Sandy............................................................................................................................................................. 5

by Karen Mancini, PhD, RN

n A Literature Review and Opinion Article on the Nurse Practitioner’s Role in

Certification and Management of Medical Marijuana ................................................................ 12

by Joseph J. Brennan, MS, AGNP, RN-BC, CCRN-CMC; and Maureen C. Roller, DNP, RN, ANP-BC.

n N urses’ Unions Can Help Reduce Stress, Burnout, Depression,

and Compassion Fatigue...................................................................................................................................... 18

by Lucille Contreras Sollazzo, MSN, RN-BC, NPD; and Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD

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I n the Aftermath of Maria: An Ethnographic Review of Rescue, Recovery, Climate, and Social Justice in Puerto Rico.............................................................................................. 45

by Carole Ann Moleti, DNP, FNP-BC, CNM; Lucille Contreras Sollazzo, MSN, RN-BC, NPD; Marc Minick, PhD, LMSW; and Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD

n What’s New in Healthcare Literature ......................................................................................................... 59 n CE Activities: Growth Through the Storm; A Literature Review and Opinion

Article; Nurses’ Unions Can Help Reduce Stress; In the Aftermath of Maria ............ 61

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The Journal of the New York State Nurses Association Editorial Board Audrey Graham-O’Gilvie, DNP, ACNS-BC Assistant Professor Touro College School of Nursing Hawthorne, NY

Caroline Mosca, PhD, RN Faculty Program Director – Team Lead BS/MS Nursing Program Excelsior College Albany, NY

Dana Deravin Carr, DrPH, MS, MPH, RN-BC, CCM Senior Care Manager/Transitions Care Coordinator Jacobi Medical Center Bronx, NY

Anne Bové, MS, RN-BC, CCRN, ANP Assistant Professor CUNY, Borough of Manhattan Community College New York, NY

Meredith King-Jensen, PhD, RN Assistant Professor Touro College Bronx, NY

Seth Dressekie, MSN, RN, NP Human Resources Administration NYC Department of Social Services New York, NY

Coreen Simmons, PhD-c, DNP, MSN, MPH, RN Professional Nursing Practice Coordinator Teaneck, NJ

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Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD, Co-Managing Editor Lucille Contreras Sollazzo, MSN, RN-BC, NPD, Co-Managing Editor David Gray, Editorial Assistant The information, views, and opinions expressed in The Journal articles are those of the authors and do not necessarily reflect the official policy or position of the New York State Nurses Association, its Board of Directors, or any of its employees. Neither the New York State Nurses Association, the authors, the editors, nor the publisher assumes any responsibility for any errors or omissions herein contained.

The Journal of the New York State Nurses Association is peer reviewed and published biannually by the New York State Nurses Association. ISSN# 0028-7644. Editorial and general offices located at 131 West 33rd Street, 4th Floor, New York, NY, 10001; Telephone 212-785-0157; Fax 212-785-0429; email info@nysna.org. Annual subscription: no cost for NYSNA members; $17 for nonmembers.

The Journal of the New York State Nurses Association is indexed in the Cumulative Index to Nursing, Allied Health Literature, and the International Nursing Index. It is searchable in CD-ROM and online versions of these databases available from a variety of vendors including SilverPlatter, BRS Information Services, DIALOG Services, and The National Library of Medicine’s MEDLINE system.

It is available in microform from National Archive Publishing Company, Ann Arbor, Michigan.

©2020 All Rights Reserved  The New York State Nurses Association

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Journal of the New York State Nurses Association, Volume 47, Number 1

n EDITORIAL Emotional Flexibility, Adaptability, Positive Outlook, and Collegiality: The Right Mix for Resiliency in Nursing It is opportune that this volume of the Journal will be published during this catastrophic COVID-19 pandemic. Now more than ever, nurses need to be engaged in collective action; cultivate team unity, solidarity, and spirit; and encourage one another to maintain our resilience within ourselves and in our practice. Practicing during the COVID-19 crisis requires resilience to manage strong feelings and emotional reactions to our present circumstances and challenges. Resilience in nursing doesn’t make problems go away, but it can give us the ability to see past our difficulties, feel less stressed, and even enhance our patient outcomes.

The articles in this issue of the Journal demonstrate how resilience turns stumbling blocks into stepping-stones. Tenacity, hope, adaptability, and interpersonal connectedness help nurses traverse bumpy, sometimes gloomy paths, and bring the light of optimism to colleagues, patients, and self with every act of caring. Relying on our moral inner compass, engaging in self-care activities, and working as a team to solve problems can help to build the resilience we need to enable us to rise above this crisis—and yes, we will rise above.

The article, “Nurses, Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue, Part 1,” reminds us that informed collective action, from individual to governmental levels, results in better work environments and caring spaces for patients to heal. “Growth Through the Storm: Perinatal Nurses’ Experiences of Hurricane Sandy,” outlines nurses’ experiences of personal strength and camaraderie that facilitated joyful birth experiences for families, despite disruption and angst in a time of disaster. “A Literature Review and Opinion Article on the Nurse Practitioner’s Role in Certification and Management of Medical Marijuana,” provides direction for nurse practitioners to make a unique treatment modality accessible to those who will benefit. In the article “In the Aftermath of Maria: An Ethnographic Review of Rescue, Recovery, Climate, and Social Justice in Puerto Rico,” international collaboration and insightful interdisciplinary commitment gently focus attention to provide care, courage, and advocacy for neglected disaster survivors.

Fear of the unknown, as in a pandemic, can result in despair and in the desire to run away. Instead, consider letting your ethics and experience guide you. To care is to put into action compassion over indifference and fear. We hope this issue will guide you on how to bring healing to families and communities while preserving your integrity as a nurse. Let uncertainty and doubt transform into empathy, which can empower you and inspire the resilience within you.

Meredith King-Jensen, PhD, RN Dana Deravin Carr, DrPH, MS, MPH, RN-BC, CCM Caroline Mosca, PhD, RN Coreen Simmons, PhD-c, DNP, MSN, MPH, RN Audrey Graham-O’Gilvie, DNP, ACNS-BC Anne Bové, MS, RN-BC, CCRN, ANP Seth Dressekie, MSN, RN, NP

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Growth Through the Storm: Perinatal Nurses’ Experiences of Hurricane Sandy Karen Mancini, PhD, RN

n A bstract

The purpose of this study was to explore the experiences of perinatal nurses who cared for patients during Hurricane Sandy through a descriptive phenomenological design. Colaizzi’s method was used to analyze the narratives of a purposive sample of seven perinatal nurses from three facilities affected by the storm. Findings revealed the essence of the experience for the participants. Six theme clusters emerged: (1) going above and beyond, (2) a storm of confidence, (3) technology: communication lifeline and barrier to care, (4) a storm of solidarity, (5) preparedness: looking back and moving forward, and (6) working through uncertainty. Perinatal nurses demonstrated professionalism and fidelity while caring for patients during Hurricane Sandy. The findings of this study highlight the need for nurses to be adequately prepared for uncertain conditions. Clinical leaders may use the findings to invite nurses’ participation when designing systems for disaster preparedness.

Keywords: Qualitative/phenomenology, lived experience, perinatal nursing, disaster preparedness

Introduction In the past decade, natural disasters have been occurring with increasing frequency. Preparing for such disasters is a top priority for the federal government and private agencies whose mission is to protect the health and welfare of populations (Bernard & Matthews, 2008). Healthcare agencies have been especially vulnerable to disasters, as evidenced in the aftermath of Hurricane Katrina in 2005, where catastrophic flooding crippled most of the healthcare facilities in coastal Louisiana (Badakhsh, Harville, & Banerjee, 2010). The Northeast region of the United States, usually spared of higher category storms, experienced the wrath of Hurricane Sandy in October of 2012. Termed a superstorm, Sandy left extensive damage to the New York metropolitan area and coastal communities. Unprepared for the extent of flooding, the city did not mandate evacuations. Nevertheless, coastal hospitals were forced to evacuate patients from facilities thought to be safe havens for the sick, as well as new life coming into the world.

Perinatal nurses from labor and delivery, neonatal intensive care, and mother/baby units were responsible for the safe evacuation of mothers and newborns. As a result of lessons learned, new and enhanced protocols for disaster management were developed, including a formal evacuation plan for labor and delivery units and nurseries in the New York City area. Ongoing

education for nurses in the core competencies necessary to respond to disasters remains a priority.

Researchers have highlighted the importance of post-disaster research by nurses to inform as well as to plan for future events (Giarratano, Savage, Barcelona de Mendoza, & Harville, 2014). Nurses are encouraged to participate in disaster preparation within their institutions as well as in the community (Association of Women’s Health, Obstetrics, and Neonatal Nurses [AWHONN], 2012). In order to provide updates and refinements to disaster preparedness curricula, understanding the experiences of nurses working in healthcare facilities during a natural disaster is essential. Such information may facilitate meeting both the physical and psychological needs of the healthcare workforce that can have an impact on patient safety.

The purpose of this study was to explore the experiences of perinatal nurses who cared for patients during the events of Hurricane Sandy.

Review of the Literature Considerable research has been conducted on the effects of disasters on population health, specifically childbearing women and infants (Harville, Giarratano, Savage, Barcelona de Mendoza, & Zotkiewicz, 2015). Extant literature in the aftermath of Hurricane Katrina suggests that the adverse

Karen Mancini, PhD, RN, is Chair of the Department of Nursing Specialties at the College of Nursing and Public Health.

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Growth Through the Storm: Perinatal Nurses’ Experiences of Hurricane Sandy

effects of stressful life events, such as experiencing a disaster, may have a negative effect on perinatal health (Harville, Xiong, & Buekens, 2010).

Studies examined the experiences of pregnant women during the days surrounding Katrina (Badakhsh et al., 2010), as well as perinatal outcomes in the years following the event (Harville et al., 2015). Perceived stress and coping styles were examined in women exposed to Katrina and research found that disaster-related stress may complicate pregnancy (Oni, Harville, Xiong, & Buekens, 2015).

Most post-Katrina studies of nurses utilized survey methodology to examine risks for compassion fatigue and post-traumatic stress disorder (Frank & Sullivan, 2015). A smaller number of studies have examined the lived experiences of nurses after Katrina. One study examined the experiences of nine nurses from various facilities and areas of practice throughout the Southeast region who were affected by the 2005 hurricane (Frank & Sullivan, 2015). Themes mirrored the nursing process such as chaos, reality check, reorganizing, stabilizing, and planning for the future.

The study provided a holistic view of the experiences of nurses and exemplified the strength of nursing as a profession.

Fewer studies have examined the experiences of the nurses who served a vital role in ensuring the health, safety, and well-being of mothers and babies. Perinatal nurses need ongoing education in order to provide care to this vulnerable population, as well as to prepare for the needs of their own families during a disaster (AWHONN, 2012). One qualitative study explored the experiences of perinatal nurses after Katrina (Giarratano, Orlando, & Savage, 2008). Themes and subthemes included duty to care, uncertain times, and strength to endure. These researchers highlighted the sense of uncertainty and great need for staff unity when confronted with chaos.

Since the nurses in this study exhibited stress responses in the aftermath of Katrina, including altered sleep, eating, and mood patterns, the authors highlighted the need for ongoing supportive interventions and continued research (Giarratano et al., 2008).

Uncovering the experiences of nurses who worked during Hurricane Sandy can add to the existing body of disaster nursing literature. Yet, less post-disaster research has been conducted following Hurricane Sandy. A recent mixed-method study conducted at one high-profile facility after Sandy concluded that nurses reported needing more hands-on disaster preparation, increased low-tech solutions for expected power outages, and training for unanticipated challenges that may occur during a disaster (VanDevanter, Raveis, Kovner, McCollum, & Keller, 2017). Using Parse’s human becoming framework, Baumann (2014) examined the experiences of a group of graduate nursing students working in various settings at the time of Sandy. Parse (1998) suggests that humans are in mutual contact with the universe, constantly changing, and interpreting the meaning of experiences and events they have witnessed in a unique and personal manner. Emergent meanings of the study highlighted the personal strength of the nurses and the continuing need for disaster preparation on a global level (Baumann, 2014). The current study is one of the first to explore the experiences of the perinatal nurses who cared for patients during the days surrounding Hurricane Sandy in October of 2012.

phenomenology is a means to explore the lived experience of individuals through thick description of the experience. The present study utilized a descriptive phenomenological approach based on the work of Husserl. The findings from a study in the philosophy of Husserl describe the essence of a phenomenon as lived by persons who have had the experience (Wojnar & Swanson, 2007). An important tenet of Husserl’s approach is the belief that the essence of lived experiences may be revealed through one-toone interactions between the researcher and participant. In order to gain insight into common features of a lived experience, Husserl believed that the researcher should practice objectivity by bracketing preconceived ideas (Lopez & Willis, 2004). The researcher of the present study did not share the experience, but witnessed extensive media coverage of the storm and its aftermath. Therefore, in order to preserve objectivity, the researcher maintained field notes during participant interviews and analysis of the transcripts. The researcher practiced reflexivity during the study by journaling, and an audit trail of the research steps were kept throughout the study to ensure confirmability. These steps were done to ensure trustworthiness of the study (Korstjens & Moser, 2018). The findings of the study were interpreted using the theory of post-traumatic growth (Tedeschi & Calhoun, 2004).

Procedure International Review Board approval was obtained through the researcher’s university. Recruitment took place through the area chapters of Sigma Theta Tau International. An invitation email was sent to members inviting their participation. Recruitment continued through snowballing.

Interested participants contacted the researcher via email and face-to-face meetings were set up. Informed consent was obtained. A semi-structured, interview guide facilitated the in-depth interviews. The main statement, “Tell me what you remember about the days you worked during Hurricane Sandy,” was followed by additional probes such as, “Think back and describe an experience that stands out in your mind as significant.” Participants were asked, “How has this experience affected you these past five years?” The guide was reviewed for content validity by an expert in qualitative research.

Sample A purposive sample of seven perinatal nurses was employed.

Participants were female and between the ages of 22 to 57 years at the time of the storm. Years of nursing practice in the field of perinatal health ranged from less than one year of practice up to 35 years. Participants had worked at their institutions for less than one year up to 20 years, and two nurses had finished their orientation period two months prior to the storm.

Five nurses worked on mother/baby units and two nurses worked in labor and delivery at three large hospitals. All nurses continue to be employed at the facilities where they were employed in 2012. Data collection and analysis were conducted concomitantly between August 2017 and September 2018.

Interviews continued until thematic redundancy was reached.

Methods

Data Analysis

Research Design

Data was analyzed using the steps of Colaizzi’s method (Creswell, 2007). Colaizzi’s method of data analysis helps to understand and apply meaning to the data in order to construct a thematic description. The

Phenomenology as a philosophy seeks to understand human consciousness and self-awareness (Lopez & Willis, 2004). Descriptive 6

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steps included reading and rereading transcripts over several days to glean significant statements and to ensure that participants’ experience of the phenomenon was the focus of the data analysis. In the next step the researcher developed formulated meanings which ascribed meaning to significant statements and looked for commonalities of the phenomenon (Wojnar & Swanson, 2007). Subsequently, six theme clusters emerged from the formulated meanings: (1) going above and beyond, (2) a storm of confidence, (3) technology: communication lifeline and barrier to care, (4) a storm of solidarity, (5) preparedness: looking back and moving forward, and (6) working through uncertainty. From the theme clusters, a description of the phenomenon growth through the storm was developed. Table 1 illustrates examples of data analysis from significant statements to theme cluster.

Results The resulting six theme clusters describe the experience of the perinatal nurses. The use of verbatim statements of the participants give insight to the essence of the experience.

Theme Cluster I: Going Above and Beyond All participants described the lengths they went to inorder to ensure that families had a meaningful birth experience despite the chaos of the storm. The perinatal nurses described stepping out of the usual care to ensure patient safety and the challenges they encountered to give patients a sense of normalcy despite uncertainty. Participants described being attentive to family units as part of the birth process. This was illustrated in a statement by Casey: “We trekked down 13 flights of stairs and went to the lobby, picked up the dad, and walked up 13 flights of stairs to bring him back to his partner and his baby.” The mother/baby nurses described how they maintained composure while trying to keep patients calm. The nurses would remind each other to go into the medication room if they were starting to “freak out.”

Once units went on emergency generators and it became apparent that evacuation would be necessary, the nurses discussed how they had to rely on astute assessment skills to triage patients and attend to patient needs. Participants described functioning in ways that were in extreme divergence from usual care. All participants described the evacuation of patients. Some carried newborns down 13 flights in a darkened stairwell lit only by flashlights. Others described the similarly daunting experience of evacuating a laboring patient with epidural anesthesia on a med sled to a waiting ambulance. In the aftermath, the nurses claimed “bragging rights” from having been through and survived working during the chaos of the storm and their roles in the safe evacuation of patients and keeping mothers and newborns safe. Sara, an experienced mother/baby nurse, described the innovative ways the nurses used to keep the unit running. All participants described their willingness to “think out of the box” and go above and beyond for their patients.

Theme Cluster II: A Storm of Confidence A common feature of the participants’ experience of working during the storm was increased confidence in their ability to care for patients.

The nurses described increased personal strength and reserve even while

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working through a chaotic situation. One participant, Nancy, noted, “It was one of the best things in the world…. It definitely made me a strong nurse… able to speak up more for my patients or even for myself as a nurse.” One experienced mother/baby nurse described personal and professional growth as a result of creating innovative ways to care for patients during the event.

Novice nurses described the most significant increases in confidence and described their professional growth as a result of the challenge. Casey, who finished orientation two months prior stated, “I would say it made me a better nurse, honestly. I kind of feel like if I can do that, what else can I do? I survived a hurricane.” As a result of working during the storm, nurses described feeling like going forward, they would be able to adapt to any situation. The experience instilled confidence and expanded the participants’ view of nursing. As noted by one participant, “There’s so much more to nursing than just bedside care.”

Theme Cluster III: Technology: Communication Lifeline and Barrier to Care Technology was often described in dichotomous terms. All participants discussed the benefits and barriers of technology. Having a cell phone to keep in touch with family was described as a lifeline during the storm and in the aftermath. Rita shared, “So as long as I could have some sort of lifeline to my parents, family, then I would be okay.” Texting colleagues in the days following the storm allowed nurses to feel connected and share experiences, which they considered to be an informal debriefing.

Conversely, the nurses described the reliance on technology that allowed them to care for patients and what it was like when it was not available. Medication administration was a common feature mentioned by participants, specifically keeping patients comfortable and pain free in the absence of an automated medication dispenser. Casey noted, “Do I have enough medication in my cart or on my poles already because if the Omnicell loses power, we can’t get to it.”

Patient safety emerged as a subtheme. All participants spoke of keeping patients safe despite not having the usual means of assessing patients with technology such as electronic fetal monitoring and blood pressure equipment. An experienced labor and delivery nurse shared the complexity of assisting with a high-risk procedure and assessing the patient’s response without the use of technology. She described relying on her sense of intuition and a keen awareness of the mother’s responses.

Another nurse, Sally, described the feelings of concern she had for patient safety: “So if we had a patient that needed like oxygen or like anything that required light, then that patient’s life would have been at risk, because we had no way of getting that done.” The lack of working technology was especially difficult for novice nurses. As noted by Gina, a senior nurse, “They were scared at first, because they had learned with all the technology and they had to figure out how they were going to do things without it.”

Difficulty with patient documentation was another common thread discussed by participants. One senior nurse who worked in a facility that relied on emergency generators for an extended period of time described the issues of inadequate supplies and difficulty with documentation and having to rely on handwritten narrative notes. Another nurse described not being able to adequately document care so she prioritized being present with patient.

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Theme Cluster IV: A Storm of Solidarity Teamwork was seen as essential to function effectively during the storm. All participants described collegial relationships being strengthened as a result of working together in order to maintain a sense of normality.

Collegiality also occurred with coworkers who were described as “mean girls” prior to the event. The concept of support was discussed by all participants and examples of supportive supervisors and administrators stood out in the nurses’ minds as one of the most helpful aspects of coping. Conversely, unsupportive managers were also described by some participants, and lack of support was sometimes described as “feeling abandoned.” One nurse described feelings of anger in the aftermath of the storm related to lack of administrative support, and thus relied on fellow nurses for support and feelings of camaraderie.

The nurses described taking on certain informal roles related to their experience. Senior nurses took on a charge role deciding which patients to move and the operations of the unit, as well as delegating care activities to less experienced nurses. In turn, novice nurses described looking to more senior nurses and being grateful for their direction. One senior nurse in a charge position spoke about coaching less experienced nurses with many aspects of care.

Interdisciplinary teamwork was seen as essential. Nurses who were involved in evacuation described the hands-on cooperation and collaboration of medical students and residents to get patients to safety.

Ancillary support teams involved in the evacuations of patients were seen as an immense help, and as a result, new bonds were formed.

Following their experiences, nurses described a sense of solidarity.

Nancy offered, “That night was really good and, even after that, people who worked together they were all very cohort. We were survivors, basically.”

Nurses described continuing to feel a sense of solidarity with colleagues that shared the experience of working during Hurricane Sandy. Rita summed it up: “It just brings you closer together. Those memories that we made, those nights of when we were all in the ambulance, nobody was sad or crying. Everyone was just like, ‘Okay, we’re doing it.’ We love what we do, and like just to have that tight-knit group, it made it so much more enjoyable considering the circumstances.”

Theme Cluster V: Preparedness: Looking Back and Moving Forward Preparedness was a common thread discussed by all participants.

This was often explained in terms of organizational preparedness as well as unit preparation prior to the storm. Unit preparations included adequate staffing and the possibility of emergency generators in the event a power outage occurred. Some of the participants described having worked through snow emergency situations, which were more frequent, but did not have an impact on patient care. Preparation was also discussed in terms of being prepared on a personal and emotional level. Nurses described what it was like when they realized that their preparedness would not be sufficient. As noted by Nancy, “We were prepared as nurses I believe, but I don’t think anybody was prepared for that exact situation because you don’t know until it happens, right? I think nobody was aware of the extent or the severity of the situation until it happened.”

This was the point that personal strength and resilience became necessary to begin alternate plans. The nurses discussed waiting for 8

Teamwork was seen as essential to function effectively during the storm.

their units to be evacuated while seeing the flood waters rise on the busy avenues outside of their facilities. Since the maternity patients were deemed the most stable, they were the last to evacuate the facilities.

Newborn evacuation was a common thread of all participants, who described the tense evacuation of newborns and immediate postpartum mothers. Participants spoke of the lack of necessary equipment to evacuate newborns.

Participants spoke about what preparations they would like to see moving forward. Elizabeth, an experienced nurse offered, “Okay if this happens, hopefully it doesn’t, but something’s going to happen, so we need to have a plan of action.” Participants discussed the necessity of having adequate supplies and an evacuation plan for the safe evacuations of newborns. All the nurses discussed the value of bedside nurses being involved in preparation for future events. Nancy offered, “I think it should be at the nursing level. If leadership is putting together something, they should really come to nursing like, ‘What do you think will work best for your patients?’” One senior nurse discussed the necessity to train nurses for different situations, including influenza pandemics and mass casualty situations. Adequate preparation and support by their organization was also cited as a key factor in the nurses’ decisions to remain at the organization.

Theme Cluster VI: Working Through Uncertainty Perinatal nurses described the experience of working during the storm as one of uncertainty. Despite preparation, it was impossible to predict the events that occurred. The nurses described the feeling of trying to remain calm in the face of panic and prepare to evacuate patients as they watched the flood waters rise. As one nurse explained, “It was chaos. Who knows where we’re going to be next? We were taking care of whomever they told you to take. I knew her basic history, but I didn’t know the extent of anything, so it was just like, ‘I’m going to stay with you; It’s all going to be okay,’” All participants described doing their best to care for patients in a situation that was both unexpected and deviated from the usual care.

Nurses described having a different perspective after the storm and the necessity of being ready for the unexpected. Despite weathering the storm in their facilities, all but one of the participants were required to work at another hospital for an extended period until her facility reopened.

This was an uncertain and stressful event for the nurses. Rita remarked, “We knew that we were going into a different hospital, but we had no idea kind of what to expect at that hospital.” Participants described adapting to a different facility’s norms and rules and feeling uncertain of what was expected of them. This was especially true for novice nurses.

