NYSNA Journal Vol 46 No 1.

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JOURNAL of the New York State Nurses Association

Volume 46, Number 1

n E ditorial: Maximizing the Efficacy of Short-Term Medical Missions and Oral Care

by Meredith King-Jensen, MSN, MA, RN; Dana Deravin Carr, DrPH, MS, MPH, RN-BC, CCM; Caroline Mosca, PhD, RN; Coreen Simmons, PhD(c), DNP, MSN/MPH, RN; Audrey GrahamO’Gilvie, DNP, ACNS-BC; Anne Bové, MSN, RN-BC, CCRN, ANP; and Seth Dressekie, MSN, RN, PMHNP-BC

n Effects of Dental Hygiene on Cognition by Zakiya Folami Moss, MS, FNP-C, CMSRN; Melanie B. Kalman, PhD, RN, CNS, Corresponding Author

n Ethical and Legal Guidelines for Short-Term Medical Missions Post Natural Disaster

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

n What’s New in the Healthcare Literature n CE Activity: Effects of Dental Hygiene on Cognition


JOURNAL of the New York State Nurses Association

Volume 46, Number 1

n Editorial: Maximizing the Efficacy of Short-Term Medical Missions ............................ 3 and Oral Care

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

n Effects of Dental Hygiene on Cognition............................................................................................................ 5 by Zakiya Folami Moss, MS, FNP-C, CMSRN; Melanie B. Kalman, PhD, RN, CNS, Corresponding Author

n Ethical and Legal Guidelines for Short-Term Medical Missions ........................................ 8 Post Natural Disaster

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

n What’s New in the Healthcare Literature.......................................................................................................38 n CE Activity: Effects of Dental Hygiene on Cognition......................................................................42


JOURNAL of the New York State Nurses Association


The Journal of the New York State Nurses Association Editorial Board

Audrey Graham-O’Gilvie, DNP, ACNS-BC Chief of Education/Designated Learning Officer Veterans Administration Hudson Valley Health Care System Montrose, NY Dana Deravin Carr, DrPH, MS, MPH, RN-BC, CCM Senior Care Manager/Transitions Care Coordinator Jacobi Medical Center Bronx, NY

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

Meredith King-Jensen, MSN, MA, RN Quality Management Specialist Veteran’s Administration Bronx, NY

Seth Dressekie, MSN, RN, PMHNP-BC Human Resources Administration NYC Dept. of Social Services New York, NY

Coreen Simmons, PhD(c), DNP, MSN/MPH, RN Professional Nursing Practice Coordinator James J. Peters VA Medical Center Bronx, NY


Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD, Co-Managing Editor Lucille Contreras Sollazzo, BSN, RN-BC, NPD, Co-Managing Editor Debra Grebert, Editorial Assistant

Anne Bové, MSN, RN-BC, CCRN, ANP Clinical Instructor New York, NY

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; E-mail 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 are 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.

©2018 All Rights Reserved  The New York State Nurses Association


Journal of the New York State Nurses Association, Volume 46, Number 1

n EDITORIAL Maximizing the Efficacy of Short-Term Medical Missions and Oral Care In this issue of The Journal, insights into the correlation between dental hygiene and cognition, as well as recommendations on how to create a systematic approach to coordinate and evaluate the performance of short-term medical missions (STMMs), will be shared. STMMs provide a valuable international service to vulnerable populations, but the outcomes of STMMs are difficult to assess. Employing this approach to the delivery of care may lead to fewer wasted resources, higher patient satisfaction, and an overall improvement in the efficacy and efficiency of medical care provided by STMM healthcare providers. In the wake of Sandy, Katrina, Harvey, Irma, Maria, and other recent hurricanes, the number and popularity of STMMs has continued to rise, with considerable financial and human resources being expended to provide these services. Despite the number and scope of STMMs, a paucity of literature on the subject exists. Without proper evaluation standards, issues of patient safety, quality control, and impact assessment are difficult to assess, since STMMs are often organized and privately funded without restrictions. This can potentially lead to disastrous results in the field, such as a fractured hip when working with an elderly dementia patient—an outcome that would result in a malpractice suit in most Western countries. Most STMMs lack an objective means of measuring their performance, as well as formalized problem-solving techniques and methods for improvement. Thus, a standardized means to coordinate and evaluate STMMs is an important and needed step toward quality improvement in international healthcare. As global populations age, care to the elderly, and thus to an increasing population of patients with dementia, will only grow. When elderly patients live through a natural disaster, employing the comfort-focused approach modeled on the groundbreaking program developed by Beatitudes Campus becomes increasingly difficult, particularly if the patient suffers from dementia. Practitioners on STMMs must rely on alternative healing modalities to help alleviate suffering and provide comfort for people with advanced dementia. Helping patients with dementia accomplish activities of daily living, such as brushing their teeth, can be undertaken in a familiar environment or one that will provide environmental cues about the activity. Brushing is sometimes difficult because a person with dementia may forget how or why it is important. Preventive care is more than just good hygiene; it is essential to overall health. Proper care of the mouth and teeth can help prevent eating difficulties, pain, and digestive problems. Poor oral care increases not only the risk of respiratory infection and pneumonia in the elderly dementia patient, it is a predisposing factor of dementia itself. Through the application of guidelines outlined in “Ethical and Legal Guidelines for Short-Term Medical Missions Post Natural Disaster,” professionals will be able to engage in quality improvement and self-analysis of their missions. We hope this approach will be beneficial to both the providers and recipients of STMM care.