As Rita described, “My friend and I who just started, who just finished orientation, look at each other and think we have no background, we just got used to being a nurse on our own, and now we’re in a totally different hospital trying to figure out their systems, their rules.” Despite uncertain conditions, the perinatal nurses faced uncertainty and emerged empowered.

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Discussion In the years since Hurricane Sandy, even though many changes have been made to existing protocols—especially regarding the safe evacuation of patients—recovery and repair to infrastructure remains ongoing. In the Northeast, the experience continues to be a reminder of the impact severe weather events can have on our healthcare system. The perinatal nurses interviewed for the present study all shared vivid recollections of their work during the storm. One nurse commented, “I remember it like it was yesterday.” The perinatal nurses in this study found increased confidence and personal strength as a result of their experiences. Similarly, Baumann (2014) found that nurses’ potential to be extraordinary was revealed as a result of working during the storm. Studies of nurses’ experiences postKatrina suggest that the dire conditions and long-term displacement resulted in shows of strength and courage to endure extraordinary conditions, which nurses only realized later (Giarratano et al., 2008). The nurses in the present study went above and beyond usual care and relied on astute assessment skills to keep patients safe. Similar studies found that nurses went back to basic nursing skills and employed creative strategies to provide quality care and ensure patient safety (Frank & Sullivan, 2015; VanDevanter et al., 2017).

This study highlights the importance of interdisciplinary teamwork and collaboration during high-impact events. The nurses in the current study said benefits were the result of collegial relationships during, and in the aftermath, of the storm. Similarly, several other qualitative studies identified similar themes. Giarratano et al. (2008) identified staff unity as a valuable resource in the aftermath of Katrina. Support of colleagues enabled 77% of nurses (n = 173) to carry out their roles (VanDevanter et al., 2017).

The participants in the present study discussed the role of technology during and in the aftermath of the storm, and the difficulty of working without necessary equipment. Similarly, VanDevanter et al. (2017) also recognized the theme of the effects of power loss on nurses’ ability to function following Hurricane Sandy. Equipment management, medication administration, and medical records were described by the nurses, as well as personal communication devices used to maintain contact with colleagues and family.

Research findings suggest the importance of adequate disaster preparation (Baack & Alfred, 2013; VanDevanter et al., 2017). The perinatal nurses in the present study discussed that, although the institutions had prepared for the storm in terms of staffing and resources, they were not prepared for the magnitude of the storm, especially the evacuation of patients. This finding is similar to studies that examined preparation of nurses after Hurricane Katrina (Frank & Sullivan, 2015; Giarratano et al., 2008). Researchers surveyed nurses who practice in a rural area in Texas and found that most nurses did not feel adequately prepared to function in a disaster situation (Baack & Alfred, 2013). In the aftermath of Hurricane Sandy, organizations in the hardest hit areas have enhanced resources and planning for the future. This is an important aspect, as one nurse in the current study described now using this criterion for accepting employment at an organization. Preparation is crucial in the perinatal area, as evacuating newborns safely is a priority. The nurses in this study all described the makeshift aspect of infant evacuations during Sandy and the experiences’ lasting impressions on the participants. At the time of the storm, the city did not have a formal evacuation plan for newborns. Since the events of Sandy, New York City formed a group of physicians, nurses, and government officials to develop formal labor and delivery and nursery evacuation plans

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(New York City Disaster Coalition, n.d.). The participants in the present study spoke of lessons learned, practicing evacuation drills in the aftermath, and wanting to be at the table for future planning and implementation. In all aspects of the nurses’ experiences of working during the storm, patient safety and facilitating an optimal birth experience was paramount.

The findings of the present study were interpreted using the model of post-traumatic growth (Tedeschi & Calhoun, 2004). The model conceptualizes enhanced interpersonal relationships as the result of a challenging life event, and emphasizes new potential and capacities discovered after the effort of overcoming the event (Baumann, 2018).

According to Tedeschi and Calhoun (2004), positive change can come from adverse events when individual narratives are shared in the social context and growth is recognized. In the present study, the perinatal nurses all described aspects of positive growth, increased self-efficacy, and enhanced collegial relationships as a result of working during Hurricane Sandy.

Limitations The present study was a retrospective account of the perinatal nurses who went above and beyond for patients during the events of Hurricane Sandy in 2012. The nurses interviewed expressed that their memories of the events were still vivid; however, time may have altered their recollection.

This was a small sample of perinatal nurses. The experiences of nurses serving in natural disasters in other regions of the country may be different, as evidenced by the events that took place after Hurricane Katrina in 2005 and Hurricane Harvey in 2017. Nevertheless, the findings of this study may be germane to nurses serving in other disasters.

Implications Preparing for natural disasters is an essential core competency for nurses as severe weather events have been occurring with increasing frequency. The findings of this study highlight the need for all nurses to be adequately prepared for untoward events that may occur in the workplace.

In practice, nurses need consistent training to be able to address the unexpected when it arises. Simulated disaster drills for all healthcare workers should be ongoing. Nurses also need the skills and resources to deliver safe patient care in the absence of technology, as was evident during and in the aftermath of Sandy. Nurses at all levels of practice should be involved in the development of disaster protocols at their institutions. Clinical leaders may use the findings of this study to invite nurses’ participation when designing systems for disaster preparedness.

As described by the nurses in the present study, unexpected events can be especially stressful for novice nurses. Consequently, it is necessary to begin preparing nursing students at the undergraduate level for disaster emergencies. Interdisciplinary disaster simulations in both undergraduate and graduate education could effectively introduce protocols and practice Nurses also need the skills and resources to deliver safe patient care in the absence of technology, as was evident during and in the aftermath of Sandy.

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Growth Through the Storm: Perinatal Nurses’ Experiences of Hurricane Sandy

disaster scenarios. Students should be encouraged to practice key manual skills that are often replaced by technology in hospitals. Research into the effectiveness of disaster simulations is warranted and can add to the existing body of disaster nursing knowledge. Research into the lived experiences of families who experienced the event is warranted.

Conclusion The perinatal nurses in the present study described what it was like to care for patients during Hurricane Sandy. These participants reported gaining confidence in their abilities and increased personal strength

while working through uncertainty. With support from colleagues and administration, they were able to assist with births and safely evacuate mothers and newborns from the hardest hit facilities. The lack of working technology was one of the challenges the nurses faced, and forced them to rely on astute judgments and innovation to maintain patient safety.

The event changed the nurses’ perspective on patient care and heightened their awareness of preparation for future events. The perinatal nurses demonstrated professionalism and fidelity as they cared for patients during Hurricane Sandy. The experiences of these nurses illustrate the essential role perinatal nurses play in family-centered care and the significance of disaster preparedness in the healthcare setting.

Table 1: Example of Data Analysis Significant statement

Formulated meaning

Theme cluster

“I had this mom who’s in front of me, who had a vaginal delivery six hours before. I’m holding her baby with all of my stuff and rain boots on and I’m thinking, ‘Please don’t fall down the stairs with this brand new newborn.’” (Rita)

Beyond usual care to ensure patient safety

Going above and beyond

“I think it's made me more adaptable, confident. It was one of the best things in the world, it was good for me. It definitely made me a strong nurse. Able to speak up more for my patients or even for myself as a nurse.” (Nancy)

Increased self-efficacy and patient advocacy

A storm of confidence

“That really stands out to me first, the camaraderie that we have, the dedication that we have to just be there for our patients and our staff members.” (Elizabeth)

Experience strengthened staff unity

A storm of solidarity

“We were at another hospital for a month. It was definitely a different everything. The way they do things was different. Their set up is different.

Their rules and regulations were different.”

(Casey)

Adapting to unexpected change

Working through uncertainty

“We were giving birth in the dark. There was no electronic fetal monitoring or vital signs capabilities. And we were administering epidurals with flashlights.” (Susan)

Providing care without technology

Technology: communication lifeline and barrier to care

“They definitely have to train for different kinds of things as far as other kinds of man-made disasters, not necessarily storms.” (Gina)

Need for training for future events

Preparedness: looking back and moving forward

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n References Association of Women’s Health, Obstetric & Neonatal Nursing. (2012).

The role of the nurse in emergency preparedness: An official position statement of AWHONN. JOGNN, 41, 322-324. doi:10.1111/j.15526909.2011.01338.x

Harville, E., Xiong, X., & Buekens, P. (2010). Disasters and perinatal health: A systematic review. Obstetrical & Gynecological Survey, 65(11), 713-728. doi:10.1097/OGX.0b013e 31820eddbe

Baack, S., & Alfred, D. (2013). Nurses’ preparedness and perceived competence in managing disasters. Journal of Nursing Scholarship, 45, 281-287. doi:10.1111/jnu.12029

Harville, E., Giarratano, G., Savage. J., Barcelona de Mendoza, V., & Zotkiewicz, T. (2015). Birth outcomes in a disaster recovery environment: New Orleans women after Katrina. Journal of Maternal Child Health, 19, 2512-2522.

Badakhsh, R., Harville, E., & Banerjee, B. (2010). The childbearing experience during a natural disaster. JOGNN. 39, 489-497. doi:10.1111/ j.1552-6909.2010.01160.x

Korstjens, I., & Moser, L. (2018). Series: Practice guidelines to qualitative research. Part 4: Trustworthiness and publishing. European Journal of General Practice, 24(1), 120-124. doi:10.1080/13814788.2017.1375092

Baumann, S. (2014). Weathering the storm: Nurses stories’ about Hurricane Sandy. Nursing Science Quarterly, 27(3), 248-253. doi:10.1177/0894318414534490

Lopez, K., & Willis, D. (2004). Descriptive versus interpretive phenomenology: Their contribution to nursing knowledge. Quality Health Research, 14, 726-735.

Baumann, S. (2018). From posttraumatic stress disorder to posttraumatic growth: A paradigm shift or paradox? Nursing Science Quarterly, 31(3), 287-290.

New York City Pediatric Disaster Coalition. Retrieved from http://www. programinfosite.com/peds/about-the-pdc/

Bernard, M., & Matthews, P. R. (2008). Evacuation of a maternal-newborn area during Hurricane Katrina. Maternal Child Nursing, 33(4), 213223.

Creswell, J. W. (2007). Qualitative inquiry & research design: Choosing among five approaches (2nd ed.). Thousand Oaks, CA: Sage Publications.

Frank, D., & Sullivan, L. (2015). The lived experience of nurses providing care to the victims of the 2005 hurricanes. Southern Online Journal of Nursing Research, 8(3).

Giarratano, G., Orlando, S., & Savage, J. (2008). Perinatal nursing in uncertain times: The Katrina effect. MCN: The American Journal of Maternal Child Nursing, 33(4), 249-257.

Giarratano, G., Savage, J., Barcelona de Mendoza, V., & Harville, E.W. (2014). Disaster research: A nursing opportunity. Nursing Inquiry, 21, 259-268.

Oni, O., Harville, E., Xiong, X., & Buekens, P. (2015). Relationships among stress coping styles and pregnancy complications among women exposed to Hurricane Katrina. JOGNN, 44, 256-267. doi:10.1111/15526909.12560 Parse, R. R. (1998). The human becoming school of thought: A perspective for nurses and other health professionals. Thousand Oaks, CA: Sage.

Tedeschi, R. G., & Calhoun, L. G. (2004). Posttraumatic growth: Conceptual foundations and empirical evidence. Psychological Inquiry, 15(1), 1-18.

VanDevanter, N., Raveis, V. H., Kovner, K. T., McCollum, M., & Keller, R. (2017). Challenges and resources for nurses participating in a Hurricane Sandy hospital evacuation. Journal of Nursing Scholarship, 49(6), 635-643.

Wojnar, D., & Swanson, K. (2007). Phenomenology: An exploration. Journal of Holistic Nursing, 25(3), 172-180. doi:10.1177/0898010106295172

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A literature review and opinion Article on the Nurse Practitioner’s role in Certification and management of medical marijuana Joseph J. Brennan, MS, AGNP, RN-BC, CCRN-CMC Maureen C. Roller, DNP, RN, ANP-BC Correction: The print version of this article mistakenly cited Joseph J. Brennan as the second author and Maureen C. Roller as the first author. The error has been corrected in this digital version.

n A bstract Marijuana is classified by the federal government as a Schedule I narcotic. Research has indicated marijuana can be beneficial in treating various symptoms and certain medical disorders, resulting in legislation allowing its usage for medicinal purposes in many states. Certification privileges were initially restricted to physicians, and many questioned if nurse practitioners (NPs) should be allowed to certify medical marijuana use. Recently, multiple states granted certification privileges to NPs, including New York State.

Currently, there exists a gap in the literature on the role of the NP as a provider of marijuana. Additional research in standardization, therapeutic uses, education, and side effects are lacking. This article addresses the nurse practitioner’s role in medical marijuana as a form of treatment.

Keywords: Medical marijuana, nurse practitioner’s role, marijuana uses

Introduction Medical marijuana use is a debate nationwide. Presently, 33 states, including New York, the District of Columbia, and the U.S. territories of Guam, Puerto Rico, and the U.S. Virgin Islands have all legalized marijuana for medical reasons (National Conference of State Legislators [NCSL], 2019; ProCon.org, 2019). Marijuana is currently federally classified as a Schedule I controlled substance. It has a high potential for dependence and abuse, and the United States Department of Justice, who oversees the Drug Enforcement Agency (DEA), has declared it has no medical cause (NCSL, 2019). Due to its class I status, human research is limited in the United States on the effects and benefits of marijuana as a form of treatment. Other countries, including Spain, Great Britain, and Israel, are presently conducting research on the use and benefits of marijuana, leaving research in the United States trailing other countries (Pettinato, 2017). However, the research that has been conducted reveals marijuana has a place in the management of specific medical conditions.

Healthcare providers do not “prescribe” medical marijuana; practitioners only certify a patient’s condition and need for its use. States

Healthcare providers do not “prescribe” medical marijuana; practitioners only certify a patient’s condition and need for its use.

are slowly accepting medical marijuana as an alternative to standard treatments, initially only allowing certification privileges at the discretion of a physician. Presently, many states have reformed their laws, extending certification privileges to nurse practitioners (NPs) and physician assistants (PAs). There are many concerns practitioners have when certifying patients for marijuana use, but formal education on this topic may diminish these worries. New York State has specific requirements a provider must meet in order to certify patients, permitting marijuana use only on specific definitive disease processes. This article will examine the nurse practitioner’s role in certification and management of medical marijuana.

Joseph J. Brennan, MS, AGNP, RN-BC, CCRN-CMC, is a staff RN at Good Samaritan Hospital in West Islip, NY. Maureen C. Roller, DNP, RN, ANP-BC, is a senior adjunct professor at Adelphi University in Garden City, NY, and an adult nurse practitioner at North Coast Internal Medicine in Sea Cliff, NY. 12

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The Nurse Practitioner’s Role in Certification and Management of Medical Marijuana

Background Marijuana is an agent derived from the cannabis plant, which has been used medically for the past 3,000 years to produce properties of relaxation and euphoria (Jarvis, Rassmussen, & Winters, 2017). Cannabis works on the endocannabinoid system and contains an ingredient called cannabidiol, which produces anti-inflammatory, anxiolytic, analgesic, and anticonvulsive effects (Ebbert, Scharf, & Hurt, 2018). Currently, studies are being performed on the use of marijuana for medical intent. In a study conducted by Philipsen, Butler, Simon-Waterman, and Artis (2014), the researchers concluded that the therapeutic use of medical marijuana is based on individualistic beliefs and not on scientific evidence.

The DEA classifies marijuana as a Schedule I controlled substance and deems it to have no medical use. Nevertheless, some states have legalized it for specific medical conditions. The conflict in state and federal laws have placed many patients and practitioners in uncomfortable legal situations. Although the federal government has seemingly decided to leave marijuana enforcement to the states (Philipsen, McMullen, & Wood, 2017), and though a state may have legalized its use, many patients and providers are hesitant to certify and use it.

The federal government’s position on prosecuting the use of cannabis that is legal under applicable jurisdiction law has been set out in U.S. Department of Justice position papers. In 2009, the U.S. Attorney General took a position that discourages federal prosecutors from prosecuting people who distribute or use cannabis for medical purposes in compliance with applicable jurisdiction law; further similar guidance was given in 2011, 2013, and 2014. In January 2018, the U.S. Office of the Attorney General rescinded the previous nationwide guidance specific to marijuana enforcement. The 2018 memorandum provides that federal prosecutors follow the wellestablished principles in deciding which cases to prosecute, namely, the prosecution is to weigh all relevant considerations, including priorities set by the attorneys general, seriousness of the crime, deterrent effect of criminal prosecution, and cumulative impact of particular crimes on the community (National Council on State Boards of Nursing [NCSBN], 2018).

States have credentialed medical practitioners to certify a patient for medical use of marijuana. These providers are trained in medical marijuana and the supervision of its use. Certification for use of medical marijuana authorizes a patient to use, procure, and self-administer (Jarvis et al., 2017).

A relationship between the patient and the medical practitioner should be well established. An alliance of no less than 6 months must occur in some states before certification can take place, which includes a current clinical visit and assessment (Kaplan, 2015). In New York State, there is no requirement of a patient-provider relationship to certify a patient for medical marijuana use.

Several facilities can be designated as a caregiver of certified patients in the use of medical marijuana. In New York, these facilities include hospitals, residential healthcare facilities, adult care facilities, mental health facilities, inpatient or residential treatment programs, residential treatment facilities for children and youth operations, and private or public schools. Once a facility has been registered as a caregiver by the patient, the facility can deliver, transfer, possess, acquire, transport, and administer an approved medical marijuana product to its certified patient. Even though New York State approves medical marijuana use in these facilities, one should review individual institutions’ policies and procedures before medical marijuana use. In the outpatient or home setting, the patient can self-administer

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medical marijuana or have assistance from a caregiver. A caregiver must be registered in the medical marijuana database before being able to possess, obtain, deliver, or administer approved medical marijuana products (New York State Department of Health [NYSDOH], 2018a).

Individual states have specific classifications for medical marijuana use, with some conditions including cancer, seizure disorders, human immunodeficiency virus (HIV), intractable pain, glaucoma, multiple sclerosis, and post-traumatic stress disorders (Kaplan, 2015). Marijuana use has been reported to increase appetites, cause relaxation and euphoria, reduce nausea and vomiting, help with chronic pain, and diminish the spasticity of muscles (Philipsen et al., 2017). Users of medical marijuana reported lower levels of anxiety, lower rates of alcohol abuse, and a reduction in nonprescription opioid use (Wall, Liu, Hasin, Blanco, & Olfson, 2019). Many patients with chronic pain self-medicate with nonprescribed medications. Studies have found that medical cannabis use in patients with chronic pain can be beneficial and reduce the use of opioids, resulting in a better quality of life (Boehnke, Litinas, & Clauw, 2016; Vigil, Stith, Adams, & Reeve, 2017).

In a 2014 study, Bachhuber, Saloner, Cunningham, and Barry found that states that allowed medical marijuana use reported lower mortality rates from opioid overdose. However, these findings have been questioned by a study done by Shover, Davis, Gordon, and Humphreys (2019). These researchers found that since 2017, there has been an increase in mortality of opioid overdoses in the states permitting the use of medical marijuana.

Marijuana can come in different forms and have varying durations.

Plant-based forms are smoked or vaporized and last for 2–3 hours. Edible products and synthetic tablets are consumed orally and have a duration of 4–12 hours. Plant extracts and mucosal sprays are taken sublingually and have unknown durations (Ciccone, 2017). Most states require product safety and labeling; however, safety and labeling are not consistent. Some states require labels to include usable cannabis amounts, potency, strain, dispensary, a medical use warning, health risks, and instructions, including abstaining from the use of machinery (Klieger, Gutman, Allen, LiccardoPacula, Ibrahim, & Burris, 2017).

The Role of the Healthcare Provider in Medical Marijuana Medical marijuana in New York State can only be used for specific medical conditions, and it must be verified by a medical provider trained in its use who is a registered member in the New York State Department of Health Medical Marijuana Program (NYSDOH MMP). Healthcare providers include physicians, nurse practitioners, and physician assistants.

These providers must hold a license in good standing, must be currently practicing medicine, must have taken a course that has been approved by the NYSDOH commissioner, and must have registered with the NYS Medical Marijuana Program. There are two courses the NYSDOH recommends, one from The Medical Cannabis Institute and the other from TheAnswerPage NY (NYSDOH, 2019).

After approval, providers have access to the Medical Marijuana Data Management System (MMDMS), which is part of the New York State Health Commerce System. The MMDMS is where the practitioner will enter the patient’s information, certifying the patient’s diagnosis that allows for the use of cannabis products. The Department of Health can deny a patient registration or approve it, and certification is valid for one year. Annual

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n The Nurse Practitioner’s Role in Certification and Management of Medical Marijuana renewal is required to continue in the MMP. The one exception is being a New York State resident who is terminally ill. There is no certification expiration for those patients who have a life expectancy of one year or less (NYSDOH, 2018b).

A requirement for all practitioners who prescribe medical marijuana is to report any patient adverse reactions to the Department of Health, using the Person-based Electronic Response Data System (PERDS), located on the Health Commerce System (NYSDOH, 2019).

New York State has allowed the use of medical marijuana in patients with specific diagnoses that are severely debilitating or lifethreatening. These illnesses include cancer, multiple sclerosis, HIV infection, acquired immunodeficiency

cost (Kurtzman & Barnow, 2017; Swan, Ferguson, Chang, Larson, & Smaldone, 2015). Nurse practitioners were initially advanced to be primary care providers in rural areas where there was a need for medical providers. Barnes, Richards, McHugh, and Martslof (2018) have found that there has been an increase in the number of nurse practitioners as primary care providers in rural and non-rural settings. Prescribing cannabis products to patients is part of the primary care provider’s responsibility. In a study conducted by Sideris et al. (2018), 41% of physicians in the study who certify medical marijuana use were in a primary care specialty.

New York State has allowed the use of medical syndrome (AIDS), Parkinson’s marijuana in patients with specific diagnoses disease, epilepsy, that are severely debilitating or life threatening.

Huntington’s disease, These illnesses include cancer, multiple sclerosis, Sideris et al. (2018) researched the perspective amyotrophic lateral sclerosis HIV infection, acquired immunodeficiency and educational value of marijuana programs.

(ALS), chronic pain, postsyndrome (AIDS), Parkinson’s disease, epilepsy, They found that healthcare providers have Huntington’s disease, amyotrophic lateral traumatic stress disorder, continued concerns after attending a program. sclerosis (ALS), chronic pain, post-traumatic These include: (1) the efficacy of marijuana; (2) neuropathy, or a spinal cord stress disorder, neuropathy, or a spinal cord the uncertainty of legal liability; (3) the potential disorder with spasticity. disorder with spasticity. No human studies for patient abuse; and (4) and the practitioners’ have confirmed evidence for neuroprotective, incomplete knowledge of adverse effects of anti-inflammatory, antitumoral, and antibacterial cannabis that might be influenced by the patient’s effects of cannabinoids (NCSBN, 2018). One or more complicating or condition, current medications, and route of administration (NCSBN, associated factors must accompany the condition. Examples of these 2018). These concerns may be a deterrent for practitioners in becoming factors include cachexia, wasting, severe nausea, chronic pain, seizures, or credentialed by the state in the certification of medical marijuana use (Jarvis persistent muscle spasms (Sideris, Khan, Boltunova, Cuff, Gharibo, & Doan, et al., 2017). Physicians lack training in medical marijuana, according to 2018). Patients who meet these criteria must be entered into the New York Evanoff, Quan, Dufault, Awad, and Bierut (2017), and future preparatory State Department of Health Medical Marijuana database, and be approved education should take into consideration this lack. Educational programs before marijuana can be certified by the prescriber (NYSDOH, 2018a). Nurse tailored to the application and certification of patients for medical marijuana practitioners should be aware that some studies have suggested that instead should be further developed, to ensure appropriate use and instruction for of cannabis treating underlying symptoms, the sedative, appetite stimulant, providers on best practice use (Balneaves, Alraja, Ziemianski, McCuaig, & and euphoric effects of cannabis may only mask symptoms and increase a Ware, 2018). subjective sense of well-being, which could improve self-reported quality of Marijuana does have its place in medicine for specific disorders like life in patients that have difficulty sleeping, chronic pain, or poor appetite cancer, HIV, spasticity disorders, chronic pain, and seizures (Kaplan, 2015; (NCSBN, 2018).