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

Journal of the New York State Nurses Association, Volume 46, Number 1


Effects of Dental Hygiene on Cognition Zakiya Folami Moss, MSN, FNP-C, RN, CMSRN Melanie B. Kalman, PhD, RN, CNS, Corresponding Author

n A bstract The population in the United States is aging. One concern for many geriatric patients is the possibility of dementia. Recent studies have found a link between Porphyromonas gingivalis (P. gingivalis) and a decrease in cognition. The link between oral hygiene and Alzheimer’s disease (AD) is new; therefore, limited research was found. Seven studies were reviewed; all studies found that there was a connection between poor oral health and a decrease in cognition. There is also evidence of a correlation between P. gingivalis and Alzheimer’s. Based on the type of studies and small sample size, more research is needed. Nurses are well positioned to counsel geriatric patients and/or their caregivers on the importance of good oral care. Counseling would be an easy, inexpensive, and quick intervention that decreases the risk of a dementia.

Effects of Dental Hygiene on Cognition The population in the United States is aging and with aging comes an increase in chronic disease. In 2011, the oldest Baby Boomers turned 65 years old. As this large cohort continues to age, there will be an increased need for healthcare and healthcare providers. One issue that many geriatric patients are fearful of is the possibility of cognitive impairment or the possibility of dementia or Alzheimer’s disease (AD). Cognitive impairment is common in the geriatric population, and, according to some studies, may lead to dementia and Alzheimer’s disease (Giuli, 2016; Kang, 2016; Zimmermann, Zimmermann, de Oliveira Marques, & Gome, 2015). Dementia is defined as a general term for a decline in one’s mental ability significant enough to impede basic daily activities. Alzheimer’s disease is one type of dementia that interferes with memory, thinking, and behavior (Alzheimer’s Association, 2016). The disease process of Alzheimer’s is thought to consist of atrophy and an abnormal accumulation of protein in the brain. According to the National Center for Biotechnology Information (NCBI, 2016), this disease accounts for 60 to 80% of all dementias.

Though Alzheimer’s is not a part of the normal aging process, advanced age is a major risk factor for Alzheimer’s disease. The prevalence of Alzheimer’s within the United States continues to grow as the U.S. geriatric population continues to increase. The Alzheimer’s Association reported that in the year 2015 the prevalence of Americans with Alzheimer’s was approximately 5.3 million. Researchers have found that one in nine people over 65 years of age develop Alzheimer’s and that 81% of people older than 75 years of age have Alzheimer’s (NCBI). The NCBI found that African Americans are twice as likely, and Hispanics are one and a half as likely to develop Alzheimer’s than white Americans. Due to the aging of the U.S. population, the incidence of Alzheimer’s is expected to increase. Individuals with Alzheimer’s disease are more likely to have coexisting medical conditions that further complicate the disease process and the financial burden (Alzheimer’s Association, 2016). One coexisting condition common among older adults in the United States is periodontitis. According to the National Institute of Dental and Craniofacial Research, a division of the National Institute of Health, 70.1% of adults 65 years and older have periodontal disease (2016).

Zakiya Folami Moss, MSN, FNP-C, RN, CMSRN, Family Nurse Practitioner, St. Joseph’s Health, Syracuse, New York Melanie B. Kalman, PhD, RN, CNS, SUNY Upstate Medical University College of Nursing, Syracuse, New York, Corresponding Author