Pettinato, 2017). Research has found that medical marijuana can reduce the As of December 17, 2019, there are 2,609 registered practitioners use of opiate medication use in chronic pain patients (Boehnke et al., 2016; in the New York State Medical Marijuana Program, which include nurse Vigil et al., 2017). Bachhuber et al. (2014) found that there is a reduction in practitioners as registered practitioners, and 111,358 patients certified for opioid overdose mortality rates with the use of medical marijuana versus medical marijuana use (NYSDOH, 2019). These numbers continue to grow. opioid pain medications.

Literature Review In a review of the literature, there is a great deal of information on the topic of medical marijuana. There were limited articles on the specifics of nurse practitioners certifying patients for medical marijuana use. This raises the questions: “Why are states limiting a nurse practitioners’ scope of practice, when they are independent practitioners?” and “Why prohibit them from certifying marijuana use for medical conditions?” In some regions of the country, nurse practitioners hold the role as a primary care provider and are, in fact, the sole medical provider. It remains a quandary as to why some states do not allow NPs to certify their patients in need of this alternative treatment to improve their patients’ quality of life. Studies have shown that advanced practice nurses perform just as well as physicians and have comparable quality of care and patient outcomes, with lower or equal 14

The DEA has classified marijuana as a Schedule I narcotic in the United States, and federal laws restrict its research (Philipsen et al., 2017). Due to this restriction, well-controlled clinical trials cannot be performed since the government determination posits that marijuana has no clinical applications (Ciccone, 2017). The American Nurses Association (ANA) endorses the use of therapeutic medical marijuana and supports controlled experimental research regarding the efficacy of medical marijuana (Philipsen et al., 2014).

Klieger et al. (2017) found that individual states have developing policies, resulting in a patchwork of regulatory strategies that are not uniformly consistent. These inconsistencies can result in a drug that does not have dosing and safety standardization or a clear clinical guideline (Klieger et al., 2017). Like all medications, including marijuana, adverse effects occur. Ebbert et al. (2018) found that there is an increase in respiratory disorders, lowbirth-weight offspring, psychosis, and abuse potential with marijuana use.

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The Nurse Practitioner’s Role in Certification and Management of Medical Marijuana

Discussion Nurse practitioners’ scope of practice in all states should include certification of patients for the therapeutic use of medical marijuana. Initially, the only acceptable provider was a physician in states that accepted medical marijuana use for patients. However, state laws are changing, allowing more nurse practitioners and physician assistants to certify patients for therapeutic use, including in New York, Oregon, and Maryland (Philipsen et al., 2017).

Not all states allow nurse practitioners and physician assistants certification privileges. Better holistic care could be provided to patients and improving patients’ quality of life if certification was granted in all or most states.

Many organizations are in favor of medical marijuana use, including the American Nurses Association (Philipsen et al., 2014). The ANA recommends: (1) marijuana’s Schedule I controlled substance status be reduced to a Schedule II class, (2) development of standards in medical marijuana, and (3) building evidence-based research for its use. By reclassifying marijuana’s status to Schedule II, additional research could be performed on marijuana use and its capabilities. The ANA recommends that patients who are authorized to use medical marijuana be protected from criminal penalties and to implement exemptions to healthcare providers who prescribe, certify, or dispense marijuana for medical reasons from criminal prosecution (ANA, 2016).

In New York State, the role of the nurse practitioner in medical marijuana is the same as physicians who certify marijuana for patient use, including the process of obtaining certification and educational training.

There is a slight difference for physician assistants, which require their supervising physician to also hold certification privileges and be a member of the NYS Medical Marijuana Program. Keeping abreast of state medical marijuana laws for NPs is critical, because there is no standardization of practice regarding medical use across state lines for nurse practitioners (Jarvis et al., 2017).

Clinical Guidelines for a Qualifying Condition The following guidelines constitute a recommended algorithm for the clinical encounter and identification of a qualifying condition for NPs who want to certify patients in medical marijuana use (NCSNB, 2018): 1. The NP should perform a clinical assessment within the framework of a professional provider-patient relationship during an in-person encounter, including a complete assessment of the patient and a review of diagnostic information in order to identify whether the patient has a condition specified in the MMP. 2. The NP should review the patient’s current treatment for the qualifying condition and the response to that treatment.

3. The NP should complete a thorough medication reconciliation, as well as a review of the jurisdiction’s prescription drug monitoring program.

4. The NP should review the patient’s mental health, alcohol and substance use history, and if present, seek a consultation or referral for that use.

Individuals with a risk of suicide or a history of suicide attempts, schizophrenia, bipolar disorder, or other psychotic condition should be cautioned that cannabis use may exacerbate existing psychoses.

5. The NP should gather specific historical and current information regarding the patient’s experience with cannabis and discuss the patient’s values, preferences, needs, and knowledge related to cannabis use.

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6. The decision to certify the MMP-qualifying condition is not to be predicated on the existence of a qualifying condition alone. The NP should also consider:  present scientific evidence for cannabis use with the specific qualifying condition;  adverse effects according to the patient’s clinical presentation;  variable effects of cannabis;  principles of dose titration;  and risks to particular groups of patients, such as those of childbearing age, pregnant, neonates, adolescents, and individuals at risk for substance abuse 7. The NP should determine the ongoing monitoring and evaluation of the patient.

Nurse practitioners take care of patients in a holistic way, which can allow for additional options in the treatment of certain diseases. A prior relationship with a patient before certification can in some cases be important to prevent abuse of the substance. According to Kaplan (2015), a provider-patient relationship should be a requirement for certifying a patient for a medical marijuana card. This relationship would ensure that those patients who need medical marijuana have access to it and are not abusing the substance. Medical marijuana has its place in medicine and can improve the quality of life for patients with life-altering diseases.

All nurse practitioners should receive education on the use of medical marijuana as an alternative to standard treatment. This education should include implications, effects, and how marijuana affects the endocannabinoid system. Providers see a broad array of patients, and an understanding of marijuana use will contribute to better and more holistic care of patients.

Policy and lawmaking, regarding medical marijuana use should include the participation of the nurse practitioner, including research, lobbying, and advocating for patients. Research on the use of medical marijuana should be conducted to allow for unbiased scientific evidence. Evidence-based research will help determine standardizations and best practice for its use.

Nurse practitioners should advocate for the removal of barriers some states have in place regarding medical marijuana.

Conclusion The use of marijuana for medical therapy has been argued for its positive and negative effects. Even though the federal government classifies the drug as illegal, many states have approved it to treat medical illnesses.

Marijuana has been found to alleviate nausea and vomiting, reduce weight loss, and help with chronic pain. Standardization for diseases, dosing, and labeling are lacking for medical marijuana therapy (Klieger et al., 2017; Philipsen et al., 2014).

The federal government should lower the substance class of marijuana to a Schedule II, allowing for more research to be undertaken, so standardizations and safe use criteria can be developed. If medical marijuana laws were revised, evidenced-based research could be conducted, and providers may not be as hesitant in certifying patients due to legal actions, knowledge deficit, and questionable efficacy. Educational programs need to be developed to teach healthcare providers standardizations for practice, including diagnoses for use, criteria for dosing, and side effects.

Nurse practitioners should be able to certify patients in the use of therapeutic medical marijuana throughout the United States. Because of

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n The Nurse Practitioner’s Role in Certification and Management of Medical Marijuana the physician shortage, many practices are relying on nurse practitioners to take the role of the primary care provider in rural and non-rural settings (Barnes, Richards, McHugh, & Martsolf, 2018). Nurse practitioners care for their patients holistically, and this role should include all treatment opportunities for their patients. Medical marijuana is an option to improve the quality of life for patients with life-threatening or debilitating illnesses.

All nurse practitioners should be able to provide marijuana therapy to their patients in need.

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Research is warranted on marijuana use, standardizations, educational programs for healthcare providers, and side effects. During the literature review, articles addressing the nurse practitioner’s role in medical marijuana were lacking, and additional investigation should be performed on this topic. Research in this area will help identify gaps, reduce provider concerns, develop improvements in the medical marijuana system, and provide a guide to the nurse practitioner’s future role in adequately caring for our patients.

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n References American Nurses Association (ANA). (2016). Therapeutic use of marijuana and related cannabinoids. Retrieved from https://www.nursingworld. org/~49a8c8/globalassets/practiceandpolicy/ethics/therapeutic-use-ofmarijuana-and-related-cannabinoids-position-statement.pdf Bachhuber, M. A., Saloner, B., Cunningham, C. O., & Barry, C. L. (2014).

Medical cannabis laws and opioid analgesic overdose mortality in the United States, 1999-2010. JAMA Internal Medicine, 174(10), 1668-1673.

Retrieved from http://dx.doi.org/10.1001/jamainternmed.2014.4005 Balneaves, L. G., Alraja, A., Ziemianski, D., McCuaig, F., & Ware, M. (2018). A national needs assessment of Canadian nurse practitioners regarding cannabis for therapeutic purposes. Cannabis and Cannabinoid Research, 3(1), 66-73. Retrieved from http://dx.doi. org/10.1089/can.2018.0002 Barnes, H., Richards, M. R., McHugh, M. D., & Martsolf, G. (2018). Rural and nonrural primary care physician practices increasingly rely on nurse practitioners. Health Affairs, 37(6), 908-914. Retrieved from http://dx.doi.org/10.1377/hlthaff.2017.1158 Boehnke, K. F., Litinas, E., & Clauw, D. J. (2016). Medical cannabis use is associated with decreased opiate medication use in a retrospective cross-sectional survey of patients with chronic pain. The Journal of Pain, 17(6), 739-744. Retrieved from http://dx.doi.org/10.1016/j. jpain.2016.03.002 Ciccone, C. D. (2017). Medical marijuana: Just the beginning of a long, strange trip? Physical Therapy, 97(2), 239-248. Retrieved from http:// dx.doi.org/10.2522/ptj.20160367 Ebbert, J. O., Scharf, E. L., & Hurt, R. T. (2018). Medical cannabis. Mayo Clinic Proceedings, 93(12), 1842-1847. Retrieved from http://dx.doi. org/10.1016/j.mayocp.2018.09.005 Evanoff, A. B., Quan, T., Dufault, C., Awad, M., & Bierut, L. J. (2017).

Physicians-in-training are not prepared to prescribe medical marijuana.

Drug and Alcohol Dependence, 180, 151-155. Retrieved from http:// dx.doi.org/10.1016/j.drugalcdep.2017.08.010 Jarvis, S., Rassmussen, S., & Winters, B. (2017). Role of the endocannabinoid system and medical cannabis. The Journal of Nurse Practitioners, 13(8), 525-531. Retrieved from http://dx.doi. org/10.1016/j.nurpra.2017.05.014 Kaplan, L. (2015). Medical marijuana: Legal and regulatory considerations.

The Nurse Practitioner, 40(10), 46-54. Retrieved from http://dx.doi. org/10.1097/01.NPR.0000471361.02487.3b Klieger, S. B., Gutman, A., Allen, L., Liccardo-Pacula, R., Ibrahim, J. K., & Burris, S. (2017). Mapping medical marijuana: State laws regulating patients, product safety, supply chains and dispensaries. Addiction, 112, 2206-2216. Retrieved from http://dx.doi.org/10.1111/add.13910 Kurtzman, E. T., & Barnow, B. S. (2017). A comparison of nurse practitioners, physician assistants, and primary care physicians’ patterns of practice and quality of care in health centers. Medical Care, 55(6), 615-622. Retrieved from http://dx.doi.org/10.1097/ MLR.0000000000000689 National Conference of State Legislators. (2019). State medical marijuana

laws. Retrieved from http://www.ncsl.org/research/health/statemedical-marijuana-laws.aspx NCSBN. (2018). NCSBN guidelines for the nursing care of patients using marijuana: APRNs certifying a medical marijuana qualifying condition.

Journal of Nursing Regulation, 9(2), S39-S45.

New York State Department of Health. (2018a). Information for designated caregivers. Retrieved from https://www.health.ny.gov/regulations/ medical_marijuana/caregiver/ New York State Department of Health. (2018b). Medical marijuana program patient certification instructions. Retrieved from https:// www.health.ny.gov/regulations/medical_marijuana/practitioner/docs/ patient_certification_instructions.pdf New York State Department of Health. (2019). New York State medical marijuana program: Practitioner information. Retrieved from https:// www.health.ny.gov/regulations/medical_marijuana/practitioner/ Pettinato, M. (2017). Medicinal cannabis: A primer for nurses. Nursing, 47(8), 40-46. http://dx.doi.org/10.1097/01.NURSE.0000521022.07638.35 Philipsen, N., Butler, R. D., Simon-Waterman, C., & Artis, J. (2014). Medical marijuana: A primer on ethics, evidence, and politics. The Journal for Nurse Practitioners, 10(9), 633-640. Retrieved from http://dx.doi. org/10.1016/j.nurpra.2014.05.015 Philipsen, N., McMullen, P. C., & Wood, C. M. (2017). Medical marijuana: A 2014-2016 update on law and policy for nurse practitioners. The Journal for Nurse Practitioners, 13(2), 145-149. Retrieved from doi. org/10.1016/j.nurpra.2016.09.011 ProCon.org. (2019). 33 legal medical marijuana states and DC: Laws, fees, and possession limits. Retrieved from https://medicalmarijuana. procon.org/view.resource.php?resourceID=000881 Shover, C. L., Davis, C. S., Gordon, S. C., & Humphrey, K. (2019).

Association between medical cannabis laws and opioid overdose mortality has reversed over time. Proceedings of the National Academy of Sciences of the United States of America, 116(26), 1262412626. Retrieved from http://dx.doi.org/10.1073/pnas.1903434116 Sideris, A., Khan, F., Boltunova, A., Cuff, G., Gharibo, C., & Doan, L. V. (2018). New York physicians’ perspectives and knowledge of the state medical marijuana program. Cannabis and Cannabinoid Research, 3(1), 74-84. Rterieved from http://dx.doi.org/10.1089/can.2017.0046 Swan, M., Ferguson, S., Chang, A., Larson, E., & Smaldone, A. (2015).

Quality of primary care by advanced practice nurses: A systematic review. International Journal for Quality in Health Care, 27(5), 396404. Retrieved from http://dx.doi.org/10.1093/intqhc/mzv054 Vigil, J. M., Stith, S. S., Adams, I. M., & Reeve, A. P. (2017). Associations between medical cannabis and prescription opioid use in chronic pain patients: A preliminary cohort study. PLoS ONE, 12(11), 1-13. Retrieved from http://dx.doi.org/10.1371/journal.pone.0187795 Wall, M. M., Liu, J., Hasin, D. S., Blanco, C., & Olfson, M. (2019). Use of marijuana exclusively for medical purposes. Drug and Alcohol Dependence, 195, 13-15. Retrieved from http://dx.doi.org/10.1016/j. drugalcdep.2018.11.009

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Nurses’ Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue Part 1: The Background Lucille Contreras Sollazzo, MSN, RN-BC, NPD Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD

n Abstract There is increasing attention in the nursing community to the importance of nurse well-being and resilience inasmuch as it not only impacts nurses themselves, but also their professional collegiality within the healthcare team, their health organizations, and most importantly, their patients. This increased recognition of the importance of nurse well-being and its concomitant potential for personal and professional consequences should serve as the impetus for nurses’ unions to design, implement, and evaluate programs in healthcare facilities that address the reduction of a nurse’s stress, burnout, and depression. Nurses’ unions can have a significant impact on addressing working conditions that influence the level of stress, burnout, compassion fatigue, depression, and resilience in nurses.

Keywords: Stress, burnout, compassion fatigue, depression, hierarchy of controls, nurse resilience, staffing, nurses unions

Introduction Stress and burnout are concepts that have sustained the interest of nurses and researchers for decades. Nearly all nurses will voice moderate, high, or very high levels of work-related stress (Jordan, Khubchandani, & Wiblishauser, 2016); and consequently, there is increasing attention in the nursing community and in the literature regarding the importance of nurse well-being. The welfare of nurses not only impacts nurses themselves, but also their team members, health organizations, and most importantly, their patients. The high rates of nurse burnout has been positively correlated to a nurses’ intention to leave the profession (RN Network, 2017), to decreased effectiveness on the job, to decreased job performance, and to a reduction in the quality of patient care (O’Mahony, 2011). Similarly, nurse burnout has been associated in the literature with poor interdisciplinary relations (Milliken, Clements, & Tillman, 2007) and poor patient outcomes (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002). Thus, the scope of the problem

becomes significant when we look at the effects of stress and burnout on nurses, the team, the hospital budget, and the patient.

More healthcare providers are investing in burnout prevention techniques to retain staff and improve employee satisfaction in the workplace. These include stress management techniques, such as breathing exercises, mindfulness, coping strategies, and social activities that help nurses deal with stressful situations. Total Worker Health®, a program designed by the National Institute for Occupational Safety and Health (NIOSH), a part of the Center for Disease Control (CDC), was specifically created to foster worker well-being throughout the United States in response to the Institute for Healthcare Improvements’ (IHI) Quadruple Aim framework’s fourth aim: worker well-being. Nevertheless, even with the introduction of initiatives and laws that address worker health, studies continue to reflect the high level of stress, burnout, compassion fatigue, and depression that nurses’ experience on a routine, daily basis.

Lucille Contreras Sollazzo, MS, RN-BC, NPD, is currently the Associate Director of Nursing Education and Practice at the New York State Nurses Association.

Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD, is currently the Director of Nursing Education and Practice at the New York State Nurses Association.

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Compassion satisfaction is the experience of feeling contentedness, joy, and pleasure that is derived from being able to do one’s work or when caring for another (see Figure 1).

More healthcare providers are investing in burnout prevention techniques to retain staff and improve employee satisfaction in the workplace. These include stress

Figure 1: A Visual Aid of Conceptual Terms

management techniques, such as breathing exercises, mindfulness, coping

Compassion Satisfaction: Heartful

strategies, and social activities that help

Compassion Fatigue: Heart Heavy

nurses deal with stressful situations.

Burnout: Heartless

Concept Analysis of Definitional Terms The basic building blocks of nursing theories are concepts. Concepts help nurses to categorize and organize personal experiences and previous knowledge into an operational definition for the concept being used and to enable the reader to clarify the meaning of the concept for the purposes of this paper. Concept analysis in nursing theory is a strategy that examines the attributes or characteristics of a particular concept. It is a formal linguistic exercise to determine certain defining attributes of the concept. The basic purpose of concept analysis is to clarify ambiguous concepts in a theory and to propose a precise operational definition, which reflects its theoretical base.

Research and evidence-based practice both rely on a clear understanding of what is being studied, or the concept, that has been chosen by the researcher.

For the purposes of this paper, key concepts are defined as follows: Concept analysis can be defined as the dissection of a concept into simpler elements to promote clarity while providing mutual understanding within nursing. A concept analysis can elucidate the meaning of the concept in current use, which can contribute to the future development of the concept.

Burnout is directly related to the dissatisfaction someone has to working conditions and generally takes place over time. It can develop as a result of short staffing, not having adequate human or material resources to complete a task or procedure, working in a non-supportive or toxic environment, and/or working long hours without sufficient time to recover. This creates frustration and anger. Symptoms of burnout include exhaustion, self-doubt, cynicism, disengagement, and feelings of ineffectiveness (see Figure 1).

Compassion fatigue occurs when nurses develop declining empathetic ability from repeated exposure to others’ suffering. Conceptual clarity is vital to curtail compassion fatigue via preventative and restorative measures at the individual and organizational level. It is very difficult to recognize unless the individual has a keen awareness of what to look for and is actively and conscientiously watching for signs of compassion fatigue. How well an entire nursing unit is versed in both the detection of compassion fatigue and in the ability to individually and collectively address it can make the difference between how healthy individuals and the entire unit are, and how dysfunctional the unit and its workers are. Compassion fatigue is different from burnout.

Burnout is specific to working conditions. Compassion fatigue occurs as a result of the healthcare practitioner being in relationship with one or more people (both patients and colleagues) who are suffering trauma or distress (see Figure 1).

From “Compassion Fatigue & Burnout in Nursing,” by Vidette Todaro-Franceschi, 2019, Enhancing Professional Quality of Life (2nd ed.). New York, NY: Springer Publishing Company.

Depression is the feeling of gloom or sadness that impacts not only the mind, but the body, causing a slowing down or loss of interest in activities. Depression can lead to a feeling of hopelessness (American Psychiatric Association, 2017).

Evidence-based practice is the gathering, evaluation, and integration of research in combination with clinical expertise to inform nursing practice.

Resilience is defined as the ability to face adverse situations, remain focused, and continue to be optimistic for the future. Resilience refers to the capacity of a dynamic system or organism (person) interacting with the environment to adapt successfully to disturbances that threaten the viability, the function, or the development of that system/ organism/person (Southwick, 2014). The competing priorities and challenges with which nurses are confronted may make it difficult for them to develop resilience characteristics.

Research is a methodical and rigorous inquiry, which provides answers to questions surrounding phenomena.

Job stress is defined by NIOSH as “when the requirements of the job do not match the capabilities, resources, or needs of the worker.” There is often confusion between the concept of job stress and job challenges.

Challenges energize us psychologically and physically, and motivate us to learn new skills, embrace new experiences, and master our jobs. When a challenge is met, we feel relaxed and satisfied (NIOSH, 2014). Stress, on the other hand, has an effect on a person physically and emotionally. Negative stress, called distress, occurs when a person feels unable to perform or cope with a situation. Negative stress causes anxiety that leads to mental and physical problems. For the purposes of this paper, job stress is the building block for distress, and distress is the basis of what this study wanted to pursue.

Theoretical Underpinnings of the Study Jean Watson’s Theory of Human Caring informs this study. Watson’s Human Caring Science as a nursing theory is focused on the concept of human caring and on a caring-to-caring transpersonal relationship. The healing potential for both the nurse who is caring and the patient who is being cared for is enhanced when the organization provides support and the tools needed to assist caregivers in formulating those caring-to-caring transpersonal relationships.

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Watson’s theory has been cited in the literature as a means to successfully provide an environment that can enrich human-to-human relations, and thus promote the delivery of better patient care and outcomes (Wei & Watson, 2019). This theory integrates the following behaviors on the part of the practitioner: (1) practicing loving-kindness to self and others; (2) being authentically present in the moment to enable faith, hope, and the inner-subjective life of self and others; (3) fostering one’s own spiritual practices; (4) developing trusting interpersonal caring relationships; (5) forgiving and showing empathy to self and others; (6) using all ways of knowing; (7) engaging in genuine teaching-learning experiences; (8) creating a caring-healing environment for all involved; (9) valuing humanity; and (10) embracing the unknowns and miracles of life (Wei & Watson, 2019).

Watson’s theory emphasizes that when a nurse practices self-care, they can bring themselves more fully and completely to their interprofessional team and to the patient, but the key to success in applying this theory is that loving-kindness must be present within and between all relationships and the environment. Thus, this theory is premised on the nurse living and working within a nurturing environment. A nurturing environment necessitates that the work setting and conditions of employment must facilitate the health of the caregiver, along with the personal satisfaction of the caregiver while working (Foss-Durant, 2014).

Two principles are central to Caring Science: (1) the caregiver must care for themself in order to be available to patients and families and (2) caring (health care) occurs (is delivered) at the point in time when two individuals are able to make a heart-to-heart connection, one that impacts all participants in a such a way that each is positively changed as a result of the interaction (Foss-Durant, 2014).

Core Values have been outlined by the National League of Nursing (NLN) (2019) to promote excellence in nursing education to build a strong and diverse nursing workforce to advance the health of our nation and the global community. Those core values include caring, integrity, diversity, and excellence.

Objectives and Purpose of the Study The purpose of this study is to identify the top stressors nurses in various specialty nursing practice units face on a daily basis on the job and to determine what interventions can be integrated into the workplace to reduce stress, burnout, compassion fatigue, and depression in nurses, while concomitantly increasing the work satisfaction of those same nurses.

A quantitative descriptive survey design and analysis will be undertaken.