Effects of Dental Hygiene on Cognition

Synthesis of Literature The link between oral hygiene and cognition is new; therefore, limited research was found. A total of 28 articles resulted from a search of CINAHL Plus, ProQuest Nursing, MEDLINE, the OVID Nursing Journal Collection, and PubMed. Seven of these studies related to decreased cognition, dementia, or AD and poor oral hygiene, and all seven studies were reviewed. Stein, Kryscio, Desrosiers, Donegan, and Gibb (2010) conducted a secondary analysis (N = 678) using data from the Nun Study, a longitudinal Canadian study on aging and Alzheimer’s disease. The aim of the study was to determine if loss of teeth and the apolipoprotein E�4 allele is related to memory loss. The apolipoprotein E�4 allele is a genetic risk factor for Alzheimer’s. The study found an association between loss of teeth and an increased risk of dementia. Ide et al. (2016) also analyzed data from the Nun Study, developed a model, and confirmed Stein et al. findings. The number of subjects (N = 144) in this study was different than the Stein study. Peres et al. (2015), using data from a cohort study in Brazil (N = 1705), examined if tooth loss was associated with loss of cognitive function. All subjects were over the age of 60 years. Researchers also developed a model and found that a fewer number of teeth was associated (OR 3.3; 95% CI [1.2, 9.3]) with greater cognitive impairment. Kaye et al. (2010) conducted a prospective study and also examined if tooth loss was related to cognitive decline. The subjects included 597 men (age range 28 to 70 years) living in the community, who attended a Veterans Affairs dental clinic. Oral exams to assess periodontal disease were conducted approximately every three years. They corroborated that loss of teeth and periodontal disease were associated with cognitive decline. In fact, “for each tooth lost per decade, the risk of a low cognitive test score increased 9 to 12%” (p. 5). Noble, Scarmeas, and Papapanou (2009), using data from a national cross-sectional study of older adults (NHANES-III), tested the relationship between Poryphyromonas gingivalis (P. gingivalis), an oral bacterium, and cognitive tests. The sample included 2,355 participants over the age of 60. Using logistic regression models, they found that those with the highest level of P. gingivalis had the most cognitive deficits as shown by delayed verbal recall (OR 2.89, 95% CI [1.14, 7.29]) and impaired subtraction (OR 1.95, 95% CI [1.22, 3.11]). Chróinín et al., in a cross-sectional study, examined hospitalized patients over 70 years (N = 202) in order to explore if there was an association between poor oral health and specific medical comorbidities and abnormalities. To assess for poor oral health, they completed the Oral Health Assessment Tool (OHAT). Using a multivariate analysis, dementias (OR 2.29, p = .02) were associated with the highest third of OHAT. The highest scores equaled poorer oral health. The results showed that there was an association between poor oral health and dementias. Finally, Poole, Singhrao, Kesavalu, Curtis, and Crean (2013), in a descriptive study, investigated periodontal disease bacteria (P. gingivalis among other bacteria) in post mortem brain tissue. They examined 10 brains from patients with Alzheimer’s and 10 brains from patients without Alzheimer’s. Those patients with Alzheimer’s were more likely to have P. gingivalis (p = 0.029). In the seven studies variables included P. gingivalis, number of teeth, cognition, dementia, Alzheimer’s disease, and age. Four studies (Ide et al., 2016; Noble et al., 2009; Peres, 2015; Stein et al., 2010) used a Delayed Word Recall test to assess cognition. One study (Kaye, 2010) used the 6

Poor oral health is correlated with cardiovascular diseases, stroke, diabetes mellitus, and aspiration pneumonia.

MiniMental State Examination and a Spatial Copying Task. Two of the seven studies linked poor oral health, specifically P. gingivalis, to Alzheimer’s disease (Ide et al., 2016; Poole et al., 2013), one found P. gingivalis linked to dementia, and the other four found decreased cognition associated with periodontal disease (Kaye, 2010; Noble et al., 2009; Peres, 2015; Stein et al., 2010). All seven found that there was a decrease in cognition in those with poor oral health. One study found the decrease occurred within six months of the onset of poor oral hygiene (Ide). P. gingivalis can cause inflammation. Lipopolysaccharide (LPS), a byproduct of P. gingivalis, can access the brain. It is hypothesized that when LPS accesses the brain it results in an inflammatory response, possibly causing Alzheimer’s disease. While a direct cause-and-effect relationship has not been established between dental health and dementia, a review of the available literature suggests a link between the two variables. Limitations of this study include a small sample size and that some of the studies used self-reporting by the subjects.

Clinical Implications and Conclusion Good oral care is important for maintaining healthy teeth, gums, and tongue. Poor oral health is correlated with cardiovascular diseases, stroke, diabetes mellitus, and aspiration pneumonia (Zenthöfer et al., 2016). New evidence demonstrates that poor oral care may increase the risk of dementia. Yet, Medicare does not reimburse for routine dental services (Medicare, 2018). Oral health screenings must be emphasized for the elderly. Since those with dementia might not be able to perform their own oral care, caregivers must be educated on the importance of and the proper technique in performing oral care. In the geriatric patient population at risk for developing dementia, primary care health providers should reiterate to caregivers why good oral care is important and demonstrate the proper technique for providing good oral care. In nursing homes, nurses should also teach caregivers the proper technique for good oral care (Zenthöfer et al., 2016). While teaching good oral care is within the domain of dental professionals, those in the healthcare field should know the basics of educating patients and caregivers about oral care and its importance. The education is an easy, quick, and inexpensive intervention. Based on the American Dental Association guidelines (American Dental Association, 2016), the incidence of periodontal disease can be decreased, ultimately with the hope of decreasing the number of individuals with dementia. With basic education, patients can learn that oral care has positive long-term effects. Although further research is needed, current research demonstrates a positive association between poor oral hygiene and dementia. The topic is new and the research available is exploratory, therefore the topic has great potential to develop in the future.