The Code of Ethics for Nurses is a nonnegotiable set of standards that each RN must uphold in any healthcare setting. The code is foundational to nursing theory, practice, morals, values, virtues, and behaviors. The first three provisions of the Code of Ethics for Nurses describe nurses’ most fundamental values and commitments to the patient and the patient’s family: to care for, respect, and exercise compassion for each individual without prejudice (ANA Code of Ethics, Provisions 1-3, 2015). The next three provisions address the nurses’ duty to self and to their colleagues: to care for, respect, advocate for, and defend a workplace conducive to nurse wellness and to those environmental conditions that promote and provide optimal care (ANA Code of Ethics, Provisions 4-6, 2015).

While it is a given that you cannot mandate caring in any one individual, under law, theory, and practice, nurses are charged with caring for their patients. The essence of nursing is caring for others and for oneself. Caring is important not only for the well-being of staff working with patients, but also when working with colleagues. A supportive, protective, and/or corrective mental, physical, societal, and spiritual work environment empowers nurses in caring partnerships with and between individuals (Pajnkihar, Stiglic, & Vrbnjak, 2017). By actively engaging in caring through authentic presence and intentionality, and by embracing the theory of Watson’s Caring Science, the nurse is able to optimize a positive energy that flows from an integrated mind, body, and spirit and the patient’s ability to heal from within.

It is the practice of healthcare employers to engage in reviews on a regular basis of the caring behavior of nurses and how this correlates to patient satisfaction to help understand and implement interventions to improve not only the quality of nursing care, but also to optimize the reimbursement rates to the healthcare organization. While caring is a core concept in nursing practice and an expectation of the employer and the patient, one way to ensure that caring is central to each patient’s experience is to endorse Watson’s Theory of Human Caring as the basis for the care provided on the clinical unit. The literature has offered the concept that caring behavior by nurses can contribute to the satisfaction and well-being of patients and is more than only the performance of tasks on the part of the nurse or the performance of the healthcare organizations that is represented by its Press Ganey scores (Burt, 2007; Kaur, Sambasivan, & Kumar, 2013; Sherwood, 1997; Wolf, Colahan, & Costello, 1998). When caring is not present, consequences can include patient dissatisfaction (Pajnkihar et al., 2017), nurse dissatisfaction (Wei & Fazzone, 2019; Wei & Watson, 2018), nurse disengagement in clinical performance (Wei & Fazzone, 2019; Wei & Watson, 2018), and patient psychological decline (Wei & Fazzone, 2019; Wei & Watson, 2018).

The objectives of this study are to determine:  If contractually mandated nurse-to-patient ratios, where increased numbers of RNs are hired onto a clinical nursing unit, would decrease nurses’ stress, burnout, compassion fatigue, and depression, while concomitantly increasing the work satisfaction of those same nurses;  If five, 5-minute mind/body/spirit exercises practiced by nurses on the job will decrease stress, burnout, compassion fatigue, and depression in nurses, while concomitantly increasing the work satisfaction of those same nurses.

Review of the Literature Nurses are Charged in Law, Theory, and Practice to Care for Their Patients 20

Studies Reveal Workplace Conditions are Highly Correlated to Stress, Burnout, Compassion Fatigue, and Depression High levels of stress can and does lead to burnout, along with other aspects of burnout, such as emotional exhaustion and depersonalization (Chang, Shyu, Wong, Chu, Lo, & Teng, 2017). Studies indicate that higher patient-to-nurse ratios are highly and positively correlated to a nurse’s experience of stress, burnout, and depression (Shin, Park, & Bae, 2018).

The Association of Women’s Health, Obstretics, and Neonatal Nurses conducted a nurse staffing survey in 2010 to determine the consequences of inadequate nurse staffing. The results of the survey indicated that short staffing was serious and potentially put patients at risk for preventable harm

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Nurses’ Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue

due to documented instances of missed care, potential failure to rescue, and job-related stress (Rice Simpson, Lyndon, & Ruhl, 2016). In one study

by Jordan, Khubchandani, and Wiblishauser (2016), researchers found that 92% of nurses surveyed had moderate-to-very-high stress levels, three quarters slept less than the recommended number of hours, over 50% failed to exercise regularly, half consumed less than five servings of fruits and vegetables per day, and over 20% were binge drinkers.

A study by Ko and Kiser-Larson (2016) further emphasized that essentially all hospital nurses surveyed revealed that their work was physically and mentally demanding, and that their nursing jobs made them fatigued. The Larson study reported that 63% of the nurses surveyed revealed that their work had a direct causal impact on feelings of burnout, and nearly 50% of nurses surveyed worried their patient care would suffer due to fatigue. Burnout caused almost half of survey participants to either consider changing hospitals or leaving the nursing profession altogether.

The literature reveals that nurses experiencing high levels of stress on a routine basis during working hours causes anxiety, depression, and psychomotor decline (Machado, Velasques, Bento, Machado, & Vianna, 2018). The stress reportedly not only affected nurses’ personally, but also impacted the patient and the interprofessional team caring for the patient.

Providing culturally competent and patient-centered care requires the nurse to be in a frame of mind conducive to empathizing with their patient, being open to conversation, and having a willingness to listen to the concerns and needs of their patient. Nurses experiencing high levels of stress have an impaired ability to express empathy, compassion, and patience (Van Vliet, Jong, & Jong, 2017).

Chronic stress leads to depression, burnout, compassion fatigue, heart attacks, hypertension, and other disorders (American Institute of Stress, 2019), and can ultimately lead to higher nurse turnover rates.

Chronic stress leads to depression, burnout, compassion fatigue, heart attacks, hypertension, and other disorders (American Institute of Stress, 2019), and can ultimately lead to higher nurse turnover rates. The healthcare organization and its culture, policies, and practices play a key role in minimizing the negative impacts of stress, depression, burnout, and compassion fatigue by creating conditions that not only reduce the risk of burnout and compassion fatigue, but also promote healthy, more effective workers. An organization that fails to take action will find that their nurses show signs of stress, burnout, and compassion fatigue; their nurses have decreased productivity (mostly due to increased workloads, (see Figure 2); they have poor patient outcomes; and they employ workers who negatively affect the physical and psychological well-being of the interdisciplinary team (Belton, 2018).

Depression can lead to increases in absenteeism, decreased worker performance, and impaired judgment, thereby exacerbating problems related to the recruitment and retention of nurses. While depression impacts 7.6% of people in the United States ages 12 and older in any two-week period (CDC, 2019), nurses have double the rate of depression than that of the

n

general population. The Robert Wood Johnson Foundation reported 18% of hospital-employed nurses suffered from depression (Harris, 2018).

Figure 2: Main Causes of Stress 6%

Lack of job security

20%

Juggling work/ personal lives

28%

People issues

46%

Workload

From “Workplace Stress,” American Institute of Stress, 2019.

Organizational Attempts to Reduce Nurses’ Stress, Burnout, Compassion Fatigue, and Depression A study by Ali (2019) examined the correlation between nurse burnout and organizational commitment to those nurses working in health services.

Results of the study revealed that organizational commitment is inversely related to burnout. That is, those institutions that had a higher level of commitment to their nurses’ well-being had a lower level of nurse burnout.

These results were reproduced in a study by Lee and Henderson (1996), Naghneh et al. (2017), and Seyedmoharrami et al. (2019).

Further studies reported that hospitals that actively engaged in activities to reduce nurse burnout by at least 30% resulted in a total of 6,239 fewer nosocomial patient infections, and an annual cost savings of up to $68 million (Cimiotti, Aiken, Sloane, & Wu, 2012). Hospitals that did not actively introduce stress-reduction initiatives into the workplace found that their turnover (attrition rates) remained high, at an annual cost of between $5.13 and $7.86 million with an RN vacancy rate trend higher than 7.5%.

The vacancy rate trend, associated with a workplace in a continuous state of flux and a decreasing market supply of nurses, resulted in staffing and work conditions that became increasingly unpredictable and unstable for the employer (Belton, 2018). This state, in turn, led to poorer quality of care, poorer patient outcomes, and a cycle of nurse dissatisfaction, a high turnover rate, short staffing, and increased nurse stress and burnout.

National Agencies Attempt to Reduce Nurses’ Stress, Burnout, Compassion Fatigue, and Depression The Institute of Healthcare Improvement: Triple and Quadruple Aims. The Institute of Healthcare Improvement’s (IHI) Triple Aim (2007) is all about patients. At its core, the overarching goal is to improve the lives of patients as the highest priority. The Triple Aim has three components: (1) to improve population health, (2) reduce the per capita cost of health care, and (3) enhance the patient experience. Triple Aim outcome measures put patients at the center of care.

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The Quadruple Aim (see Figure 3) was implemented with a fourth aim: to attain joy at work. The fourth aim was added in response to research that overwhelmingly supports that having a strong and healthy workforce is critical to achieving the IHI’s first three aims. The well-being of the care team is key in the pursuit of the Triple Aim (Brysson Johnson, 2019). Even in healthcare facilities that achieved a Grade A on the the Leapfrog Group’s healthcare ratings and reports, found that burnout, compassion fatigue, depression, and staff and patient dissatisfaction had a direct, negative impact on the experience of the patient and are highly associated with lower patient satisfaction, reduced health outcomes, and potentially increased healthcare costs (Bodenheimer & Sinsky, 2014). Staff are much more likely to be enthusiastic and positive about securing the best outcomes for patients when they feel supported, empowered, and respected.

reduce healthcare costs; improve opportunities for family, community, and societal gains; and provide a working environment where productivity is fostered, not hindered (NIOSH, 2019). This program is premised on a hazard free work environment for all workers. NIOSH developed a Hierarchy of Controls (see Figure 4) that should be integrated into organizational culture, policies, and procedures, with best practices including the elimination of working conditions that are the root cause of stress.

Figure 4: NIOSH Hierarchy of Controls for Total Worker Health® From “Hierarchy of controls applied to NIOSH Total Worker Health.®” by Centers for Disease Control and Prevention, 2018 (https://www.cdc.gov/niosh/twh/letsgetstarted.html)

Building on the IHI’s Quadruple Aim, Anne Arundel Medical Center initiated a successful well-being program with five prongs: (1) purpose well-being: doing something every day that is challenging and enjoyable, giving a person a sense of purpose; (2) social well-being: having strong relationships and love in your life, having a supportive work environment where coworkers care about one another; (3) financial well-being: having resources to have long-term economic security; (4) physical well-being: having good energy and an ability to get things done every day; and (5) community well-being: being engaged in the community where one lives and works (Jacobs, McGovern, Heinmiller, & Drenkard, 2018). Employees who feel cared for help to improve organizational outcomes (Jacobs, McGovern, Heinmiller, & Drenkard, 2018).

Figure 3: Quadruple Aim

Patient Experience

01

02 Population Health

Quadruple Aim Care Team Well Being

04

03 Reducing Costs

From “Quadruple Aim,” Kinetix Group. Retrieved from https://thekinetixgroup.com/the-era-ofthe-quadruple-aim/quadruple_aim_graphic/

The National Institute for Occupational Safety and Health: Total Worker Health®. The National Institute for Occupational Safety and Health (NIOSH) developed a program called Total Worker Health® (TWH) that was specifically designed to address the total health and well-being of the workforce in the United States. Included in this program are the following key elements: reduce workplace injuries and illnesses; improve workers’ job satisfaction; enhance organizational culture of trust, safety, and health; increase meaningful work; reduce work-related stress; improve health opportunities; 22

Eliminate working condition that threaten safety, health, and well-being Substitute health-enhancing policies, programs, and practices Redesign the work environment for safety, health and well-being Educate for safety and health Encourage personal change

Previously, employers’ attributed stress, burnout, compassion fatigue, and depression to individuals and assisted employees at the “encourage personal change” level by offering them their Employee Assistance Program (EAP) benefits. The message to the worker was not only are these problems viewed as the individual’s problem, but the problem is also the individual’s alone to fix.

The TWH program constitutes a paradigm-shift in the approach to health and well-being in the workplace. While most employers operate from a cultural perspective that emphasizes the bottom level of the NIOSH hierarchy of controls, “encourage worker personal change,” the TWH program requires the employer to take ownership and affirmative action to integrate protections from the highest level of the NIOSH hierarchy of controls, “eliminate working conditions that threaten safety, health, and well-being,” as the most effective way to enhance worker safety, health, and well-being (Schill, 2017). TWH mandates that workplace stress in healthcare facilities is an issue that must be taken on from an organizational, collective, individual, union (if appropriate), and clinical unit perspective. The TWH program recognizes that although the “substitute, redesign, educate, and encourage” levels are less effective than the previous levels in descending order, all levels should be integrated and implemented in the workplace when it comes to addressing stress, burnout, compassion fatigue, and depression. This totality concept is important, because no one level can completely address the specific working conditions that threaten worker safety and health.

NIOSH Hierarchy of Controls Requires a Holistic Focus on the Workplace. The NIOSH TWH challenges organizations to take a holistic approach to a broad set of issues that affect worker safety, health,

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and well-being (see Figure 5) and affirmatively search for the root cause of worker dis-ease. Once the root cause is found, the employer is challenged to implement the NIOSH hierarchy of controls and integrate changes in organizational culture, policy, and procedure to address negative influences on worker well-being.

a clear understanding from the nurses’ perspective as to what the greatest health risks, dangers and barriers are to worker health and well-being. Once known, management should develop policies, procedures, and mechanisms to minimize the risks, dangers, and barriers to health. Financial resources should be secured to address nurses’ top priorities.

Nurse Unions Attempts to Reduce Nurses’ Stress, Burnout, Compassion Fatigue, and Depression Using TWH

Substitute Health Enhancing Policies, Procedures, and Practices. The nurses’ union can work with its nurses to ensure that the facility is creating a culture of health. Union and management can perform an initial assessment and review of policies, and subsequently revise and modify outdated ones. New policies, procedures, and practices can also be created to ensure nurse well-being. Nurses’ unions can also negotiate

Eliminate Threatening Working Conditions. In a unionized environment, it is important for management and the nurses’ union to have

Figure 5: Issues Related to Advancing TWH Control of hazards and exposures

Compensation benefits

Changing workforce demographics

 Chemicals  Physical agents  Biological agents  Psychosocial factors  Human factors  Risk assessment and risk management

 Adequate wages and prevention of wage theft  Equitable performance appraisals and promotion  Work-life programs  P art time off (sick, vacation, caregiving)  D isability insurance (short- & long-term) W orkers’ compensation benefits  A ffordable, comprehensive health care and life insurance  P revention of cost shifting between payers (workers’ compensation, health insurance)  R etirement planning and benefits  C hronic disease prevention and disease management  A ccess to confidential, quality health care services  C areer and skills development

 Multigenerational and diverse workforce  Aging workforce and older workers  Vulnerable worker populations  Workers with disabilities  Occupational health disparities  Increasing number of small employers  Global and multinational workforce

Organization of work  Fatigue and stress prevention  Safe staffing  Overtime management  Healthier shift work  Reduction of risks from long work hours  Flexible work arrangements  Adequate meal and rest breaks

Built environment supports  Healthy air quality  Access to healthy, affordable food options  Safe and clean restroom facilities  Safe, clean and equipped eating facilities  Safe access to the workplace  Environments designed to accommodate worker diversity

Leadership  Shared commitment to safety, health, and well-being  Supportive managers, supervisors and executives  Responsible business decision-making  Meaningful work and engagement  Worker recognition and respect

Community supports  Healthy community design  S afe, healthy and affordable housing options  S afe and clean environment (air and water quality, noise levels, tobacco-free policies)  A ccess to safe green spaces and nonmotorized pathways  A ccess to affordable, quality health care and well-being resources

Policy issues  Health Information privacy  Reasonable sccommodations  Return-to-work  Equal employment opportunity  Family and medical leave  Elimination of bullying, violence, harassment, and discrimination  Prevention of stressful job monitoring packages  Promoting productive aging

New employment patterns  Contracting and subcontracting  Precarious and contingent employment  Multi-employer worksites  Organizational restructuring, downsizing and mergers  Financial and job security

November 2015 “Total Worker Health” is a registered trademark of the U.S. Department of Human Services Journal of the New York State Nurses Association, Volume 47, Number 1

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Nurses’ Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue

collective bargaining agreements that ensure nurse well-being. Some examples of negotiated benefits are provided in Table 1. In addition, the union can encourage the employer to integrate alternative healing modality

exercises for nurses into the workday. Some examples of alternative healing modalities that nurses can engage in on the job are provided in Table 2.

Table 1: Nurse Well-Being Contractual Benefits Negotiate mental health days as a legitimate reason to utilize a sick day.

Allow for assignment changes when a nurse is experiencing compassion fatigue, signs of burnout, stress, or depression.

Provide non-patient workdays.

Give workers more flexibility and control over their working conditions and schedules.

Ensure that staffing is sufficient for nurses to be able to take meal breaks and rest breaks.

Develop and implement a caring for self and eachother program.

Table 2: Alternative Healing Modalities*

Yoga

Yoga has been shown to increase parasympathetic tone, and reduce symptoms of depression and perceived stress in women with elevated symptoms of depression (Chu, Wu, Lin, Chang, Lin, & Yahng, 2017).

Meditation

Nurses who have engaged in meditation have found that there are multiple benefits that inure to both themselves and to others. Meditation increased their ability to focus, improved collegial teamwork, decreased stress, improved attitude, and increased compassion for patients (Resnicoff & Julliard, 2018).

Diaphragmatic breathing practice

Meditative breathing improves cognitive performance and reduces negative subjective and physiological consequences of stress (Ma, Yue, Gong, Zhang, Duan, Shi, Wei, & Li, 2017).

Qigong

Those who practice this meditative, energy movement have found that their stress levels decreased, resilience increased, anxiety decreased significantly, and symptoms of depression improved significantly (Jahnke Rogers, Larkey, & Etnier, 2010).

Acupressure

Pressing on specific places on your body can release muscle tension, promote blood circulation, relieve stress and anxiety, relieve headaches, and improve concentration (Acupressure Point Guide, 2014).

Stretching

Stretching exercises reduce stress in working nurses (Costa, et. al, 2019).

Self-reiki/therapeutic touch

The practice of keeping your energy body as clean and charged up as possible (Bukowski, 2015).

Aromatherapy

The properties of essential oils travel through the body and eventually to the brain where they have both stress-reducing physiological and psychological effects (Graham Cannard, 1996).

*The working environment should encourage nurses to engage in these alternative modalities both on the job during their breaks and off the job. Developing policies and practices that include groups of nurses engaging in these activities at the same time would be a necessary component for achieving the Quadruple Aim. Adequate staffing would need to be scheduled to allow nurses to take their breaks and cover the unit. A dedicated location would also need to be provided. Lastly, nurses would need education and training on the benefits of these modalities and how to perform these exercises properly.

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Redesign the Work Environment. Healthcare facilities are required by the New York State Safe Patient Handling Act to provide safe patient handling equipment to help reduce the risk of injury, protect patient dignity, improve quality of care, increase consumer satisfaction, and enhance caregiver morale. Nurses’ unions can advocate and work with nurses collectively to place pressure on the employer to create facility policies and provide safe patient handling equipment, along with an infrastructure to make use of equipment easy for staff.

Similarly, since July 1, 2009, healthcare facilities are required by the New York State Labor Law to eliminate mandatory overtime for nurses. Working excessive hours leads to performance error, unsafe working conditions, and negative patient outcomes. Nurses’ unions can negotiate for safe nurse-topatient ratios to eliminate the need for mandatory overtime.

In addition, since November 1, 2010, New York State implemented its Felony D Law making it a felony to engage in acts of violence against a nurse. Nurses’ unions can negotiate for policies and procedures to help ensure that the workplace and its inhabitants are in a safe environment.

Educate for Safety and Health. Under New York State Codes, Rules, and Regulations, healthcare facilities are required to provide consistent staff development to ensure the competency, skills, and quality of care of its nurses. Healthcare employers should develop a culture and

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habit of inviting the education departments of nurses’ unions to train its nurses on the signs, symptoms, and effects of stress, compassion fatigue, depression, and burnout, and as well as how to address these conditions on a personal, clinical unit, and organizational level. Nurses’ unions can also instruct nurses on how to exercise their rights under labor law to advocate for themselves on a collective as well as individual basis. Advocacy for self, the workplace, colleagues, and ultimately the patient, is mandated by the Code of Ethics for Nurses.

Encourage Personal Change. Personal change can mean that the nurse or a group of nurses determines that the work environment is toxic and and a choice must be made to (1) stay and try to advocate for change in the physical environment, and/or (2) engage in self-care exercises and work toward resilience development, and/or (3) leave the place of employment.

It is crucial that a healthcare facility provide the encouragement and the infrastructure for the nurse(s) to be able to engage in self-care and resilience development while on and off the job. Nurses’ unions can be instrumental in advocating for nurses by fostering collective action to ensure that such an infrastructure and organizational culture is developed and can be utilized on a daily basis throughout all work shifts.

State Nurses Association’s Survey Focuses on the Workplace.

The New York State Nurses Association (NYSNA) emailed a health and safety survey in 2017 via SurveyMonkey® to a total of 42,000 RNs, working in over 165 hospitals throughout New York State who were represented by NYSNA for collective bargaining purposes. A convenience sampling of 1,817 nurses responded to the survey questions on how stress impacted their work and health. The results of the survey corroborated the existence of a major short staffing issue in hospitals throughout the state. The following are the results of that survey questionnaire (see Tables 3-8).

Nurses’ unions can be instrumental in advocating for nurses by fostering collective action to ensure that such an infrastructure and organizational culture is developed and can be utilized on a daily basis throughout all work shifts.

Table 3: New York State Nurses Association Health & Safety Survey Questionnaire (2017): Do You Experience Adverse Health Effects from Stress Due to Your Work?

Answered: 1,872 Skipped: 1,245

Yes No 0%

10%

20%

30%

40%

50%

60%

70%

80%

Answer choices

Responses

Yes

70.73%

1,324

No

29.27%

548

Total

90%

100%

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Table 4: New York State Nurses Association Health & Safety Survey Questionnaire (2017): Which Adverse Health Effect Have You Experienced?

Answered: 1,393 Skipped: 1,724

Headaches Hypertension Sleep disruption Gastrointestinal distress

Appetite suppression or over eating Extreme or chronic fatigue Depression Other (please specify) 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Table 5: New York State Nurses Association Health & Safety Survey Questionnaire (2017): What Are the Three Greatest Causes of Stress on Your Unit?

Answered: 1,817 Skipped: 1,300

Inadequate staffing levels Conflict with manager Conflict with doctor Conflict between coworkers

Pressures to carry out duties out of scope of practice Harassment due to race, gender, sexual orientation or identity, age, country of origin Excessive number of hours worked Lack of adequate supplies and/or equipment Inadequate policies Inadequate training Other (please specify) 0% 26

10%

20%

30%

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50%

60%

70%

80%

90%

100%

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Table 6: New York State Nurses Association Health & Safety Survey Questionnaire (2017): Does Stress Affect Your Ability to Provide Quality Patient Care?

Answered: 1,891 Skipped: 1,226

Yes No 0%

10%

20%

30%

40%

50%

60%

70%

80%

Answer choices

Responses

Yes

74.67%

1,412

No

25.33%

479

Total

90%

100%

1,891

The NYSNA uses protest of assignment (POA) forms, written documents that notify an employer that a nursing assignment is unsafe, to survey its nurses regarding the issue of how stress is impacting their health. Repeatedly, nurses respond that their stress is highly correlated

to inadequate nurse-to patient-ratios. In 2018, NYSNA received a total of 26,387 POAs signed by over 94,319 nurses. Table 7 indicates some of the reasons nurses filed POAs.

Table 7: Reasons Cited for Filing POAs (2018)

Reason cited

Number of POAs filed

Patient acuity higher than usual

18,005

Caseload too high, impeding safe care

9,370

Inadequate time for documentation

18,347

Lack of resources needed such as supplies, medication, equipment, and/or ancillary personnel

5,186

Inadequate number of qualified licensed staff

19,643

Not adequately trained for the situation

2,741

Volume of admissions and discharges too high

10,793

Other reasons

2,954

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Nurses’ Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue

The NYSNA 2017 Health & Safety Survey identified the greatest causes of stress on the job for nurses’ units, including the top three: inadequate

staffing levels, lack of adequate supplies and/or equipment, and inadequate policies. The results appear in Table 8.