Journal of the New York State Nurses Association, Volume 46, Number 1

Effects of Dental Hygiene on Cognition


n References Alzheimer’s Association. (2016). Alzheimer’s disease facts and figures. Alzheimer’s & Dementia, pp. 11, 332. American Dental Association. (2016). Gum Disease. Mouthhealty.org, http://www.mouthhealthy.org/en/az-topics/g/gum-disease

National Institute of Dental and Craniofacial Research. (2016). Retrieved from https://www.nidcr.nih.gov/OralHealth/Topics/GumDiseases/ PeriodontalGumDisease.htm ?_ga=1.182919663.878490602.141528 3936#pageContent

Chróinín, D. N., Montalto, A., Jahromi, S., Ingham, N., Beveridge, A., Foltyn, P., & Dent, B. (2016). Oral health status is associated with common medical comorbidities in older hospital inpatients. Journal of the American Geriatrics Society, 64, 1696-1700. doi:10.1111/jgs.14247

Noble, J. M., Scarmeas, N., & Papapanou, P. N. (2009). Poor Oral Health as a Chronic, Potentially Modifiable Dementia Risk Factor: Review of the Literature. Current Neurology and Neuroscience Reports, 13, 383-90. doi:10.1007/s11910-013-0384-x

Giuli, C., Fabbietti, P., Paoloni C., Pensieri, M., Lattanzio, F., & Postacchini, D. (2016). Subjective memory complaints in Italian elderly with mild cognitive impairment: Implication of psychological status. Neurological Sciences, 37, 1153–1157. doi:10.1007/s10072-016-2553-6)

Peres, M. A., Bastos, J. L., Watt, R. G., Xavier, A. J., Barbato, P. R., & D’Orsi E. (2015). Tooth loss is associated with severe cognitive impairment among older people: Findings from a population-based study in Brazil. Aging & Mental Health, 19, 876-884. doi.org/10.1080/13607863.20 14.977770

Ide, M., Harris, M., Stevens, A., Sussams, R., Hopkins, V., Culliford, D., Fuller, J. et al. (2016). Periodontitis and cognitive decline in Alzheimer’s disease, PLOS One. 1-9. doi:10.1371/journal.pone.0151081 Kang, J-Y., Kim, C-H., Sung E-J., Shin, H-C., Shin, W-J., & Jung, K-H. (2016). The Association between frailty and cognition in elderly women. Korean Journal of Family Medicine, 37, 164–170. doi: 10.4082/ kjfm.2016.37.3.164 Kaye, E. K., Valencia, V., Baba, N., Spiro III A., Dietrich, T., & Garcia, R. I. (2010). Tooth loss and periodontal disease predict poor cognitive function in older men. Journal of American Geriatric Society. 58, 713–718. doi:10.1111/j.1532-5415.2010.02788.x Medicare. (2018). Your Medicare coverage: Dental services. Retrieved from https://www.medicare.gov/coverage/dental-services.html National Center for Biotechnology Information (NCBI). (2016). Panel on Race, Ethnicity, and Health in Later Life. Retrieved from https://www. ncbi.nlm.nih.gov/books/NBK25535/

Poole, S., Singhrao, S. K., Kesavalu, L., Curtis, M. A., & Crean, S. (2013). Determining the presence of periodontopathic virulence factors in short-term postmortem Alzheimer’s disease grain tissue. Journal of Alzheimer’s Disease, 36, 665-677. doi:10.3233/JAD- 121918 Stein, P. S., Kryscio, R. J., Desrosiers, M., Donegan, S. J., & Gibbs, M. B. (2010). Tooth loss, apolipoprotein E, and decline in delayed word recall. Journal of Dental Research, 89, 473-77. doi:10.1177/0022034509357881 Zenthöfer, A., Meyer-Kühling, I., Hufeland, A. L., Schröder, J., Cabrera, T., Baumgart, D., Rammelsberg, P., & Hassel, A. J. (2016). Carers’ education improves oral health of older people suffering from dementia—results of an intervention study. Clinical Interventions in Aging, 11, 1755-1762. Zimmermann, I. M., Zimmermann, R. D., de Oliveira Marques, A. P., & Gome, E. C. C. (2015). Factors associated with cognitive impairment in institutionalized elderly individuals: Integrative review. Journal of Nursing UFPE online, Recife, 9, 1320-28.

Journal of the New York State Nurses Association, Volume 46, Number 1


Ethical and Legal Guidelines for Short-Term Medical Missions Post Natural Disaster Carol Lynn Esposito, EdD, JD, MS, RN-BC,NPD Lucille Contreras Sollazzo, BSN, RN-BC, NPD

n A bstract In the past decade, international volunteerism on short-term medical missions (STMMs) has been on the rise in the wake of natural and/or man-made disasters. Although there are ethical and legal principles governing medical and nursing practice within each country and/or state, concerns have been raised regarding the limited oversight of the care provided by healthcare professionals on STMMs. Currently, there are no government agencies or accrediting bodies that assess the organization, coordination, practice, and follow-up provisions of such missions, or the scope and impact of STMM care. Neither are there governing bodies that have established standards of care for such missions. These facts raise ethical concerns, especially because the patient population comprises some of the world’s most vulnerable people. This article discusses the various legal and ethical challenges surrounding STMM volunteering. Organizational and practice guidelines within legal and ethical frameworks governing STMMs are discussed.

Introduction More than 1.3 billion people across the world lack access to basic healthcare services (Colduvell, 2017). Similarly, the health and welfare of more than eight million people across the northern hemisphere have suffered in the wake of five hurricanes in 2017: Harvey, Jose, Irma, Maria, and Nate (Maines, 2018).

of resiliency efforts post disaster. Lessons learned supported the notions that post-disaster emergency planning must include protocols to coordinate backup staffing, delineation of services that must continue post disaster, clear guidelines to coordinate resources across local and community agencies, and training for transitioning into unfamiliar disaster response roles (FEMA, 2013; Shipp Hilts, Mack, Eidson, Nguyen, & Birkhead, 2016).

While responses to Hurricane Sandy, Hurricane Katrina, other hurricanes, tornadoes, and floods have played an integral role in reducing the suffering of survivors and supporting communities toward recovery, post-action reviews highlighted that medical missions and their associated costs brought many challenges to the forefront for recovery teams, including a broader, sustained analysis on the need for adaptation and the importance

The United Nations has articulated that international medical volunteering on short-term medical missions (STMMS) involves three fundamental characteristics: (a) the action is not primarily undertaken for financial reward; (b) the action is undertaken without compulsion (i.e., voluntarily) and, finally; (c) the action is of benefit to someone other than the volunteer (Elgafi, 2014; United Nations, 2001).

Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD, is currently employed by the New York State Nurses Association as the Director of Nursing Education and Practice. She also has held positions at NYSNA as the Director of Labor Education, and as Associate Director in NYSNA’s Labor Program. An attorney with over 25 years of experience in the field of medical and nursing malpractice, and 30 years as a nursing educator, Dr. Esposito has been adjunct faculty at Adelphi University School of Nursing; Hofstra University; University College of Continuing Education; Dowling College; and Excelsior College School of Nursing. She has authored many articles and text materials on subjects of interest to nurses. Lucille Contreras Sollazzo, BSN, RN-BC, NPD, is currently employed by the New York State Nurses Association as the Associate Director of Nursing Education and Practice. She also has held positions at NYSNA as the Associate Director in NYSNA’s Labor Program and as a Nursing Representative in the Labor Program. A nurse for over 30 years, having worked in many specialty areas and is currently close to completion of a Masters Degree in Nursing Education. 8

Journal of the New York State Nurses Association, Volume 46, Number 1

Ethical and Legal Guidelines for Short-Term Medical Missions Post Natural Disaster

Although medical missions were originally developed by religious organizations to provide basic healthcare to needy global populations while working to improve the community, an increasing number of organizations now arrange short-term medical missions (STMMs) to developing nations and populations suffering in the aftermaths of man-made and/or natural disasters, such as the massive hurricanes of 2017: Harvey, Jose, Irma, Maria, and Nate. Generally, volunteers are motivated by a sense of charity, compassion, and altruism toward those who belong to the more vulnerable and disadvantaged groups in society (Malay, 2017). Increasingly, however, there has been a growing body of literature criticizing the ethics and sustainable outcomes of STMMs (Elgafi, 2014; Hawkins, 2013; Hensley, 2016; Lal & Spence, 2016; Malay, 2017; Martiniuk, Manouchehrian, Negin, & Zwi, 2012; Stuart & Grippon, 2016; Umapathi, Choon Yong, Lan Yong, & Teik Lee, 2015). Common criticisms of STMMs noted in the literature include, but are not limited to: unsafe practices; lack of consideration for cultural differences; lack of coordination with the host country; lack of flexibility on the part of the practitioner; lack of documentation and data for analysis and follow-up care; inadequate knowledge; unfamiliarity with the native language and customs; inadequate resources; limited accountability; unavailability of or inadequate health records, health histories, laboratory testing, emergency services, examination facilities, and referral services for follow-up; and that the self-satisfaction felt by providers on STMMs does not justify the cost of the ventures (Elgafi, 2014; Hassler, 2017; Hawkins, 2013; Hensley, 2016; Malay, 2017). Improving the outcomes of STMMs requires increased organizational and practice guidelines and an awareness of the potential pitfalls. With awareness and planning, the positive impact of STMMs in providing needed services to resource-limited countries can exceed the potential negative impact (Hawkins, 2013). Guidelines and forms for STMMs created by the New York State Nurses Association (NYSNA) are included in this article.