Table 8: New York State Nurses Association Health & Safety Survey Questionnaire (2017): Top Causes of Stress on the Job

Answer choices

Responses

Inadequate staffing levels Conflict with manager Conflict with doctor Conflict between co-workers Pressure to carry out duties outside scope of practice Harassment due to race, gender, sexual orientation or identity, age, country of origin Excessive number of hours worked Lack of adequate supplies and/or equipment Inadequate policies Inadequate training Other (please specify) Total respondents: 1,817

State Nurses Associations’ Bargain for Changes in the Workplace Conducive to Nurse Well-Being. The potential of nurses’ associations and unions to influence the ability of nurses to achieve and maintain wellbeing, resilience, compassion satisfaction, and job satisfaction is vast.

Nurses associations have an interest in providing opportunities for nurses to adhere to their obligations under the Code of Ethics for Nurses (ANA, 2015) in their workplaces. Provision 5 of the code intensifies and legitimizes the nurses’ right to collectively bargain for a workplace environment supportive of the virtues, goals, and mission of the profession, along with the health and welfare of each individual nurse. Similarly, a healthcare facility has an obligation under the federal Occupational Safety and Health Act (OSHA) and the New York State Public Employee Safety and Health Act (PESH) laws to ensure the safety, well-being, and professional environment of nurses who work within their healthcare facilities.

Professional nurses’ associations and unions have the power to address nurses’ stress in several ways. Firstly, nurses’ unions can take collective action and bargain for benefits that address identified external stressors (see Table 5), such as poor staffing; lack of equipment needed for safe patient handling or to provide exemplary nursing care; lack of human, material, or financial resources; negative working conditions, such as rotating shifts or having to work overtime; and addressing exposure to violence. Secondly, nurses’ unions can provide education and skills training that addresses stress from an internally motivated and individual perspective, such as providing programs on prevention of lateral workplace violence, stress reduction modalities, self-help modalities, nutrition, and sleep.

In 2019, the New York State Nurses Association entered into coordinated bargaining sessions with more than ten major hospitals 28

85.75% 20.14% 14.14% 23.94% 22.40% 4.07% 12.16% 49.59% 24.22% 16.62% 19.32%

1,558 366 257 435 407 74 221 901 440 302 351

throughout the state. Language was negotiated that addresses nurses’ top stressor: lack of staffing to meet the immediate needs of every patient (see Tables 3–8). The agreement between the employers and the nurses’ union included the following: fill all vacant positions (a total budgeted vacancies of 807.56); fund staffing improvements above currently budgeted nurse-to-patient levels in existing units (a total additional budget of $100 million); modify contractual nurse-to-patient ratios resulting from a drop or increase in patient census or patient acuity; and determine appropriate nurse-to-patient ratios in new units and/or in units where there is a clinical programmatic change that fundamentally alters the character of the unit.

Methods Design This study was conducted using a quantitative descriptive survey design. Experimental quantitative research designs measure subjects before and after a treatment. This descriptive study established only associations between variables, i.e., the relationship between one thing (lack of staffing as the independent variable) and another thing (reduction of stress as an outcome, or dependent variable).

Participants and Setting This study was conducted using a convenience sampling of nurses working in five different unionized acute care hospitals in New York State.

Nurses working in management in these hospitals were excluded from the study. The hospitals selected ranged from large university hospitals to smaller

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general hospitals and all agreed to the negotiated language noted above. Units in this study included medical surgical units and telemetry units.

7. Do 5-minute meditation exercises practiced by nurses on the job increase the work satisfaction of the working nurse?

Instruments

8. Do 5-minute meditative breathing exercises practiced by nurses on the job decrease stress, burnout, compassion fatigue, and depression of the working nurse?

This study was conducted using surveys created by the New York State Nurses Association that were based on the surveys created by the NIOSH Quality of Life Survey (Lake, 2002; Aiken et. al, 2010). A copy of the NYSNA survey is attached as Exhibit 1.

Procedure Permission to have face-to-face conversations to obtain answers to the NYSNA survey at the selected hospitals was granted by the human resource departments, nursing departments, and unit managers. NYSNA staff scheduled appointments with nurses on the medical surgical and telemetry units within the selected hospitals and asked each nurse the questions on the NYSNA survey in an interview format. Answers were recorded on the NYSNA survey. One survey was filled out for each nurse interviewed. The names of the nurses surveyed do not appear on the survey.

NYSNA held a conference on alternative stress reduction modalities and invited the union leaders working in the selected hospitals and on selected nursing units (Exhibit 2) to attend. Nurse union leaders were taught exercises that can easily be implemented on the job (see Table 2).

Leaders carried the exercises back to their units, taught the exercises to their colleagues, and carried out a plan to incorporate the exercises into the daily routine of the nurses on the unit. Pre- and post-exercise program stress surveys (Exhibit 1) were given to unit nurse participants, and each unit nurse participant completed a weekly questionnaire and journal entry (Exhibit 3). The leaders reconvened after one year to report on the successes and shortcomings of the initiative.

Data Analysis Data was analyzed through the use of statistical and logical reasoning to determine patterns, relationships, and trends.

Questions to Be Answered by This Study 1. What are the top three stressors nurses face on a daily basis on the job?

2. Do contractually mandated nurse-to-patient ratios reduce stress, burnout, compassion fatigue, and depression of the working nurse?

3. Do contractually mandated nurse-to-patient ratios increase the work satisfaction of the working nurse?

4. Do 5-minute yoga exercises practiced by nurses on the job decrease stress, burnout, compassion fatigue, and depression of the working nurse?

5. Do 5-minute yoga exercises practiced by nurses on the job increase the work satisfaction of the working nurse?

6. Do 5-minute meditation exercises practiced by nurses on the job decrease stress, burnout, compassion fatigue, and depression of the working nurse?

9. Do 5-minute meditative breathing exercises practiced by nurses on the job increase the work satisfaction of the working nurse?

10. Do 5-minute Qigong exercises practiced by nurses on the job decrease stress, burnout, compassion fatigue, and depression of the working nurse?

11. Do 5-minute Qigong exercises practiced by nurses on the job increase the work satisfaction of the working nurse?

12. Do 5-minute acupressure exercises practiced by nurses on the job decrease stress, burnout, compassion fatigue, and depression of the working nurse?

13. Do 5-minute acupressure exercises practiced by nurses on the job increase the work satisfaction of the working nurse?

Conclusion Following education, and through self-reflection and an awareness of self, nurses will be able to assess their own symptoms, feelings, and behaviors, and determine if they are developing or are suffering from stress, burnout, compassion fatigue, and/or depression. Often, however, it takes an astute and aware coworker, family member, or friend knowledgeable in the signs and symptoms of these disorders to bring awareness, perspective, compassion, and care to the nurse experiencing these symptoms. Union nurse leaders, as colleagues, will help working nurses make these determinations and encourage them to engage in self-care and advocacy actions.

Nurses suffering from burnout, depression, and compassion fatigue are frequently judged negatively by their employers. However, these conditions are more likely than not created by the healthcare environment and its system of delivery, policies, and procedures. While consistently and routinely engaging in self-care and advocacy actions are not easy for most nurses, it is crucial that they do so. Sometimes self-care takes the form of saying “no” to an assignment that is too stressful, taking a day off, or acknowledging that sometimes one cannot do something, rather than pushing to achieve a superhero status. As nurses, we frequently find ourselves in situations where we think we have to choose between the patient and our work or ourselves. Nurses have become conditioned to think that choosing ourselves over our patient or our commitment to our employer is selfish or unethical. It is important to remember the old adage: How can you take care of someone else if you haven’t taken care of yourself?

Please look for a discussion of the results of our study in the next edition of the Journal of the New York State Nurses Association in our article “Nurses’ Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue” in “Part 2: The Results.”

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EXHIBIT 1 1. How long have you worked in your present job?

years

2. Which of the following best describes your usual work schedule?  Day shift

 Evening shift

 Night shift

 Weekends only

 Rotating shift

 Other:

3. How long is your typical shift?  8 hours

 10 hours

 12 hours

Other: 4. How many extra hours do you work beyond your usual schedule in a typical week?

5. How often do you find your work stressful?  Always

 Often

 Sometimes

 Hardly ever

 Never

6. My stress level at work has negatively affected my health.  Strongly

 Agree

 Agree

 Disagree

 Strongly Disagree

7. Thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?

8. Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good.

9. During the past 12 months, how often have you had trouble falling asleep or staying asleep?  Often

 Sometimes

 Rarely

 Never

10. Have you experienced adverse health effects due to job stress?  Yes

 No

If yes, what adverse health effects have you experienced? Check all that apply:  Headaches and/or other body aches

 Hypertension

 Sleep disruption

 Gastrointestinal distress

 Appetite suppression or overeating

 Extreme or chronic fatigue

 Depression and/or anxiety

 Tachycardia

 Other (please specify): 11. I have too much work to do everything well.  Strongly Agree

 Agree

 Disagree

 Strongly Disagree

12. How often are there not enough RNs to get all the work done?  Often

 Sometimes

 Rarely

 Never

13. How often are there not enough ancillary staff (LPNs, PCAs, PCTs, CNAs, clerks, transporters, etc.) to get all the work done?  Often

 Sometimes

 Rarely

 Never

14. How often are there not enough MDs to get all the work done?  Often

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 Sometimes

 Rarely

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15. I usually receive enough help to get the job done.  Strongly agree

 Agree

 Disagree

 Strongly disagree

16. Adequate support services allows me to spend enough time with my patients.  Strongly agree

 Agree

 Disagree

 Strongly disagree

17. I have enough time and opportunity to discuss patient care problems with other nurses.  Strongly agree

 Agree

 Disagree

 Strongly disagree

18. Not having a full complement of staff is a source of stress for me.  Strongly agree

 Agree

 Disagree

 Strongly disagree

19. There are enough registered nurses on my unit to provide quality patient care.  Strongly agree

 Agree

 Disagree

 Strongly disagree

20. My workload causes me to miss changes in patients’ conditions.  Strongly agree

 Agree

 Disagree

 Strongly disagree

 Rarely

 Never

21. Is being floated off your unit a cause of stress?  Often

 Sometimes

22. Is having staff floated onto your unit a cause of stress?  Often

 Sometimes

 Rarely

 Never

23. Have you ever taken any of the following actions to protest inadequate staffing? Check all that apply:  Filed a protest of assignment form (POA)

 Signed a letter or petition protesting inadequate staffing

 Participated in a union action to protest inadequate staffing

 Participated in contract negotiations to fight for improved staffing levels

Other: 24. Is there a nurse stress reduction program at your workplace?  Yes

 No

25. If yes, have you participated in it?  Yes

 No

26. What are the 3 greatest causes of stress on your unit? Please check 3:  Inadequate staffing  Conflict with managers  Conflict with doctors  Conflict between coworkers  Pressure to carry out duties out of scope of practice  Harassment due to race, gender, sexual orientation or identity, age, country of origin  Excessive number of hours worked  Lack of adequate supplies and/or equipment  Inadequate policies  Inadequate training Other (please specify):

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27. How many patients are routinely assigned to you?

28. Do you have a staffing grid or nurse/patient ratio for your unit in your contract?  Yes

 No

If yes what is it?

Is this currently upheld?  Yes

 No

29. Is there a process for modifying agreed upon staffing grids or nurse/patient ratios to account for census and acuity changes?  Yes

 No

 Don’t know

If yes, describe: 30. Does the hospital promptly fill all vacancies?  Yes

 No

 Don’t know

31. Is there a process to adequately orient newly hired staff?  Yes

 No

 Don’t know

32. Is there a process to adequately precept newly hired staff?  Yes

 No

 Don’t know

33. What can be done to reduce the stress you experience at work?

34. What do you do to decrease your stress level?

35. What techniques have you found helpful in reducing your stress level?

36. What is your age?

37. What is your gender?  Female  Male  Non-binary Other: 38. What is the highest degree you have received?  AD

 BSN

 MSN

Other:

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EXHIBIT 2 Listing of Nurse Specialty Units in Pilot Study Adult Health:

Family Maternal Child Health:

 Ambulatory  Radiology

 Antepartum  Labor and Delivery

 Dialysis  Cardiac/Telemetry/Stepdown

 Mother Baby  Neonatal ICU

 ICU’s  Med/Surg

 Pediatric Units  Family Planning

 Neurology  Oncology  Rehabilitation  OR  PACU  Same Day Surgery

Behavioral Health:  CPEP  Adult Behavioral Health  Detox  Pediatric Behavioral Health

Emergency Nursing:

 Pediatric ICU

Gerontology:  Assisted Living  Long Term Care  Gerontological Units

Home Care:  Home Care Services

Public Health:  Clinics  Community Health  Public Health

 Adult ER  Fast Track  Triage  Pediatric ER

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EXHIBIT 3 WEEKLY QUESTIONNAIRE AND JOURNAL ENTRY

Instructions: You are invited to participate in a pilot survey study about the effects of self-care exercises on nurses’ stress levels in the workplace.

Your participation will require doing a 5-10 minutes self-care exercise of your choice each day that you work in a four (4) week period.

In addition, your participation will require you to fill out one (1) pre self-care exercise survey, one (1) post self-care exercise survey, and one (1) self-care exercise packet.

This self-care exercise packet contains 9 pages. Please fill out 2 pages at the end of each week for four (4) consecutive weeks.  Use pages 2 and 3 for week 1  Use pages 4 and 5 for week 2  Use pages 6 and 7 for week 3  Use pages 8 and 9 for week 4  There are three questions/statements on pages 2, 4, 6, and 8.  There is one page for you to write your personal reflections regarding that week’s self-care exercise’s effect on you on pages 3, 5, 7, and 9.

Please answer all questions on pages 2, 4, 6, and 8. Please respond with sentences; do not use one/two word responses.

Please write a paragraph statement after each self-care exercise session on pages 3, 5, 7, and 9.

Your personal reflections page should describe how the self-care exercise session impacted you. You may describe emotions, thoughts, or visuals that may have occurred.

Please take the pre self-care exercise survey before you begin your self-care exercise packet.

Please take the post self-care exercise survey after you complete your self-care exercise packet.

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WEEK 1 The self-care exercises I used this week were (check all that apply):  Aromatherapy  Deep Breathing  Self-Reiki/Therapeutic Touch/Crystals  Meditation  Yoga  Stretching

Q1: What impact did the self-care exercise have on your stress and anxiety levels? Please describe the impact of EACH modality used.

Q2: What was your overall experience of your self-care sessions?

Q3: How did the self-care sessions impact your work at the hospital today? Please be specific in your description.

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WEEK 1: Personal reflections on my self-care experience.

Please describe how your self-care exercise session impacted you. You may describe emotions, thoughts, or visuals that may have occurred.

Please also describe when you were able to do the exercises during your shift, how many times you did the exercises per shift, and describe whether it was easy or difficult to do your self-care exercises.

My Reflections:

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WEEK 2 The self-care exercises I used this week were (check all that apply):  Aromatherapy  Deep Breathing  Self-Reiki/Therapeutic Touch/Crystals  Meditation  Yoga  Stretching

Q1: What impact did the self-care exercise have on your stress and anxiety levels? Please describe the impact of EACH modality used.

Q2: What was your overall experience of your self-care sessions?

Q3: How did the self-care sessions impact your work at the hospital today? Please be specific in your description.

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WEEK 2: Personal reflections on my self-care experience.

Please describe how your self-care exercise session impacted you. You may describe emotions, thoughts, or visuals that may have occurred.

Please also describe when you were able to do the exercises during your shift, how many times you did the exercises per shift, and describe whether it was easy or difficult to do your self-care exercises.

My Reflections:

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Journal of the New York State Nurses Association, Volume 47, Number 1

Nurses’ Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue

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WEEK 3 The self-care exercises I used this week were (check all that apply):  Aromatherapy  Deep Breathing  Self-Reiki/Therapeutic Touch/Crystals  Meditation  Yoga  Stretching

Q1: What impact did the self-care exercise have on your stress and anxiety levels? Please describe the impact of EACH modality used.

Q2: What was your overall experience of your self-care sessions?

Q3: How did the self-care sessions impact your work at the hospital today? Please be specific in your description.

Journal of the New York State Nurses Association, Volume 47, Number 1

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WEEK 3: Personal reflections on my self-care experience.

Please describe how your self-care exercise session impacted you. You may describe emotions, thoughts, or visuals that may have occurred.

Please also describe when you were able to do the exercises during your shift, how many times you did the exercises per shift, and describe whether it was easy or difficult to do your self-care exercises.

My Reflections:

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Journal of the New York State Nurses Association, Volume 47, Number 1

Nurses’ Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue

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WEEK 4 The self-care exercises I used this week were (check all that apply):  Aromatherapy  Deep Breathing  Self-Reiki/Therapeutic Touch/Crystals  Meditation  Yoga  Stretching

Q1: What impact did the self-care exercise have on your stress and anxiety levels? Please describe the impact of EACH modality used.

Q2: What was your overall experience of your self-care sessions?

Q3: How did the self-care sessions impact your work at the hospital today? Please be specific in your description.

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WEEK 4: Personal reflections on my self-care experience.

Please describe how your self-care exercise session impacted you. You may describe emotions, thoughts, or visuals that may have occurred.

Please also describe when you were able to do the exercises during your shift, how many times you did the exercises per shift, and describe whether it was easy or difficult to do your self-care exercises.

My Reflections:

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Centers for Disease Control and Prevention. (2018). Hierarchy of controls applied to NIOSH Total Worker Health.ÂŽ Retrieved from https://www.cdc.gov/niosh/twh/letsgetstarted.html Chang, H. Y., Shyu, Y. I. L., Wong, M. K., Chu, T. L., Lo, Y. Y., & Teng, C. I. (2017). How does burnout impact the three components of nursing professional commitment? Scandinavian Journal of Caring Sciences, 31, 1003-1111. doi:10.111/scs.12425 Cimiotti, J. P, Aiken, L. H., Sloane, D. M., Wu, E. S. (2012). Nurse staffing, burnout, and health care associated infection. American Journal of Infection Control, I(6), 486-490. doi: 10.1016/j.ajic.2012.02.029

Harris, C. (2018). Why depression is causing nurses to leave the profession: Another day on the unit. Retrieved from https://thriveglobal.com/ stories/nursing-depression-burnout/ Jacobs, B., McGovern, J., Heinmiller, J., & Drenkard, K. (2018). Engaging employees in well-being: Moving from the triple aim to the quadruple aim. Nursing Administrative Quarterly. 42(3), 231-245. doi:10.1097/ NAQ0000000000000303 Jahnke, R., Larkey, L., Rogers, C., Etnier, J., & Lin, F. (2010). A comprehensive review of health benefits of qigong and tai chi. American Journal of Health Promotion, 24(6). doi:10.4278/ajhp.081013-LIT-248 Jordan, T. R., Khubchandani, J., & Wiblishauser, M. (2016). The impact of perceived stress and coping adequacy on the health of nurses: A pilot investigation. Nursing Research and Practice. doi:10.1155/2016/5843256 Kaur, D., Sambasivan, M., & Kumar, N. (2013). Effect of spiritual intelligence, emotional intelligence, psychological ownership and burnout on caring behaviour of nurses: A cross-sectional study. J Clin Nurs. 22(21-22), 3192-202.

Ko, W., & Kiser-Larson, N. (2016). Stress levels of nurses in oncology outpatient units. Clinical Journal of Oncology Nursing, 20(2), 158164.

Lake, E. T. (2002). Development of the practice environment scale of the nursing work index. Research in Nursing & Health, 25(3), 176-188.

Retrieved from https://doi.org/10.1002/nur.10032 Lee, V., & Henderson, M. C. (1996, May). Occupational stress and organizational commitment in nurse administrators. J Nurs Adm, 26(5), 21-8. doi:10.1097/00005110-199605000-00006 Ma, X., Yue, Z. Q., Gong, Z. Q., Zhang, H., Duan, N. Y., Shi, Y., Wei, G. X., & Li, Y. F. (2017). The effect of diaphragmatic breathing on attention, negative affect and stress in healthy adults. Frontiers in Psychology, 8, 1-23. doi:10.3389/fpsyg.2017.00874 Machado, D. A., Figueiredo, N. M. A., Velasques, L. S., Bento, C. A. M., Machado, W. C. A., & Vianna, L. A. M. (2018). Cognitive changes in nurses working in intensive care units. Revista Brasileirade Enfermagem REBEn, 71(1), 73079. doi:10.1590/0034/7167-2016-0513 Milliken, T. F., Clements, P. T., Tillman, H. J., (2007). The impact of stress management on nurse productivity and retention. Nursing Economics, 25(4), 203-210.

National Institute for Occupational Safety and Health. (2014). Stress at work.

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National League for Nursing. (2019). Core values. Retrieved from http:// www.nln.org/about/core-values Naghneh, M., Tafreshi, M. Z., Naderi, M., Shakeri, N., Bolourchifard, F., & Goyaghaj, N. S. (2017). The relationship between organizational commitment and nursing care behavior. Electronic physician, 9(7), 4835-4840. doi:10.19082/4835 O’Mahony, N. (2011). Nurse burnout and the working environment.

Emergency Nurse: The Journal of the RCN Accident and Emergency Nursing Association, 19(5), 30-7. doi:10.7748/en2011.09.19.5.30.c8704 Pajnkihar, M., Štiglic, G., & Vrbnjak, D. (2017). The concept of Watson’s carative factors in nursing and their (dis)harmony with patient satisfaction. PeerJ, 5, e2940. doi:10.7717/peerj.2940 Pratt, L. A., Brody, D. J. (2014). Depression in the U.S. household population, 2009-2012. NCHS data brief, no 172. National Center for Health Statistics. Hyattsville, MD. Retrieved from https://www. cdc.gov/nchs/products/databriefs/db172.htm Rice Simpson, K., Lyndon, A., & Ruhl, C. (2016). Consequences of inadequate staffing include missed care, potential failure to rescue, and job stress and dissatisfaction. Journal of Obstetric, Gynecologic & Neonatal Nursing. 45(1), 481-490. doi:10.1016/j.jogn.2016.02.011 RN Network. (2017). Survey finds nearly half of nurses considering leaving the profession. Retrieved from https://rnnetwork.com/blog/rnnetworknurse-survey/ Schill, A. L. (2017). Advancing well-being through Total Worker Health®. Workplace health & safety, 65(4), 158-163. doi:10.1177/2165079917701140 Seyyedmoharrami, I., Dehaghi, B. B., Abbaspour, S., Zandi, A.,

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Tatari, M., Teimori, G., & Torbati, A. G. (2019). The relationship between organizational climate, organizational commitment and job burnout: Case study among employees of the University of Medical Sciences. The Open Public Health Journal, 12, 94-100. doi:10.2174/1874944501912010094 Sherwood, G. D. (1997, summer). Meta-synthesis of qualitative analyses of caring: Defining a therapeutic model of nursing. Adv Pract Nurs Q, 3(1), 32-42.

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Journal of the New York State Nurses Association, Volume 47, Number 1

In the Aftermath of Maria: An Ethnographic Review of Rescue, Recovery, Climate, and Social Justice in Puerto Rico Carole Ann Moleti, DNP, MPH, FNP-BC, CNM Lucille Contreras Sollazzo, MS, RN-BC, NPD Marc Minick, PhD, LMSW Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD

n A bstract

Social determinants of health, climate change, social justice inequities, and an inadequate U.S. federal government response to Hurricane Maria were the cause of thousands of deaths in Puerto Rico in 2017. Prolonged delays in restoration of essential resources, including power, water, and healthcare services impacted infrastructure, jobs, schools, and the health of many Puerto Ricans, particularly the elderly and the disabled. The Disruptive Design and Force Field Analysis ethnographic study methods were implemented in this research project to examine the effectiveness of providing ongoing direct patient care services and while advocating for policy change to support the recovery efforts of Puerto Rican citizens.

Introduction Prior to 2017, Hurricane Katrina was the worst natural disaster in the United States of the past 75 years. It affected an area as large as Great Britain, killed more than 1,000 people, uprooted 500,000 others, and caused more than $100 billion in damage (Rosenbaum, 2006). On September 25, 2017, five days after Hurricane Maria, and before the world was even aware of the extent of the destruction, Time Magazine published a glowing review of the Federal Emergency Management Agency (FEMA) and its handling of hurricanes Harvey and Irma, claiming “a lot of smart people did a lot of things right to prevent a historic hurricane from doing historic damage” (Klugerand & Sweetland Edwards, 2017, p. 36). In addition to dispatching 64,000 workers to the affected area, mass evacuations of vulnerable areas were ordered. The actions were credited with saving many lives during Hurricane Irma, which laid waste to Barbuda, Havana, and Saint Martin. Kluger and Sweetland Edwards (2017) boasted, “in a world in which climate change is making storms both more powerful and more deadly, we’re clearly doing a better job than we ever have of learning on the fly—and applying what we learn” (p. 38).