Evidenced-Based Qualitative Descriptive Approach On January 21, 2018, a multidisciplinary team of professionals consisting of one MD, one DNP, one clinical sociologist, and six registered professional nurses from New York embarked on a STMM to Puerto Rico in the aftermath of hurricanes Maria and Irma. The team was also comprised of two New York Transport Worker Union (TWU) drivers who transported the professionals to various sites post-hurricane (Centro Comunal Los Naranjos in Vega Baja, Ramon Torres Elementary School in Morovis, Manuel A. Perez Housing in San Juan, Guayaba Dulce at Adjuntas, Concepcion Perez Elementary School in Ciales, Margarita Janer Palacios High School in Guaynabo, Escuela Segunda Unidad Nueva in Loiza, and the Jesús T. Piñero Intermediate Escuela in Manati). Four of the RNs, the drivers, the DNP, and the MD spoke fluent Spanish. Furthermore, three of the RNs and the two drivers were of Puerto Rican heritage. The ages of the volunteers ranged from 30 to 70 years old, and the volunteers had a combined total of two years of service on previous humanitarian missions. Their personal clinical areas of concentration included school health, maternal and child health, public health, critical care, pediatrics, and mental/behavioral health. Each of the two drivers had military experience as well.


Improving the outcomes of STMMs requires increased organizational and practice guidelines, and an awareness of the potential pitfalls.

The team provided ‘responsive’ care to 348 patients, or responded to a wide range of medical conditions from primary care to responding to injuries and severe mental trauma (PTSD, depression, anxiety, suicide ideation), maternal and child care, vaccine distribution, wound care, and infectious disease management. Care was dispensed on site at temporary clinics, in women’s clinics already established within Puerto Rico, in homes, and in makeshift Red Cross settings. Key medical conditions addressed by this team included skin infections, hypertension, diabetes, gynecological care, rashes, asthma, PTSD, depression, anxiety, suicide ideation, coordinating dental care, prescription refill requests, anxiety, and skin ulcers. A qualitative descriptive approach was used in this study. Volunteers were involved in a 4-hour, semi-structured, in-depth interview one month following the completion of their STMM. Interviews were tape-recorded, transcribed, described, and interpreted using Morse and Field’s (1996) approach so that the social situations and human experiences of the volunteer healthcare professionals could be captured and better understood. Analysis of the emergent themes informed the guidelines for evidencedbased practices on STMMs.

Interpretive Analysis In attempting to describe and understand life experience, a phenomenological, philosophical, and methodological evidenced-based practice approach was used. Phenomenological research can be understood as the study of lived experience (Morse & Richards, 2002). Phenomenology attempts to uncover the essential structures and meanings of a particular lived experience as it is experienced by a particular group, thus clarifying and illuminating a deeper understanding of that lived experience (Laverty, 2003; Rich, Graham, Taket, & Shelly, 2013; Van Manen, 1997). Phenomenology, through a process of description, reflection, and communication assists us in identifying meanings of a lived experience (Morse & Richards, 2002; Rich et al., 2013).

Medical Missions To Puerto Rico: What Healthcare Professionals Need To Know Ethical Considerations Motivations for engaging in STMMs are many and varied. Sometimes there is an overwhelming health need present, which can easily be addressed by a healthcare professional on a short-term program. Sometimes there is an overwhelming need and desire on the part of the practitioner to help those who are less fortunate. Sometimes there is an invitation from a host

Journal of the New York State Nurses Association, Volume 46, Number 1


n Ethical and Legal Guidelines for Short-Term Medical Missions Post Natural Disaster partner country/state with a specific goal that can be better achieved with participation from a multidisciplinary team of healthcare professionals. Whatever the motivations, healthcare practitioners must remember that there are ethical obligations and accountabilities when engaging in STMMs (Elgafi, 2014).

These and other 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, 2014).

Human Rights Obligations and Ethical Codes of Conduct for Healthcare Professionals

Likewise, all healthcare professionals are bound by common ethical principles that should be respected while interacting with individuals, families, and communities during 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 (remaining competent in your practice); justice (treating all patients equally and fairly); veracity (telling the truth in all communications with the patient); totality and integrity (considering the entire person when deciding what therapies, treatments, medications, or procedures a patient should receive); and fidelity (maintaining commitments based on virtue of caring) (Muse, 2018; Silva & Ludwick, 1999).

Numerous human rights treaties, as well as other international legal instruments, contain provisions aimed at protecting the right to health and healthcare. For example, the Declaration of Alma-Ata (1978) affirmed the following: Primary healthcare is essential healthcare based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation…. It forms an integral part of both the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. The philosophical basis of the Alma-Ata establishes healthcare as a human right, and accessible primary care as a fundamental entitlement to every person, thus closing the gap between the rich and the poor. Consistent with this philosophy are excerpts from the Nurses Code of Ethics (ANA, 2015) (Table 1) and The American Medical Association’s Code of Ethics (2001) (Table 2).

Lastly, the World Health Organization has declared the following ethical principles for healthcare professionals on STMMs (WHO, 2018): 

Integrity: To behave in accordance with ethical principles and act in good faith, intellectual honesty, and fairness.

ccountability: To take responsibility for one’s actions, decisions, A and their consequences.

I ndependence and impartiality: To conduct oneself with the interests of [the coordinating organization] and to ensure that

Table 1: Nurses Code of Ethics Provision 1

The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.

Provision 2

The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population.

Provision 3

The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.

Provision 4

The nurse has authority, accountability and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to provide optimal patient care.

Table 2: Physicians Code of Ethics


Provision 1

A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.

Provision 4

A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.

Provision 8

A physician shall, while caring for a patient, regard responsibility to the patient as paramount.

Provision 9

A physician shall support access to medical care for all people.

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Ethical and Legal Guidelines for Short-Term Medical Missions Post Natural Disaster

personal views and convictions do not compromise ethical principles, official duties, or the interests of [the coordinating organization]. 

espect: To respect the dignity, worth, equality, diversity, and R privacy of all persons.

ommitment: To demonstrate a high level of professionalism and C loyalty to the [coordinating organization], its mandate, and objectives.

Legal Considerations A lack of resources; a lack of familiarity with the patient population, the language and the common health problems in the region visited; the shortterm nature of many trips that results in a lack of follow-up; lack of familiarity with host-country standards of practice; and inadequate health records, laboratory testing, emergency services, examination facilities, and referral services can lead to inappropriate treatments and medical malpractice. Limited time with the patient further inhibits the ability to perform a proper health assessment. Student volunteers who are at the early stages of their training may unwittingly take advantage of the unregulated environment in an attempt to practice skills and techniques that may be beyond their scope and level of training (Elgafi, 2014). The International Court of Justice considers that the consequence of an unlawful harmful act is the duty to provide compensation (Elgafi, 2014; Mongelard, 2006). While healthcare professionals can have obligations under international law, virtually none of the laws provides for a mechanism for the enforcement of any liability that may arise, or lays down any obligation for non-state entities to make reparation; they leave it to the states parties to the treaties to choose how to apply the rules (Mongelard, 2006). Generally speaking, however, U.S. tort law principles applicable to Puerto Rican STMMs provide the following guidance: before any healthcare practitioner can be found liable in malpractice, the injured party must show the following three elements:

including high premiums and limited coverage and lack of availability in certain locations. The scope of available policies varies, and coverage can be purchased for both short- and long-term missions (Uejima, 2011). Currently, the most common scenario is one in which the healthcare provider travels without liability coverage (Elgafi, 2014).

Reducing Potential Liability There are a number of best-evidenced, risk-management steps that can be taken to reduce the potentiality of medical malpractice and corporate liability on STMMs. Coordinating organizations and healthcare practitioners should do the following (Elgafi, 2014; Hensley, 2016; Stuart & Grippon, 2016): dhere to the fundamentals of medical ethics, namely autonomy, A beneficence, non-malfeasance, justice, fidelity, veracity, totality, and integrity.  Volunteering practitioners should practice within their scope of practice as defined in their home countries/states.  Volunteering practitioners should undergo pre-deployment screening (including resume review, qualifications check, psychological testing, and verification of prior experience).  Volunteering practitioners should be provided an equipment checklist.  Volunteering practitioners should undergo a structured briefing, including of their legal rights and responsibilities, and a review of the limitations that practitioners can accomplish on a STMM.  Volunteering practitioners should undergo mandatory predeployment educational sessions, including sessions on: 

baseline information on disease prevalence; a n overview of the state of public health in the visiting country/state;  an overview of non-communicable diseases such as heart disease, stroke, cancer, diabetes, and chronic lung diseases, which are becoming more prevalent in world health statistics and the statistics of the host country/state;  social determinants of health;  chronic diseases;  the system of healthcare in effect;  environmental and occupational hazards prevalent;  cultural competence and language;  adult teaching and learning;  communication and conflict resolution techniques; and  disaster-related concepts and strategies aimed at mitigating risks, minimizing impacts, and speeding the process of community recovery in the aftermath of a natural disaster. 