Nevertheless, according to Robles (2018), who was on the ground in Puerto Rico and writing for the New York Times, FEMA vastly underestimated how much food and fresh water it would need, and how hard it would be to

get additional supplies to the island. They were only prepared for a tsunamilike disaster, not a major hurricane that devasted the whole island.

FEMA’s warehouse in Puerto Rico was nearly empty, its contents having been rushed to aid the United States Virgin Islands, which were affected by Irma two weeks before Maria. There was not a single tarpaulin or cot left in stock. The 2017 hurricane season in the United States was the most destructive on record. According to the report, nearly five million people registered for FEMA assistance in 2017, exceeding the combined total from four previous major hurricanes—Rita, Wilma, Katrina, and Sandy.

Hurricanes Irma and Maria caused a total of $265 billion in damage and badly stretched FEMA’s capacity to respond (Robles, 2018).

Those and other shortcomings are detailed in a FEMA report assessing the agency’s response to the 2017 storm season, when three major hurricanes slammed the United States in quick succession, leaving FEMA struggling to deliver food and water quickly to storm victims in Puerto Rico. The after action report confirms many of the criticisms that have been leveled at the agency, described as “an initially chaotic and disorganized relief effort on the [Puerto Rican] island that was plagued with logistical problems and stretched into the longest feeding mission in the agency’s history” (Robles, 2018, p. 1). The report indicated FEMA had thousands fewer workers than it

Carole Ann Moleti, DNP, MPH, FNP-BC, CNM, is a certified nurse-midwife at the Sunset Park Family Health Center at NYU Langone Hospital-Brooklyn.

She was working as a family nurse practitioner at Montefiore Medical Center in The Bronx at the time this article was written.

Lucille Contreras Sollazzo, MS, RN-BC, NPD, is currently the Associate Director of Nursing Education and Practice at the New York State Nurses Association.

Marc Minick, PhD, LMSW, is an adjunct professor at Fordham University’s Graduate School of Social Service.

Carol Lynn Esposito EdD, JD, MS, RN-BC, NPD, is currently the Director of Nursing Education and Practice at the New York State Nurses Association.

n An Ethnographic Review of Rescue, Recovery, Climate, and Social Justice in Puerto Rico needed, and many of those were not qualified to handle major catastrophes. FEMA had to borrow workers from other agencies to help it manage the immense demand for essentials, including drinking water, in the aftermath of the storms (Robles, 2018).

Although FEMA distributed 130 million meals after Hurricane Maria, only 35 million of them were distributed in Puerto Rico, and the agency took longer than expected to secure supplies and lost track of much of the aid it delivered and who needed it. The most frequently reported problems were an inability to access medications (14.4% of households) and the need for respiratory equipment requiring electricity (9.5%), but many households also reported problems with closed medical facilities (8.6%) or absent doctors (6.1%). In the most remote category, 8.8% of households reported that they had been unable to reach 911 services by telephone (Kishore, Marquez, & Mahmud et al. 2018).

All healthcare professionals are bound by common ethical principles that should be respected while interacting with individuals, families, and communities during short-term medical missions (STMMs). Those principles include autonomy and self-determination (respecting the wishes of the patient, even if you do

Kishore et al. (2018) estimated the Islandwide mortality rate from September 20, 2017, to December 31, 2017, to be 14.3 deaths per 1,000 persons (95% CI [9.8,18.9]). This rate yielded a total of 4,645 excess deaths during this period (95% CI [793, 8498]), equivalent to a 62% increase in the mortality rate as compared with the same period in 2016. Hurricane-related migration was also “substantial” (Kishore et al., 2018). A household-based survey suggested that the number of excess deaths related to Hurricane Maria in Puerto Rico was more than 70 times the official estimate.

As of June 2018, about 22,000 residents, or 10% of the population, were still without (being compassionate and power and running water (Suh, 2018). Power following through based upon was finally restored to Ponce, the last city to a desire to do good), nonregain power, on August 15, 2018. Even so, there malfeasance (competent were still homes that needed additional work to practice), justice (equal and fair restore power. Many tourist zones, highways, and residential streets continued to go dark at treatment), veracity (truth in all sundown because an estimated 100,000 light communications), totality and bulbs were on backorder until crews could shift When President Donald Trump visited integrity (considering the entire from repair to replacement (Florido, 2018). The Puerto Rico at the time, he stated that the person), and fidelity (honoring power remained out on the island of Culebra, and disaster “threw our budget a little out of whack” commitments). its one hospital remained closed in November while Puerto Rican hospitals were struggling to 2018 (Oliver Belez, 2018). Even without any function. There were shortages of diesel fuel damaging storms, communities that had their to power generators, and the death rate on the power grids repaired suffered as many grid failures after repairs as there island was soaring (Robles, 2018). Following public debate over the Trump were before the storm (Florido, 2018). administration’s initial reluctance to deploy the USS Comfort, the floating not agree), beneficence

hospital arrived two weeks into the disaster. Its mission and capabilities were unclear to doctors on the island and it lacked the ability to treat some important areas of need. Complex referral procedures made little sense on a battered island with scant power or telephone service (Robles & Fink, 2017).

Failure to override the Jones Act, the law that regulates maritime commerce, until nine days after the storm, kept ships from other countries from delivering assistance. Puerto Rico Governor Ricardo Rosselló repeatedly begged for more federal assistance, calling the situation “a humanitarian crisis” (Thompson-Reuters, 2017). Frantic calls for help by short-staffed hospitals without power went unanswered. This lack of response can be blamed for the deaths of many who relied on respirators, nebulizers, and dialysis equipment. Without air conditioning, heat took its toll on the hospitalized, ill, elderly, and homebound, who also lost the assistance of nebulizers, oxygen, dialysis, diabetic testing supplies, and insulin.

Kishore et al. (2018) estimated that most victims of the storm died between September 20 and December 31, 2017, as a direct or indirect result of Puerto Rico’s worst natural disaster in 90 years. One-third reportedly perished because of delayed or interrupted medical care (Kishore et al., 2018; Emery, 2018). The official death toll was increased on August 9, 2018, after the results of a George Washington University study commissioned by Governor Rosselló was delivered to the United States Congress. Begnaud (CBS, 2018) reported almost a year post-Maria that while things had improved, “the problems in Puerto Rico are so systemic and have been around for so long that they are only pecking away at the surface.”

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Purpose of the Study The purpose of this study was to provide and then describe short-term medical care to Puerto Ricans following Maria. Concomitantly, a Disruptive Design (Christensen, 2019) methodology and Force Field Analysis (Lewin, 1951) were undertaken in order to create and activate long-standing, continuing disaster relief approaches and services thus facilitating a longterm and positive impact in Puerto Rico. These methodologies were used for inquiry, discovery, and development of strategies in addressing the complex, real-world problem of recovery efforts following a massive natural disaster.

Analysis of ethnomethodological themes including autonomy, indexicality (phrases that are associated with different meanings on different occasions and may be dependent on a variety of non-linguistic features, such as hand gestures), and reflexivity (being able to examine one’s own feelings, reactions, and motives, reasons for acting and how these influence what one does or thinks in a situation) were used to categorize patient and provider responses as well as for qualitative summary and evaluation (Terry, 2012).

Literature Review Legal, Ethical, and Safety Implications of Short-Term Medical Missions Legal and Ethical Implications The primary goal of short-term global healthcare experiences is to

Journal of the New York State Nurses Association, Volume 47, Number 1

An Ethnographic Review of Rescue, Recovery, Climate, and Social Justice in Puerto Rico improve the health and well-being of the individuals and communities where they occur. All healthcare professionals are bound by common ethical principles that should be respected while interacting with individuals, families, and communities during short-term medical missions (STMMs).

Those principles include autonomy and self-determination (respecting the wishes of the patient, even if you do not agree), beneficence (being compassionate and following through based upon a desire to do good), non-malfeasance (competent practice), justice (equal and fair treatment), veracity (truth in all communications), totality and integrity (considering the entire person), and fidelity (honoring commitments) (Muse, 2018; Silva & Ludwick as cited by Esposito & Sollazzo, 2018).

The World Health Organization (WHO) (2018) declared the following ethical principles for healthcare professionals on STMMs: integrity, accountability, independence and impartiality, respect, and professional commitment. Global health ethical activities include respecting different cultural norms, avoiding unintended harms, protecting privacy, working within one’s scope of practice, and managing resource constraints and priority setting. Volunteer healthcare personnel who participate in STMMs have ethical duties and special obligations to advocate for sustainable, mutual benefit; a fair and equitable distribution of resources; and partnership with and respect for the individuals and communities they serve (DeCamp, Soleymani, Jaeel, & Horwitch, 2018).

Safety Implications STMM volunteers may face physical risks from damaged infrastructure, unsafe roads, water and food shortages, security concerns, the sustained effort required throughout the mission, the effort required to reach survivors, and the effort required to deliver care with limited resources.

Emotional risk should not be minimized, because, by definition, STTMs address most emergent needs with little or no ability for follow-up care, death, catastrophic injury, and/or disabilities. While debriefing of mission participants may not be possible during rescue operations, debriefing sessions should take place whenever possible to maintain cohesiveness and an interdisciplinary approach to medical care.

The Mental Health of the Puerto Rican Population Post Storm The damage caused by Maria—which included destroying much of the island’s electrical grid, wiping out communications infrastructure, and knocking out water supplies for up to a year in some places, affected an island already dealing with a decade-long economic crisis and high unemployment (Vincens, 2018). The storm’s effect on mental health and suicide rates was the subject of a New York Times mini documentary (2018), which followed a separate Times piece (2018) examining the mental health crisis predicted after the hurricane.

Many Puerto Ricans reported intense feelings of abandonment, anxiety, and depression for the first time in their lives, along with fears that a disaster would strike again. Those who had mental illnesses before the storm, and who had been cut off from therapy and medication, saw their conditions deteriorate (Dickerson, 2017). For most Puerto Ricans, logistical barriers like

n

scarce water and electricity, as well as closed schools and businesses, made any return to normalcy feel impossible (Dickerson, 2017).

Vicens (2018) reported an increase in suicides. The total number of men who took their own lives in Puerto Rico saw a jump from 2016 to 2017 from 174 to 271, as did women from 22 to 36. Rates varied by age and location. Aguadilla had the highest increase, from 6% to 12%, followed by the metro area from about 4% to 6%. Suicides were more frequent in older age groups. Between 2016 and 2017, the rate of suicide went up from about 9–15 per 100,000 in those aged 55–59, up from 6–13 per 100,000 in those aged 65–69 from 4–12.5 per 100,000 in those aged 74–79, and up from 5–8.5 per 100,000 in those aged older than 85 (Vicens, 2018).

Males accounted for the largest proportion of suicides (174–217) from 2016–17. In females the number also increased from 22–36 as compared to 2016–17 (Vicens, 2018).

Ethnographic research entails intensive involvement with participants by immersion in their culture and world during fieldwork. Methodologies include participant observation and interviews (Terry, 2012). Traditional ethnographic research focuses on the meanings participants ascribe to their experiences, knowledge, behaviors, and activities gleaned during multiple interviews with participants over time (Ploegg, as cited in Terry, 2012, p. 91). Researchers live in the culture being studied for an extended period of time. In anthropology, folkloristics, and the social and behavioral sciences, emic and etic refer to two kinds of field research done and viewpoints obtained: emic, from within the social group (from the perspective of the subject, i.e., how members of the community perceive their world); and etic, from outside (from the perspective of the observer and how the observer perceives and interprets the behaviors of the subjects). The context of the culture is particularly important, and includes the social, political, and economic perspectives (Ploegg as cited in Terry, 2012, p. 91).

Theoretical Underpinnings of Structuring Care in Disaster Situations One approach to structuring care in disaster situations is to use the interrelated theoretical frameworks of Maslow’s hierarchy of needs (1970), Peplau’s conceptualization of levels of anxiety (1963), and crisis intervention theory by Aquilera and Messick (1986).

Food, clothing, clean air, shelter, clean water, and sanitation are basic and foremost needs following a disaster (Maslow, 1970). Anxiety and depression are common psychological responses associated with disasters and are highly associated with reduced quality of life, psychological morbidity, increased risk of mortality, disability, increased medical care, and functional impairment in daily activities (Zarea, Maghsoudi, Dashtebozorgi, Hghighizadeh, & Javadi, 2014).

Peplau developed a theory for purposeful nurse-patient therapeutic communications and treatment that can be implemented on STMMs in order to facilitate reducing anxiety and depression. Using Peplau’s theory, the registered nurse (RN) volunteer should assess the type of anxiety experienced by the patient and create a therapeutic care plan in accordance with the level of anxiety (see Table 1).

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n An Ethnographic Review of Rescue, Recovery, Climate, and Social Justice in Puerto Rico Table 1: Peplau’s Levels of Anxiety

Level of anxiety

Symptomatology

Intervention

Mild anxiety

Fidgeting, irritability, sweaty palms, heightened senses

Situational – answer questions, role play, teach back, deep breathing, engage in relaxing activity; therapeutic communication.

Moderate anxiety

Increased heartbeat, dry mouth, sweating, stomach pain, nausea, rapid speech, high pitched speech, exaggerated hand and arm movements, nail biting, wringing hands

Situational – answer questions, role play, teach back, deep breathing; therapeutic communication, meditation

Severe anxiety

Pounding heartbeat, chest pain, headache, vomiting, diarrhea, trembling, scattered thoughts, erratic behavior, feeling of dread

Ability to focus and solve problems is impaired; therapeutic touch, listening, deep breathing; attempt to remove from stress environment

Panic-level anxiety

Inability to move or speak or inability to sit still, distorted perceptions

Overwhelms capacity to function; do whatever is possible to ease suffering.

Aguilera and Messick developed a theory of crisis intervention to thwart the personality disorganization and functional impairment that can result from experiencing a crisis with concomitant unavailability of

social supports. In this theory, three factors work together to determine whether or not a crisis, and thus unhealthy behavior, will evolve after a crisis-precipitating event. Table 2 presents a summary of these major factors.

Table 2: Concepts of Aguilera and Messick’s Theory of Crisis Intervention Crisis Crisis-precipitating event Balancing Factors

Patient’s perception of the event

Primary appraisal

Secondary appraisal Reappraisal

Available support systems

Available coping mechanisms Continuing medical and psychological care should be an ethical obligation and goal of any STMM team. The shortage of personnel and the fact that most psychological therapies on short-term medical missions are, in fact and in practice, short termed, if at all provided, necessitates an alternative approach to the anxiety and depression diagnosed in the patient population during an STMM. Moleti’s (1990) stepwise approach for care providers to help survivors reduce anxiety, meet immediate basic needs, and manage crises. These

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concepts can be adapted to disaster situations to help the individual cope with disaster situations (see Figure 1).

Using Minick’s (2018) One Shot Deal (OSD) counseling model, survivors were given an opportunity to share feelings, express emotions, identify past and current strengths, identify potential future success, and learn new stress-reduction activities such as listening to thoughtful music and self-healing massage. Continuing care long-term was encouraged by developing ongoing relationships with native caregivers (see Figure 2).

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Figure 1: Paradigm for Management of Psychosocial Risk Identify curiosity level (Hay)

Identify level of need (Maslow)

Identify self-care defecits (Orem)

Physiologic

Mild

Safety

Moderate

Belongingness and love

Severe Panic

Esteem Self actualization

Reduce anxiety by giving information

Gather background data Age

Emotional support

Socieconomic status Fears Hopes Ethnicity Educational level

Identify and emphasize strengths

Identify and restructure weaknesses

Plan to meet needs Problem list Goals Referrals Consultations Perform interventions

Evaluate outcome (Moleti, 1990; adapted from Hay, 1962; Maslow, 1951; Orem, 1980) Journal of the New York State Nurses Association, Volume 47, Number 1

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n An Ethnographic Review of Rescue, Recovery, Climate, and Social Justice in Puerto Rico Figure 2: Implementing the Disruptive Design Method and Force Field Analysis Methodologies in Puerto Rico

Methods Research Design A multidisciplinary approach to team building fostered the goal to meet critical basic physiologic and safety needs and to assist survivors to regaining self-sufficiency. An ethnocentric, ethnographic approach was implemented to effectuate the delivery of targeted, sensitive, and culturally appropriate services in disaster situations. Proper training, support, briefings, and debriefing by the sponsoring agencies helped ensure the physical and emotional safety of responders and best outcomes for both care providers and survivors.

Procedure The emergent, immediate nature of disaster situations precludes many of the steps necessary for Institutional Review Board proceedings for the Protection of Human Subjects in outcomes research. Informed consent, data collection, delivery, and documentation of care, and preservation of records are nonetheless required to the extent possible. Multiple treaties imply that victims of a natural disaster or conflict have a right to the necessary measures being taken to safeguard, protect and improve their lives if threatened, and that it is the duty of others to take these measures, notably the state under which they live, but also other actors, such as volunteering healthcare professionals, should the state fail to do so (Elgafi as cited by Esposito et al., 2018).

Selection of Volunteers The New York State Nurses Association (NYSNA), New York RN 50

(NYRN), and Healthcare Without Borders sent out calls for nurses and other health professionals to join successive STMMs to Puerto Rico. Three missions took place: October 2017, November 2017, and January 2018.

Access to and assistance at service sites was coordinated with local Puerto Rican community organizers and La Universidad de Puerto Rico (UPR) in San Juan. The third mission took place in the recovery rather than in the rescue phase of the disaster, which enabled more preparation of volunteers, local sites, and debriefing. Data presented in this paper are from the third mission in January 2018.

Volunteers were interviewed by a mission coordinator to screen for mental, emotional, and physical readiness. Two interdisciplinary teams were chosen to care to 348 patients for a wide range of medical conditions in children and adults. The team consisted of nurse practitioners, medical doctors (MDs), registered professional nurses, licensed clinical social workers (LCSWs), and also included two New York Transit Workers Union (TWU) drivers, who transported the professionals to mission sites.

The ages of the volunteers ranged from 30 to 70 years old, and the group’s prior contribution on previous humanitarian missions was a combined two years of experience. Their personal clinical areas of concentration included family practice, school health, maternal-child health, public health, emergency and critical care, pediatrics, and mental/behavioral health. Three of the RNs and the two drivers were of Puerto Rican heritage. Both drivers had military experience and one RN had previously worked as a corrections officer. Four RNs, both drivers, the DNP, and the MD spoke fluent Spanish. Both mission coordinators were of Puerto Rican heritage and spoke Spanish. The LCSW was a PhD, and previously served as the director of a behavioral health service.

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Sample Size Two teams, consisting of one nurse practitioner or physician, two registered nurses, a mental health provider (RN or LCSW), and a professional driver provided care to a total of 348 patients.

The patients were seen at the following sites: Centro Comunal Los Naranjos in Vega Baja, Ramon Torres Rivera Elementary School in Morovis, Caserio Manuel Pérez (which included a women’s shelter) in San Juan, Guayaba Dulce in Adjuntas, Concepcion Pérez Elementary School in Ciales, Margarita Janer Palacios High School in Guaynabo, Escuela Segunda Unidad Nueva in Loiza, and the Jesús T. Piñero Intermediate School in Manati. Home visitation was provided at all sites upon request of the patients and/or community organizers.

All visits in the public housing project Caserio Manuel Pérez and the women’s shelter were home-based, though some patients walked in to the nursing information and resource center run by the nursing professors at UPR and were seen by mission staff. Two patients received assistance in the street from the back of the van: one a blind, homeless person who was provided with a reflective blanket and food; and the other an assault victim who received care for a scalp laceration. Children were given coloring books, stickers, pencils, and crayons.

Care was dispensed at temporary or pop-up clinics in schools and community centers, in already established women’s clinics, in residential settings, and in makeshift settings during drive-by cruising. Home visits to elderly, disabled, and homebound patients were coordinated with public health officers, nurses from La Universidad de Puerto Rico, San Juan, and community organizers—the vast majority of whom were teachers and members of La Federación de Maestras. Encounter forms for patients needing follow-up care were turned over to community organizers, public health nurses, or home visitors to assure continuity.

On January 21, 2018 (121 days after Hurricane Maria), a multidisciplinary team of one medical doctor, one doctor of nursing practice (DNP), two mental health practitioners (one RN and one LCSW), and six RNs evaluated and treated a convenience sample of 151 patients from the Puerto Rican population (see Table 3).

Mission Findings and Data Collection Results Descriptive Statistics An ethnographic methodology was used to examine data, which was tabulated to provide descriptive statistics and general prevalence of conditions treated. Focus groups post mission assisted teams in coping with the emotional impact of their service, while also contributing to the developing body of knowledge for preparing for future STMM deployments.

A need was identified for future missions to assist with recovery and health policy changes post-hurricane in coordination with relief organizations to assist with general public health and sanitation, housing, animal care and control, environmental cleanup and remediation.

Facilitative leadership was implemented to support team building as well as to guide the conduct of nursing assessments and care for survivors.

n

Encounter forms were turned over to community organizers to assure continuity, and the forms included a signed permission to be seen and initially evaluated by RNs who triaged the patients and then referred the patient to a medical provider and/or mental health provider (often both).

In some cases, the RNs provided individual or group nursing interventions based upon physical or psychosocial needs.

Pre-mission training and orientation, cohabitation in affected communities, and facilitative problem-solving allowed participants to bond quickly and develop an empathic bond with survivors. Daily briefing and debriefing by the mission coordinators, as well as communal living arrangements and meal times, enabled teams to rapidly build trust and develop workflows. This helped to meet the needs of up to 60 patient visits per day in areas with significant damage to homes and infrastructure, areas that often lacked access to transportation, electricity, running water, and cellular communication. Mission members participated in twice daily debriefings while in the field. Huddles were called as needed to address and remedy concerns, patient care needs, and changing conditions.

Data was extracted and tabulated to provide descriptive statistics of the population served and general prevalence of conditions treated during the missions. These were compared to published rates before hurricanes Irma and Maria.* The ages of patients ranged from 21 to 107 years old, with a mean age of 57.57 years old. The pediatric population served ranged from ages 0 months to 18 years old, with a mean age of 11.95 years old. A total of 139 pediatric patients were served (see Table 3 and Figure 3).

In adults, medical needs addressed included skin infections and rashes, hypertension, diabetes, gynecological issues, asthma, post-traumatic stress disorder (PTSD), dental care, prescription refill requests, anxiety, depression, skin and decubitus ulcers, pneumonia, abscess, and cellulitis. Psychological issues were evident in a moderate percentage of patients. There was one actively suicidal individual assessed by the group, who was referred for psychiatric care. Pediatric patients were treated for skin and respiratory infections and asthma (see Table 4).

Public Health Sightings In Caserio Manuel Pérez, a housing project near San Juan, pre-existing problems with coordination of care had been compounded by loss of providers, communication, and transportation options after the hurricane.

Several elderly residents were missing critical medications such as insulin, and equipment such as glucose test strips and nebulizers. Many were homebound, several bedbound, some with inadequate housing and without daily care providers. There was evidence of malnutrition and teams noted decubitus ulcers, cellulitis, contractures, and pneumonia in the population.

Infrastructure and environmental damage persisted even in the capital, San Juan. During the STMM, over 122 days after Hurricane Maria, tires were still piled as high as the roof on street corners with water trapped inside breeding mosquitos despite posters warning of the risks of Zika and Chinkungunya infections. Many blocks featured rows of abandoned buildings covered with black mold. Downed trees narrowed already dangerous curves

*Basic health statistics in Puerto Rico indicate that the island faced significant health concerns even before the storm. Puerto Ricans were much more likely to report having fair or poor general health compared to the U.S. population overall (34% compared to 18%). The percentage of people living with a disability (estimated for 2011-2015) was 15.4% compared to 8.6% in the United States overall. Puerto Rico had a higher percentage of low-birthweight infants and a higher infant mortality rate compared to the U.S. population overall. The prevalence of diabetes was 50% higher in Puerto Rico compared to the rest of the U.S., including a death rate due to diabetes that was more than three times the U.S. average. The HIV death rate in Puerto Rico was nearly four times higher than that of the U.S. population overall, and second highest of any state, territory, or federal district in the country (after Washington, D.C.). The number of people living with HIV in Puerto Rico in 2014 was estimated at 17,072, which represented one of the highest rates of people living with HIV per 100,000 in the United States (Michaud & Kates, 2017).

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n An Ethnographic Review of Rescue, Recovery, Climate, and Social Justice in Puerto Rico Table 3: Descriptive Statistics of the Number of Patients Seen

Figure 3: Age Distribution of Patients Treated, January 2018 0% 1% 2%

Number of patients seen

Age 0-12 Months 2-3 Years 4-5 Years 6-11 Years 12-18 Years 19-34 Years 35-44 Years 45-64 Years 65 years and above Total

4 1 6 48 80 21 17 59 54 290

19%

17%

20%

28% 6%

0% ....0-12 Months 17% ..6-11 Years 6% ....35-44 Years

7%

1% ....2-3 Years 28% ..12-18 Years 20% ..45-64 Years

2% ....4-6 Years 7% ....19-34 Years 19% ..6 Years and above

Table 4: Chief Complaints at Manati and Guaynabo Clinics, January 2018 35 30 25 20 6-11 Years

12-18 Years

6-11 Years

12-18 Years

15 10

Neuro GYN ENT

bite

Anim

al/in sect

Derm

refill

Med

ealth

CV

crine

GI

Men tal h

Sleep disturbance

ENT

Allergic reaction

Endo

Resp

GYN

Neu

ro

CV

Pain

GI

Well visit

Well -v Age in Gender years

Resp Aller gic r eact ion Slee p dis turb ance

isit

0

Pain

5

Endocrine

Mental health

Med refill

Derm

Animal/ insect bite

6-11

F

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

12-18

F

12

3

0

1

1

1

2

0

1

1

0

2

0

1

0

6-11

M

2

0

1

0

0

0

0

0

0

0

0

3

0

0

0

12-18

M

17

2

2

0

1

1

1

0

0

2

1

4

0

1

0

52

Journal of the New York State Nurses Association, Volume 47, Number 1

An Ethnographic Review of Rescue, Recovery, Climate, and Social Justice in Puerto Rico on the cluttered streets, in which emaciated cats roamed and an occasional rat carcass (Leptospirosis was also endemic) littered the sidewalks. Traffic lights were not functioning on many of the major roadways, including those leading to and from Luis Muñoz Marín International Airport. Traffic dangers were compounded by loose and dangling overhead signs and potholes.

Many of the schools where researchers conducted pop-up clinics to address the communities’ medical and mental health needs were without electricity, further disrupting a struggling educational system from which many children and their families had left Puerto Rico for the mainland.

A local resident wandered alone near a once popular beachfront that was now littered with plastic bottles and other debris. She shared stories of her major depression after the terror at the height of the storm as palms were being plucked from the ground like a giant was tossing them, the decimation of her community, and the lack of federal assistance and support.

Herds of thin, scraggly stray horses and dogs foraged, the former nibbling on grass, the latter observed dragging a carcass of a large animal, possibly a raccoon or opossum, into an abandoned building.

Physical, Psychological, and Psychiatric Disorders There were high levels of anxiety, depression, uncontrolled hypertension, skin infections, gastrointestinal complaints, and asthma exacerbation. In Ciales, one woman shared the memory of holding the door to her house closed while her children screamed with fear as the storm raged and the wind threatened to blow debris and flood waters in.

She was thankful for prescriptions as well as treatments for the children’s rashes and asthma, including her five-month-old who needed a nebulizer treatment. Her pharmacy cooperated with prescriptions from New York State providers, but Puerto Ricans in other areas where the situations were “normalized” were not so fortunate, requiring multiple phone calls and maneuvers to fill out-of-state prescriptions written by nurse practitioners.

Other survivors waited hours for prescriptions for generators, which they needed to receive a FEMA-issued generator for refrigeration of insulin, or prescriptions for nebulizers, antibiotics, and topical treatments for skin and other infections, or refills on blood pressure and cholesterol medication.

At 133 days, as FEMA contemplated pulling out of Puerto Rico on January 31, 2018, the water treatment facility in the community of Vega Baja (also without power and running water) remained riddled with debris and garbage, its runoff being discharged directly into the Atlantic Ocean. Canned food heated on propane stoves and bottled water were being used in most homes, and most homes were without generators or refrigeration. Children were attending only a half day of school, and many residents had fled to the U.S. mainland. Many of those remaining, including bedridden elderly with respiratory ailments, were being cared for by neighbors, whose own homes still had not been cleaned up or repaired. Many homes had blue tarpaulins as roofs or no roof covering at all, while residents awaited FEMA response to their applications for assistance. The unmet medical needs of this population included patients with diabetes and hypertension, depression, and anxiety.

Qualitative Analysis Qualitative analysis of ethnomethodological themes was performed using encounter forms, notes taken during daily debriefings, journal entries of the volunteer staff, and notes taken during post-mission focus groups. Despite the constraints of short-termed service and conditions that limited choices

n

and action patterns, the ethnographic themes examined included autonomy, indexicality, and reflexivity (Terry, 2012). Categorization of both patient and provider responses were analyzed for qualitative summary and evaluation.

Assumptions made by the team were that there would be single encounters of about 5–10 minutes during which the patient’s most urgent need(s) would be addressed. It was also expected that this would be a difficult task given limited resources. Encounter forms were used to process patients through triage to the appropriate provider or group counseling (indexicality). Those in need of more services were referred to the appropriate mental health provider and/or medical provider, often both (autonomy). Physicians, social workers, and nurse practitioners worked closely to coordinate and ensure ongoing care as needed for patients with complex or acute medical and/or psychosocial needs (indexicality). Huddles were called as needed to address any concerns (reflexivity).

Assumptions by survivors seemed to be an expectation for help with one need, such as a prescription for medications or a generator, a check-up to reassure them they were okay, or to talk about their feelings.

Many needed help with chronic disease control or management. Children and adolescents somaticized many of their feelings, but several were ill or had chronic conditions, infections, and/or asthma that required treatment, monitoring, and/or prescriptions. The community organizer in Vega Baja explained that survivors numbered the days since Hurricane Maria struck on September 20, 2018, as a way of marking the passage of time and the dramatic effect that it has had on their way of life (indexicality).

The community organizer’s perspective was much broader since, as a teacher, she had been drawn into rescue and recovery efforts to help her students and, by extension their families, and was outwardly focused on others and events occurring around her rather than how she herself was impacted by the storm. She recounted that being a teacher who could not teach because of the disruption caused by evacuations, relocations, lack of power, lack of toilet and handwashing facilities, and the inability to provide children with lunch, meant her job had become teaching and advocating for her community. This was only one example of reflexivity by teachers, who were the coordinators for many of the mission sites the team visited. Along with nurses, physicians, and pharmacists from La Universidad de Puerto Rico, they organized local community missions and medical and social service resource centers in Rio Piedras, Caserio Manuel Pérez, and Adjuntas.

Community organizers in Ciales, Morovis, Guayanbo, and Loiza, the majority of who were school principals and teachers, prepared space in the schools for the arrival of the mission teams, despite ongoing issues with communication systems. Most missions, except those in the hardest hit areas and the housing projects, saw 50–60 patients per session in pop-up clinics. When turnout was low, teams were dispatched to the homes of those determined to be in need by the coordinators, and services were provided out of the back of the mission vans in the streets (reflexivity).

Nursing professors at UPR facilitated visits in their health information center and a women’s center. They also directed teams to El Caserio Manuel Pérez accompanied by community health worker escorts from the local public health service familiar with the patients and the situations that required further assessment, supplies, and medications. The coordinators also assumed responsibility for seeing that the patients in need of follow-up services would be directed to local resources for ongoing care (autonomy).

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n An Ethnographic Review of Rescue, Recovery, Climate, and Social Justice in Puerto Rico Some patients, such as the homebound, frail elderly, and mothers and/or grandmothers with several young children, required more time and attention. Nurses did group teaching and counseling for children, and nurses and social workers worked on relaxation, stress management, and assessment of younger children in classrooms and in group settings for behavioral issues and other flags that indicated more in-depth care was needed (autonomy). Mission coordinators (also nurses), were able to assist as needed, and huddles were called by any team member who needed to address flow, a particular patient issue, or concern (reflexivity).

The role and critical contributions of the professional drivers who served as runners for needed supplies, escorts, and translators for those who were not fluent in Spanish, cannot be overstated (reflexivity). Team members debriefed on the drive home, after dinner, and over the course of the mission to process what was working with team development and function, and what needed to be changed or modified. Conflicts were few, but were resolved in a facilitative manner by the mission coordinators (reflexivity). Mission staff purchased and delivered essential supplies and

medications to several patients, using personal funds or money donated by family and friends (reflexivity).

There were some notable, humbling moments when the only thing mission participants could do was listen. Survivors in Vega Baja, a beachfront area without power, clean water, wastewater treatment or disposal, where most houses were severely damaged and uninhabitable on day 127, described almost drowning in the floods and being evacuated by boats to a gymnasium where they slept on cardboard boxes. There was little emotion in the telling, but one survivor held back tears when a mission team on a home visit validated how frightening and difficult the experience must have been. The family considered themselves lucky to be alive, despite losing their home and having to live with an elderly neighbor they’d been caring for without water, power, or communication capabilities. They stated that a typical Puerto Rican heavy rainstorm and street flooding continued to trigger a post-traumatic stress reaction from the family members (reflexivity) (see Figure 4).

Fiure 4: A House That Was Washed Away by Heavy Surf During the Passing of Hurricane Maria in Manati on October 6, 2017, and a Photo Taken of the Beachfront at Vega Baja on March 18, 2018

From “Puerto Rico six months after Hurricane Maria: then and now,” in The Guardian, March 26, 2018. Retrieved from https://www.theguardian. com/artanddesign/2018/mar/26/puerto-rico-six-months-after-hurricanemariathen-and-now

From Vega Baja by the authors, March 18, 2018

Themes Identified in Post-Mission Debriefing and Focus Groups

Limitations of the Study

Post-mission focus groups examined their experiences in post-mission debriefings and identified the following themes: mission participation was premised on “nursing care as it should be,” “direct and uncomplicated by electronic devices and record keeping,” “heart, head, hands,” and the fact that the experiences were “life changing.” One participant commented that “RNs are used to running units in intense and ever-changing situations so they’re the best choice to lead and facilitate relief missions.”

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Limitations of the ethnographic approach for this study identified by the group included:  Overidentification with survivors  Difficulty adjusting to a “normal” work environment upon returning.  Worries and lasting feelings of concern that more could have been done, particularly for fragile, homebound elderly and disabled patients who were poorly connected to care and follow up services. “I felt panicked that the most vulnerable and sickly of the patients we saw would not

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receive follow-up care, even though we transferred information to the community health workers,” said one mission volunteer.

support and care coordination, rehabilitation, physical and occupational therapy.

“When I practice in New York, I always get to see my patients again.

Knowing I couldn’t follow-up myself left me with a feeling of non-closure.

I feel the need to go back to see those same patients at some time in the future,” said one mission member.

 Increased utilization of nurse practitioners and mental health professionals as part of existing public health programs and “wellness centers,” including granting prescriptive authority to address the needs of populations who have difficulty accessing care due to geographic, financial, psychosocial, or physical barriers.

Principles identified by Vernberg (2016) were helpful to team members for incorporating specific strategies for their own emotional issues and coping. Items marked with an asterisk (*) were included in STMM documentation and continuing education requirements of the supporting agencies.  relaxation exercises  calming self-talk  meditation  journaling*  talking with peers for support*

Implications Findings of this study will be used to inform and guide planning, training, debriefing, and the conduct of future missions to Puerto Rico, as well as collaboration with local health departments for educational and health policy initiatives. Ongoing STTMs to Puerto Rico are in progress.

Linkages with academic institutions on the mainland and the National Association of Hispanic Nurses are being developed to work with health professionals and educators at La Universidad de Puerto Rico to explore health policy initiatives that include:  Support of homebound, chronically ill, and medically underserved populations with intense community-based public health nursing

 Mobile vans to provide opportunities for health maintenance, chronic disease management, acute care, well child and women’s health care, as well as a coordinated response to future weather-related emergencies.  Coordination of academic staff and programs in Puerto Rico with students and faculty from mainland schools of nursing, public health, medicine, social work, dentistry, and veterinary medicine for needs assessment and environmental remediation, which includes housing, water, waste and sewage disposal, education, care coordination, and direct care services targeted to individual communities.  Health policy and direct service initiatives to work with residents of Puerto Rico to better enhance their personal preparedness for the aftermath of future weather events.

Conclusion Pitfalls of the ethnographic approach included overidentification with survivors, worries and lasting feelings of concern that more could have been done, particularly for fragile, homebound elderly and disabled patients who were poorly connected to care and follow-up services. Some expressed difficulty adjusting to a “normal” work environment upon their return. Still, the participants stated that the experience was well worth the effort—it’s “nursing care as it should be,” a joy to be giving of your “heart, head, and hands.”

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Sudbury, MA: Jones and Bartlett Learning.

Thompson-Reuters. (2017, September 25). Puerto Rico governor fears humanitarian crisis in wake of Hurricane Maria. Retrieved from https://www.cbc.ca/news/world/puerto-rico-humanitarian-crisisworries-1.4306205 Vernberg, E. M., Hambrick, E. P., Cho, B., & Hendrickson, M. L. (2016). Positive psychology and disaster mental health: Strategies for working with children and adults. Journal of Clinical Psychology, 72(12), 1333-1347.

Vicens, A. (2018, February 12). After the hurricane Puerto Rico’s suicide rates spike. MotherJones.com. Retrieved https://www.motherjones.com/ politics/2018/02/after-the-hurricane-puerto-ricos-suicide-rates-spike/ World Health Organization. (2018). Ethical principles. World Health Organization. Retrieved from http://www.who.int/about/ethics/en/ Zarea, K., Maghsoudi, S., Dashtebozorgi, B., Hghighizadeh, M. H., & Javadi, M. (2014). The Impact of Peplau’s Therapeutic Communication Model on anxiety and depression in patients candidate for coronary artery bypass. Clinical practice and epidemiology in mental health: CP & EMH, 10(159-165). Retrieved from https://doi. org/10.2174/1745017901410010159

Journal of the New York State Nurses Association, Volume 47, Number 1

THE

JOURNAL of the New York State Nurses Association

Call for Papers

The Journal of the New York State Nurses Association is currently seeking papers.

Authors are invited to submit scholarly papers, research studies, brief reports on clinical or educational innovations, and articles of opinion on subjects important to registered nurses. Of particular interest are papers addressing direct care issues. New authors and student authors are encouraged to submit manuscripts for publication.

Information for Authors

For author’s guidelines and submission deadlines, go to the publications area of www.nysna.org or write to journal@nysna.org.

Call for Editorial Board Members Help Promote Nursing Research The Journal of the New York State Nurses Association is currently seeking candidates interested in becoming members of the publication’s Editorial Board.

Members of the Editorial Board are appointed by the NYSNA Board of Directors and serve one 6-year term. They are responsible for guiding the overall editorial direction of The Journal and assuring that the published manuscripts meet appropriate standards through blinded peer review.

Prospective Editorial Board members should be previously published and hold an advanced nursing degree; candidates must also be current members of NYSNA. For more information or to request a nomination form, write to journal@nysna.org.

Journal of the New York State Nurses Association, Volume 47, Number 1

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n WHAT’S NEW

IN HEALTHCARE Literature n Vaccinations in Adults Clinical Practice Guidelines n ACIP, (2020, March 2). Vaccinations in Adults Clinical Practice Guidelines. Medscape.

The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) has released an updated schedule for vaccination in adults, which includes changes for the administration of several vaccines, including those for influenza human papillomavirus (HPV), hepatitis A and B, and meningitis B, as well as the pneumococcal 13-valent conjugate (PCV13) vaccine.

PCV13 Vaccine The PCV13 vaccine is no longer recommended for routine vaccination in immunocompetent adults.

Immunocompromised adults aged 19 years or older: Recommended in adults with immunocompromising conditions, cerebrospinal fluid leak, or cochlear implant.

Immunocompetent adults aged 65 years or older: Need for vaccination based on shared decision making between patient and clinician (i.e., no longer routinely recommended for all adults ≤ 65 years).

Human Papillomavirus Catch-up immunization is recommended in persons aged 15–26 years (previous cutoff age in men was 21 years).

The ACIP advises considering vaccination in some patients aged 27–45 years who have not been adequately vaccinated.

Influenza For the 2019–20 influenza season, routine influenza vaccination is recommended in all persons aged 6 months or older who have no contraindications. In areas with more than one appropriate available option, the ACIP does not recommend any product over another.

Hepatitis A Routine hepatitis A vaccination is recommended in all persons aged 1 year or older who have HIV infection, regardless of their level of immune suppression.

Hepatitis B For hepatitis B vaccine, pregnant women at risk for infection or an adverse infection-related pregnancy outcome have been added to the list of vulnerable patients who may benefit from vaccination.

Whereas older formulations are safe, the ACIP does not recommend the HepB-CpG (Heplisav-B) vaccine during pregnancy because of lacking safety data.

Meningitis B Persons aged 10 years or older who have complement deficiency, who use a complement inhibitor, who have asplenia, or who are microbiologists should receive a meningitis B vaccine dose 1 year following completion of a primary series. Afterward, they should receive booster doses every 2–3 years as long as their risk is elevated.

Vaccination should be discussed with individuals aged 16–23 years, even if they are not at an increased risk for meningococcal disease.

Persons aged 10 years or older who are at increased risk during an outbreak should receive a one-time booster dose if at least one year has elapsed since completion of a meningitis B primary series.

Td/Tdap Vaccine The ACIP now recommends that either the diphtheria and tetanus toxoids (Td) or tetanus and reduced diphtheria toxoids/acellular pertussis (Tdap vaccine) be administered in cases in which just the Td vaccine is currently recommended; that is, for the 10-year booster shot and for tetanus prophylaxis in wound management and the catch-up immunization schedule, including for pregnant women.

Varicella Vaccination against varicella should be considered in individuals with HIV infection who do not have evidence of varicella immunity and whose CD4 counts are ≥ 200 cells/µL.

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n Herbal Compounds Treat Lyme Disease ■ Feng, J., Leone, J., Schweig, S., & Zhang, Y. (2020, 21 February).

Evaluation of natural and botanical medicines for activity against growing and non-growing forms of B. burgdorferi. Frontiers in Med. Retrieved from https://doi.org/10.3389/fmed.2020.00006 Lyme disease is an infectious disease caused by the bacterium Borrelia burgdorferi (B. burgdorferi). The disease spreads to humans through the bite of a tick that carries the bacterium, and it infects an estimated 300,000 people each year in the United States alone.

Currently, healthcare professionals choose between three antibiotics in the treatment of Lyme disease. These are doxycycline, cefuroxime, and amoxicillin.

Sometimes, however, antibiotics are not effective in eradicating all traces of B. burgdorferi from the system, which means that the disease can

persist. When this happens, bacterial cells that have developed antibiotic resistance can continue to proliferate. These are known as persister cells.

Because of this, researchers have been looking into alternative modes of fighting the bacterium, and their first line of inquiry has focused on natural remedies.

Researchers have found that seven natural product extracts at 1% were found to have good activity against the stationary phase B. burgdorferi culture compared to the control antibiotics doxycycline and cefuroxime.

These active botanicals include Cryptolepis sanguinolenta, Juglans nigra (black walnut), Polygonum cuspidatum (Japanese knotweed), Artemisia annua (sweet wormwood), Uncaria tomentosa (cat’s claw), Cistus incanus, and Scutellaria baicalensis (Chinese skullcap).

n Use of Hair Dye and Hair Straighteners Are Correlated with Breast Cancer ■ NIH/National Institute of Environmental Health Sciences. (2019, December 3).

Hair dye and chemical straightener use and breast cancer risk in a large US population of black and white women. International Journal of Cancer.

DOI: 10.1002/ijc.32738 Use of permanent hair dye or hair straightening chemicals were both associated with a higher risk for breast cancer than “never use”—and the risks are particularly pronounced among black women, a new analysis of a 50,000-participant study shows.

n Breast Cancer Drugs May Severely Inflame Lungs, the FDA Warns ■ Mulcahy, N. (2019). Breast cancer drugs may severely inflame lungs, FDA warns. Medscape. Retrieved from https://www.medscape.com/ viewarticle/918408 The U.S. Food and Drug Administration (FDA) issued a warning on September 13, 2019, that the commonly prescribed breast cancer therapies known as cyclin-dependent kinase 4/6 (CDK 4/6) inhibitors may cause rare but severe inflammation of the lungs.

Healthcare professionals are advised to monitor patients on these drugs regularly for pulmonary symptoms indicative of interstitial lung disease (ILD) and/or pneumonitis, such as hypoxia, cough, dyspnea, or interstitial

infiltrates on radiologic exams in patients.

Professionals should interrupt CDK 4/6 inhibitor treatment in patients who have new or worsening respiratory symptoms, and permanently discontinue treatment in patients with severe ILD and/or pneumonitis.

Specific risk factors for severe lung inflammation among patients on these drugs have not been identified.

The overall benefit of CDK 4/6 inhibitors is still greater than the risks when used as prescribed, the FDA says. CDK 4/6 inhibitors have been shown to improve patients’ progression-free survival.

n FDA Clears Faster Diagnostic Test for MRSA ■ Brooks, M. (2019). FDA clears faster diagnostic test for MRSA. Medscape. Retrieved from https://www.medscape.com/viewarticle/922233 In 2017, there were more than 323,000 cases of methicillin-resistant Staphylococcus aureus (MRSA) in hospitalized patients and more than 10,000 deaths, according to the U.S. Centers for Disease Control and Prevention.

On December 5, 2019, the US Food and Drug Administration (FDA) approved a new, faster diagnostic test based on bacterial viability and a novel technology to detect MRSA bacterial colonization, a common cause of hospital-acquired infections.

60

The cobas vivoDx MRSA test uses a new bacteriophage technology based on bioluminescence to detect MRSA from nasal swab samples in as few as 5 hours compared with 24 to 48 hours for conventional cultures.

The cobas vivoDx MRSA test adds a new tool in the fight to prevent and control MRSA in high-risk settings.

In performance testing, the cobas vivoDx MRSA test correctly identified MRSA in about 90% of samples where MRSA was present and correctly identified no MRSA in 98.6% of samples free of MRSA.

Journal of the New York State Nurses Association, Volume 47, Number 1

n CE Activity: Growth Through the Storm: Perinatal Nurses’ Experiences of Hurricane Sandy

Thank you for your participation in “Growth Through the Storm: Perinatal Nurses’ Experiences of Hurricane Sandy,” a new 1.0 contact hour continuing education (CE) activity offered by NYSNA. NYSNA members and nonmembers are invited to take part in this activity; you do not need to be a resident of New York State.

INSTRUCTIONS In order to receive contact hours for this educational activity, participants are to read the article presented in this issue of the Journal, complete and return the post-test, evaluation form, and earn 70% or better on the post-test.

This activity is free to NYSNA members and $10 for nonmembers.

Participants can pay by check (made out to NYSNA) or credit card.

The completed answer sheet and evaluation form may be emailed, mailed, or faxed back to NYSNA; please see the evaluation form for more information.

The New York State Nurses Association is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

NYSNA wishes to disclose that no commercial support was received for this educational activity.

All planners and authors involved with the development of this independent study have declared that they have no vested interests.

NYSNA program planners and authors declare that they have no conflict of interest in this program.

OBJECTIVES Upon completion of the article, the reader should be able to: 1. Understand positive aspects of the lived experience of perinatal nurses caring for patients following a natural disaster that nurses can incorporate into future disaster responses.

2. Identify the need for disaster plans in a practice setting that includes nursing input, adequate training, preparation, and the availability of supplies.

Please answer either True or False to the questions below. Remember to complete the answer sheet by putting the letter of your corresponding answer next to the question number. Each question has only one correct answer.

The 1.0 contact hour for this program will be offered until July 30, 2023.

1) Facilities should have disaster plans; nurses should have input into the plan; there should be adequate training and preparation, and the facility should have needed supplies on hand. These were all factors that were identified as potentially influencing a nurse’s intention to stay with or choose to work with an organization. a. True b. False 2) Informal role changes, interdisciplinary teamwork, and positive nursing leadership contributed to an experience of solidarity.

INTRODUCTION

a. True

Disasters such as Hurricane Sandy cause considerable economic, environmental, and human loss. Sometimes adversity gives way to opportunity, as was the case with the perinatal nurses who provided all that nursing can offer during a difficult time. They tried to normalize birth events for families, mitigating the families’ potentially adverse consequences to stressful birth experiences. They recalled inserting epidurals with flashlights, holding onto newborns while walking down stairs with rain boots and gear on, hoping the baby wouldn’t fall. Through a phenomenologically designed study, the narratives of nurses who cared for mothers, babies, and their families during Hurricane Sandy revealed six theme clusters. Professional experiences during the disaster included role changes, confidence, use of technology, group solidarity, perceptions about preparedness and working through uncertainty that enhanced interpersonal relationships, and personal growth.

b. False

LEARNING OUTCOME Participants will be able to recognize how role adaptation, group cohesion, communication, and preparedness plans are important for both the nurses and the care of patients during a disaster response in perinatal or other clinical practice setting.

3) Resilience did not contribute to perinatal nurses’ ability to adapt to a stressful, evolving situation. a. True b. False 4) New York City did not have a formal evacuation plan for newborns prior to Hurricane Sandy, but positive changes can come from adverse events when individuals learn from these experiences and advocate for change. a. True b. False 5) Team unity and support were valuable behaviors that helped nurses carry out their role in the aftermath of Hurricane Sandy. a. True b. False

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6) Working under the conditions of limited and sometimes nonexistent technology revealed the tendency toward overreliance on technology and the need to use intuition and utilize astute assessment skills. a. True

9) Colaizzi’s method of data analysis helps researchers identify themes from research subjects’ interviews. a. True b. False

b. False 7) Novice nurses were less distressed than senior nurses when they were transferred to a different facility. a. True b. False

10) T he model of post-traumatic growth conceptualizes reduced interpersonal relationships as a result of a challenging life event. a. True b. False

8) Inexperienced nurses had a greater increase in confidence and professional growth than senior nurses after providing perinatal care for mothers and families under disaster conditions. a. True b. False

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Journal of the New York State Nurses Association, Volume 47, Number 1

The Journal of the New York State Nurses Association, Vol. 47, No.1

Answer Sheet Growth Through the Storm: Perinatal Nurses’ Experiences of Hurricane Sandy Note: The contact hour for this program will be offered until July 30, 2023.

Please print legibly and verify that all information is correct.

First Name: MI: Last Name: Street Address: City: State: Zip Code: Daytime Phone Number (Include area code): Email: Profession: NYSNA Member # (if applicable):

Currently Licensed in NY state? Y / N (Circle one)

License #:

License State:

ACTIVITY FEE: Free for NYSNA members/$10 nonmembers PAYMENT METHOD Check—payable to New York State Nurses Association (please include “Journal CE” and your CE code D6F880 on your check).

Credit Card:

Mastercard

Visa

Discover

American Express

Card Number: Name:

Expiration Date:

Signature:

/

CVV# Date:

/

/

Please print your answers in the spaces provided below. There is only one answer for each question.

1._________ 2._________ 3._________ 4._________ 5. _________

6._________ 7._________ 8._________ 9._________ 10._________

Please complete the answer sheet above and course evaluation form on reverse.

Submit both the answer sheet and course evaluation form along with the activity fee for processing.

Mail to: NYSNA, attn. Nursing Education and Practice Dept.

131 West 33rd Street, 4th Floor, NY, NY 10001 Or email to: education@nysna.org or fax to: 212-785-0429 Journal of the New York State Nurses Association, Volume 47, Number 1

63

Learning Activity Evaluation Growth Through the Storm: Perinatal Nurses’ Experiences of Hurricane Sandy

Please use the following scale to rate statements 1-7 below:

Poor

Fair

Good

Very Good Excellent

1. The content fulfills the overall purpose of the CE Activity.

2. The content fulfills each of the CE Activity objectives.

3. The CE Activity subject matter is current and accurate.

4. The material presented is clear and understandable.

5. The teaching/learning method is effective.

6. The test is clear and the answers are appropriately covered in the CE Activity.

7. How would you rate this CE Activity overall?

8. Time to complete the entire CE Activity and the test?

____ Hours (enter 0–99) _____ Minutes (enter 0–59)

9. Was this course fair, balanced, and free of commercial bias?

Yes / No (Circle one)

10. Comments:

11. Do you have any suggestions about how we can improve this CE Activity?

64

Journal of the New York State Nurses Association, Volume 47, Number 1

n CE Activity: A Literature Review and Opinion Article on the Nurse Practitioner’s Role in Certification and Management of Medical Marijuana Thank you for your participation in “A Literature Review and Opinion Article on the Nurse Practitioner’s Role in Certification and Management of Medical Marijuana,” a new 1 (one) contact hour continuing education (CE) activity offered by NYSNA. NYSNA members and nonmembers are invited to take part in this activity; you do not need to be a resident of New York State.

INSTRUCTIONS In order to receive contact hours for this educational activity, participants are to read the article presented in this issue of the Journal, complete and return the post-test, evaluation form, and earn 70% or better on the post-test.

This activity is free to NYSNA members and $10 for nonmembers.

Participants can pay by check (made out to NYSNA) or credit card. The completed answer sheet and evaluation form may be emailed, mailed, or faxed back to NYSNA; please see the evaluation form for more information.

The New York State Nurses Association is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

NYSNA wishes to disclose that no commercial support was received for this educational activity.

All planners and authors involved with the development of this independent study have declared that they have no vested interests.

NYSNA program planners and authors declare that they have no conflict of interest in this program.

OBJECTIVES Upon completion of the article, the reader should be able to: 1. Identify the difference between “prescription” and “certification” of medical marijuana.

2. Recognize the need for the development of standards for medical marijuana use and potentially help expand the use of medical marijuana to more states.

3. Understand the process that exists for nurse practitioners to become credentialed to certify patients for medicinal marijuana use.

Please answer either True or False to the questions below. Remember to complete the answer sheet by putting the letter of your corresponding answer next to the question number. Each question has only one correct answer.

The 1.0 contact hour for this program will be offered until July 30, 2023.

1) There are some states that have legalized the use of marijuana for specific medical conditions, including the State of New York. Some patients are hesitant to use medical marijuana because of the conflict between state and federal law. a. True b. False 2) In New York State, only nurse practitioners who have taken a course on the use of medical marijuana approved by NYS Department of Health and who have registered with the NYS Medical Marijuana Program can certify a patient’s diagnosis which allows for the use of cannabis products. Not all states allow nurse practitioners to certify patients, even with adequate education. a. True

INTRODUCTION The nurse practitioner’s role in certifying patients for medical marijuana use was examined by performing a literature review of recent publications on the topic. Federal classification of marijuana as a Schedule I controlled substance has conflicted with states’ intentions to extend the medical benefits of this substance. The process for becoming credentialed to certify patients for medical marijuana use is different state by state. Patients with a variety of diagnoses suffer from symptoms that may be alleviated by marijuana. Because of the physician shortage, many regions rely on nurse practitioners to take the role of the primary care provider. Given their holistic approach and quality provider-patient relationships, nurse practitioners are well situated to offer this unique treatment to patients with life-threatening or debilitating illnesses.

LEARNING OUTCOME Participants will understand the role of the nurse practitioner for patients' use of medical marijuana and the advances that are required for broader use.

b. False 3) In New York State, a close personal provider-patient relationship lasting no less than six months must exist in order for a practitioner to certify a patient for medical marijuana use. a. True b. False 4) The (DEA) Drug Enforcement Agency continues to classify medical marijuana as a Schedule I narcotic in the United States, which limits human research necessary to understand its effects, uses, and benefits. Professional organizations, such as the American Nurses Association, recommend a status change from a Schedule I to a Schedule II substance in order to allow evidence-based research to develop standards in medical marijuana use. a. True b. False

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5) Research consistently finds lower mortality rates from opioid overdose in states permitting medical marijuana use than in states that do not allow its use. a. True b. False 6) In New York State, while physicians and nurse practitioners can certify marijuana for patient use, there are different processes for obtaining certification. a. True b. False 7) Inconsistencies between federal and state governmental laws and policies have obstructed the advancement of the science of marijuana.

This has contributed to unclear safety standards and clinical guidelines.

8) All 50 states have legalized marijuana for medical reasons. a. True b. False 9) There is a plethora of research addressing the nurse practitioner’s role in linking patients in need with medical marijuana. a. True b. False 10) All states where use of medical marijuana is legal allow for nurse practitioners and physician assistants to certify patients. a. True b. False

a. True b. False

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Journal of the New York State Nurses Association, Volume 47, Number 1

The Journal of the New York State Nurses Association, Vol. 47, No.1

Answer Sheet A Literature Review and Opinion Article on the Nurse Practitioner’s Role in Certification and Management of Medical Marijuana Note: The contact hour for this program will be offered until July 30, 2023.

Please print legibly and verify that all information is correct.

First Name: MI: Last Name: Street Address: City: State: Zip Code: Daytime Phone Number (Include area code): Email: Profession: NYSNA Member # (if applicable):

Currently Licensed in NY state? Y / N (Circle one)

License #:

License State:

ACTIVITY FEE: Free for NYSNA members/$10 nonmembers PAYMENT METHOD Check—payable to New York State Nurses Association (Please include “Journal CE” and your CE code D6F880 on your check).

Credit card:

Mastercard

Visa

Discover

American Express

Card Number: Name:

Expiration Date:

Signature:

/

CVV# Date:

/

/

Please print your answers in the spaces provided below. There is only one answer for each question.

1._________ 2._________ 3._________ 4._________ 5. _________

6._________ 7._________ 8._________ 9._________ 10._________

Please complete the answer sheet above and course evaluation form on reverse.

Submit both the answer sheet and course evaluation form along with the activity fee for processing.

Mail to: NYSNA, attn. Nursing Education and Practice Dept.

131 West 33rd Street, 4th Floor, NY, NY 10001 Or email to: education@nysna.org or fax to: 212-785-0429

Journal of the New York State Nurses Association, Volume 47, Number 1

67

Learning Activity Evaluation A Literature Review and Opinion Article on the Nurse Practitioner’s Role in Certification and Management of Medical Marijuana

Please use the following scale to rate statements 1-7 below:

Poor

Fair

Good

Very Good Excellent

1. The content fulfills the overall purpose of the CE Activity.

2. The content fulfills each of the CE Activity objectives.

3. The CE Activity subject matter is current and accurate.

4. The material presented is clear and understandable.

5. The teaching/learning method is effective.

6. The test is clear and the answers are appropriately covered in the CE Activity.

7. How would you rate this CE Activity overall?

8. Time to complete the entire CE Activity and the test?

____ Hours (enter 0–99) _____ Minutes (enter 0–59)

9. Was this course fair, balanced, and free of commercial bias?

Yes / No (Circle one)

10. Comments:

11. Do you have any suggestions about how we can improve this CE Activity?

68

Journal of the New York State Nurses Association, Volume 47, Number 1

n CE Activity: Nurses’ Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue Thank you for your participation in “Nurses’ Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue,” a new 1.0 contact hour continuing education (CE) activity offered by NYSNA. NYSNA members and nonmembers are invited to take part in this activity; you do not need to be a resident of New York State.

INSTRUCTIONS In order to receive contact hours for this educational activity, participants are to read the article presented in this issue of the Journal, complete and return the post-test, evaluation form, and earn 70% or better on the post-test.

This activity is free to NYSNA members and $10 for nonmembers.

Participants can pay by check (made out to NYSNA) or credit card. The completed answer sheet and evaluation form may be emailed, mailed, or faxed back to NYSNA; please see the evaluation form for more information.

OBJECTIVES Upon completion of the article, the reader should be able to: 1. Distinguish among concepts related to workplace stress and efforts to improve it.

2. Understand that nurse burnout can lead to decreased effectiveness on the job, decreased job performance, poor interdisciplinary relations, and poor patient outcomes.

3. Recognize symptoms of stress, burnout, compassion fatigue, and depression in themselves and colleagues.

4. Identify stress management strategies for use at work and in personal life.

5. Understand the role of unions in recognizing and mitigating workplace stress, burnout, compassion fatigue, and depression while increasing work satisfaction.

The New York State Nurses Association is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

Please answer either True or False to the questions below. Remember to complete the answer sheet by putting the letter of your corresponding answer next to the question number. Each question has only one correct answer.

NYSNA wishes to disclose that no commercial support was received for this educational activity.

The 1.0 contact hour for this program will be offered until July 30, 2023.

All planners and authors involved with the development of this independent study have declared that they have no vested interests.

1) The Institute for Healthcare Improvement recognizes that joy at work improves population health and reduces healthcare costs.

NYSNA program planners and authors declare that they have no conflict of interest in this program.

INTRODUCTION Work-related stress can lead to burnout and physical and psychologic consequences. While national initiatives and laws that address worker health have been implemented, studies continue to reflect the high level of stress, burnout, compassion fatigue, and depression that nurses experience on a routine and daily basis. The approach to recognizing and treating work-related stress has shifted from being a problem the individual employee experiences and must fix to one which the National Institute for Occupational Safety and Health requires the employer to address in order to protect worker health and well-being. The Institute for Healthcare Improvement has made the improvement of patients’ lives their highest priority. They seek to improve population health, reduce the per capita cost of health care, and enhance the patient experience. To accomplish these aims, they recognize that a strong and healthy workforce is needed. Sources of work-related stress for nurses include higher patient-to-nurse ratios as well as the physical and mental demands of the work. There are several stress management techniques, coping strategies, and social activities that help nurses deal with stressful situations.

Unions can have an important role in mitigating workplace stress, burnout, compassion fatigue, and depression by helping nurses address the extrinsic causes of stress and develop the intrinsic resilience of nurses.

LEARNING OUTCOMES Participants will be able to identify ways in which unions can help nurses in the workplace reduce and/or mitigate workplace stress, burnout, depression, and compassion fatigue.

a. True b. False 2) High levels of stress at work can cause workers to experience anxiety, depression, hypertension, heart attacks, and compassion fatigue. a. True b. False 3) Burnout, depression, and compassion fatigue are more likely caused by a nurse’s personal life than by the healthcare environment and its policies, procedures, and healthcare delivery. a. True b. False 4) Resilience is the experience of feeling the contentment, joy, and pleasure that is derived from being able to do one’s work or when caring for another. a. True b. False 5) Nurses have twice the rate of depression than members of the general population. a. True b. False

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6) Collective bargaining can be used to negotiate improvements in staffing that would have a positive impact on stress, and to negotiate mental health days as a legitimate reason to utilize a sick day. a. True

9) Higher patient-to-nurse ratios cause emotional exhaustion, depersonalization, and place patients at risk for preventable harm. a. True b. False

b. False 7) Qigong is an alternative healing modality that can help staff achieve decreases in stress, burnout, and depression. a. True b. False

10) Significant reduction in nurse burnout can result in thousands fewer nosocomial infections and millions of dollars in hospital cost savings. a. True b. False

8) The most commonly cited adverse health effect experienced by nurses in a recent survey of more than 1,000 nurses was sleep disruption. a. True b. False

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Journal of the New York State Nurses Association, Volume 47, Number 1

The Journal of the New York State Nurses Association, Vol. 47, No.1

Answer Sheet Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue Note: The contact hour for this program will be offered until July 30, 2023.

Please print legibly and verify that all information is correct.

First Name: MI: Last Name: Street Address: City: State: Zip Code: Daytime Phone Number (Include area code): Email: Profession: NYSNA Member # (if applicable):

Currently Licensed in NY state? Y / N (Circle one)

License #:

License State:

ACTIVITY FEE: Free for NYSNA members/$10 nonmembers PAYMENT METHOD Check—payable to New York State Nurses Association (Please include “Journal CE” and your CE code D6F880 on your check).

Credit card:

Mastercard

Visa

Discover

American Express

Card Number: Name:

Expiration Date:

Signature:

/

CVV# Date:

/

/

Please print your answers in the spaces provided below. There is only one answer for each question.

1._________ 6._________ 2._________ 7._________ 3._________ 8._________ 4._________ 9._________ 5. _________ 10._________

Please complete the answer sheet above and course evaluation form on reverse.

Submit both the answer sheet and course evaluation form along with the activity fee for processing.

Mail to: NYSNA, attn. Nursing Education and Practice Dept.

131 West 33rd Street, 4th Floor, NY, NY 10001 Or email to: education@nysna.org or fax to: 212-785-0429

Journal of the New York State Nurses Association, Volume 47, Number 1

71

Learning Activity Evaluation Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue

Please use the following scale to rate statements 1-7 below:

Poor

Fair

Good

Very Good Excellent

1. The content fulfills the overall purpose of the CE Activity.

2. The content fulfills each of the CE Activity objectives.

3. The CE Activity subject matter is current and accurate.

4. The material presented is clear and understandable.

5. The teaching/learning method is effective.

6. The test is clear and the answers are appropriately covered in the CE Activity.

7. How would you rate this CE Activity overall?

8. Time to complete the entire CE Activity and the test?

____ Hours (enter 0–99) _____ Minutes (enter 0–59)

9. Was this course fair, balanced, and free of commercial bias?

Yes / No (Circle one)

10. Comments:

11. Do you have any suggestions about how we can improve this CE Activity?

72

Journal of the New York State Nurses Association, Volume 47, Number 1

n CE Activity: In the Aftermath of Maria: An Ethnographic Review of Rescue, Recovery, Climate, and Social Justice in Puerto Rico

Thank you for your participation in “In the Aftermath of Maria: An Ethnographic Review of Rescue, Recovery, Climate, and Social Justice in Puerto Rico,” a new 1.0 contact hour continuing education (CE) activity offered by NYSNA. NYSNA members and nonmembers are invited to take part in this activity; you do not need to be a resident of New York State.

LEARNING OUTCOME Participants will be able to contextualize the experiences of individuals and communities following a disaster to better support communities in need when volunteering to assist in community-based disaster relief efforts.

OBJECTIVES

INSTRUCTIONS This activity is free to NYSNA members and $10 for nonmembers.

Participants can pay by check (made out to NYSNA) or credit card.

The completed answer sheet and evaluation form may be emailed, mailed, or faxed back to NYSNA; please see the evaluation form for more information.

The New York State Nurses Association is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

NYSNA wishes to disclose that no commercial support was received for this educational activity.

All planners and authors involved with the development of this independent study have declared that they have no vested interests.

NYSNA program planners and authors declare that they have no conflict of interest in this program.

INTRODUCTION During 2017, three major storms struck the United States in quick succession. This left FEMA overextended and unable to provide adequate relief to Puerto Rico following Hurricane Maria. In September 2017, Hurricane Maria devastated the entire island of Puerto Rico, causing mass long-term power outages and thousands of deaths, the final count of which is still uncertain. All infrastructure, including the island’s health system was incapacitated. While the death toll is staggering, so was the reduced quality of life experienced by Puerto Ricans, particularly for the poor and vulnerable. FEMA’s response was woefully inadequate. A year and a half later, 10% of the island’s residents were still without power, neighborhoods remained hazardous, and disease and stressful living conditions were prevalent. Long-term utilities’ failure and business and school closures made return to normal life impossible for many residents. In several areas, suicide rates increased, doubling in Aguadilla. Three successive shortterm medical missions, in cooperation with the New York State Nurses Association, New York RN, Healthcare Without Borders, local Puerto Rican community organizers, and La Universidad de Puerto Rico were launched to support medical needs in devastated communities. The third mission, consisting of nurse practitioners, registered nurses, medical doctors, social workers, and two NYC Transit Workers Union drivers, sought to provide short-term medical care while employing a disruptive design method and force field analysis in order to create and activate long-standing positive impact in Puerto Rico.

Upon completion of the article, the reader should be able to: 1. Describe ways participants of a short-term medical mission can prepare for and cope with the experience of a medical mission.

2. Identify strategies nurses use to facilitate disaster response, recovery, social justice work, and knowledge development.

3. Understand how disaster outcomes are influenced by complex societal and political factors.

4. Recognize how the unique professional perspective of nurses is critical in supporting communities and health systems locally and globally before, during, and after a disaster.

Please answer either True or False to the questions below. Remember to complete the answer sheet by putting the letter of your corresponding answer next to the question number. Each question has only one correct answer.

The 1.0 contact hour for this program will be offered until July 30, 2023.

1) Resolving conflict between medical mission participants as soon as possible keeps the team cohesive and can be fostered by the medical mission nurse leader. a. True b. False 2) The majority of patient encounters were for mental health, pointing to the need for mobile vans to provide opportunities for health maintenance, chronic disease management, and acute care. a. True b. False 3) Debriefing is a method used to maintain an effective medical team and mitigate emotional risk during rescue operations. a. True b. False

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4) A theme identified for short term medical missions is that RNs, because of the work they do every day, are the best choice to lead and facilitate short-term medical missions. a. True

8) Almost 1.5 years after the hurricane, 10% of residents remained without power. a. True b. False

b. False 5) According to Peplau’s theory, nurses on short-term medical missions can relieve a patient’s moderate anxiety by answering questions and by attempting to remove stress from an environment. a. True

9) Ethical principles such as autonomy, beneficence, non-malfeasance, justice, veracity, and fidelity can be suspended during a global health response. a. True b. False

b. False 6) Relaxation techniques and preparation for the short-term medical mission aid in the ability of team members to cope. a. True

10) A third of the deaths in Puerto Rico from Hurricane Maria were caused by interrupted or delayed medical care. a. True b. False

b. False 7) FEMA underestimated how much food and fresh water it would need and how hard it would be to get additional supplies as they prepared for a more local tsunami instead of a major hurricane devastating the entire island. a. True b. False

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Journal of the New York State Nurses Association, Volume 47, Number 1

The Journal of the New York State Nurses Association, Vol. 47, No.1

Answer Sheet In the Aftermath of Maria: An Ethnographic Review of Rescue, Recovery, Climate, and Social Justice in Puerto Rico Note: The contact hour for this program will be offered until July 30, 2023.

Please print legibly and verify that all information is correct.

First Name: MI: Last Name: Street Address: City: State: Zip Code: Daytime Phone Number (Include area code): Email: Profession: NYSNA Member # (if applicable):

Currently Licensed in NY state? Y / N (Circle one)

License #:

License State:

ACTIVITY FEE: Free for NYSNA members/$10 nonmembers PAYMENT METHOD Check—payable to New York State Nurses Association (please include “Journal CE” and your CE code D6F880 on your check).

Credit card:

Mastercard

Visa

Discover

American Express

Card Number: Name:

Expiration Date:

Signature:

/

CVV# Date:

/

/

Please print your answers in the spaces provided below. There is only one answer for each question.

1._________ 6._________ 2._________ 7._________ 3._________ 8._________ 4._________ 9._________ 5. _________ 10._________

Please complete the answer sheet above and course evaluation form on reverse.

Submit both the answer sheet and course evaluation form along with the activity fee for processing.

Mail to: NYSNA, attn. Nursing Education and Practice Dept.

131 West 33rd Street, 4th Floor, NY, NY 10001 Or email to: education@nysna.org or fax to: 212-785-0429 Journal of the New York State Nurses Association, Volume 47, Number 1

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Learning Activity Evaluation In the Aftermath of Maria: An Ethnographic Review of Rescue, Recovery, Climate, and Social Justice in Puerto Rico

Please use the following scale to rate statements 1-7 below:

Poor

Fair

Good

Very Good Excellent

1. The content fulfills the overall purpose of the CE Activity.

2. The content fulfills each of the CE Activity objectives.

3. The CE Activity subject matter is current and accurate.

4. The material presented is clear and understandable.

5. The teaching/learning method is effective.

6. The test is clear and the answers are appropriately covered in the CE Activity.

7. How would you rate this CE Activity overall?

8. Time to complete the entire CE Activity and the test?

____ Hours (enter 0–99) _____ Minutes (enter 0–59)

9. Was this course fair, balanced, and free of commercial bias?

Yes / No (Circle one)

10. Comments:

11. Do you have any suggestions about how we can improve this CE Activity?

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Journal of the New York State Nurses Association, Volume 47, Number 1

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