1. The coordinating organization and the healthcare practitioner has a legal duty to conform to a certain standard of care, determined by the reasonably prudent practitioner under similar circumstances principle; 2. the organization and/or healthcare practitioner fails to meet that standard; and 3. an injury has occurred as a direct result of this failure, and there are no intervening cause and/or contributory negligence that can be correlated/contributed to the injury. In certain countries specific legislation covers volunteering or disasters, while in other countries volunteer work is covered by general laws. Only a small number of countries have specific legislation regarding volunteering in emergencies. Notably, the legal position remains largely uncertain, as only a few cases of alleged malpractice have ever been brought before the courts. Additionally, patients in developing countries often have problems with access to justice. Pertinent barrier issues include massive case backlogs, weak judicial institutions, inadequate legal infrastructure, corruption, and other problems endemic in the developing world (Elgafi, 2014).

Volunteering practitioners should debrief on a daily basis.

olunteering practitioners should coordinate with indigenous V healthcare organizations and professionals, and transfer health data so as to ensure consistent follow-up healthcare after the team leaves.

olunteering practitioners should provide teaching to indigenous V healthcare and community health workers (CHWs) to increase their knowledge and skills in the provision of public healthcare.

olunteering practitioners should work in teams, with team roles V clearly delineated and with at least one team member who is an indigenous mentor/volunteer.

Malpractice Insurance Most traditional healthcare professional liability insurance policies do not cover actions abroad and coverage is usually only available in the form of specialized policies. These policies, however, have limitations,


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oordinating organizations should ensure that volunteers follow C standard safety guidelines and work closely with host country providers and translators for improved communication.

oordinating organizations should ensure that there are ample C supplies of medications and equipment that can be obtained from philanthropic organizations, local providers, pharmaceutical companies, and international mission pharmaceutical suppliers.

Medical Missions To Puerto Rico: What Healthcare Professionals Need To Do Addressing Motivational Purposes Spending time examining personal motivations prior to participation on a mission trip should be part of an ethical self-assessment. Reasons for engaging in STMMs vary, and can include the following (Malay, 2017; Smith et al., 2016):

public health;  social determinants of health and health disparities;  chronic diseases;  system of healthcare in effect post-disaster;  environmental and occupational health and hazards prevalent post disaster;  cultural competence and language;  adult teaching and learning (to teach CHWs and patients necessary information);  communication and conflict resolution techniques;  resilience and peer listening training;  overview of CHW roles and goals;  disaster preparedness and recovery; and  mental and behavioral health. 

a recognition of humanitarian needs and a desire to serve those with relatively fewer resources;

a desire for a relationship with people from other cultures and to contribute positively to other groups;

a response to “peer pressure” from colleagues;

resources, barriers, and health systems

a response to a broad interest in North America on “paying back” for perceived previous grievances;

and in collaboration with local health

a response to an interest in global health;

a recognition that the individual patient is a citizen of the world;

a recognition of the benefits and potential long-term impact of capacity building in less developed nations or in places following natural disasters;

a personal invitation to go with someone;

a cademic benefits to a participant’s curriculum vitae, participation in research, and international networking;

a desire to experience missions and other cultures, or a personal connection to a country or culture; and

personal enjoyment of adventure or travel.

Nursing and medical practice in countries with limited resources requires a focus on healthcare education. One of the best gifts a healthcare professional can give is the knowledge that they have. Motivation for participating in a healthcare mission experience should result in personal growth for the participant along with valuable service to the host community. Purely self-centered motivations are improper. This is the basis of ethical practice.

Addressing Practice Concerns Specialized knowledge and healthcare experience are essential, but not sufficient for volunteering on a STMM. An understanding of the local cultures and customs, local language, socioeconomic climate, political, and environmental setting of the visiting country/state is imperative, as it is likely to be vastly different from those of the developed world (Lal & Spence, 2014). It is for these reasons that the NYSNA required each 12

volunteer to undergo a qualifications interview, along with 10 hours of mandatory educational sessions on the following topics as part of NYSNA’s mission objectives:

Working with awareness of the local

care teams promotes independence and empowerment within local communities.

Addressing Organizational Mission Concerns Working with awareness of the local resources, barriers, and health systems, and in collaboration with local healthcare teams promotes independence and empowerment within local communities. Indeed, nursing and healthcare practitioner “power” can only be accomplished when the outcome of volunteer intervention results in increasing dependence on the services that can be provided by the visiting country/state, thus overriding the humanistic ethical values of beneficence, which often initially attracts many healthcare professionals into voluntary service (Lal & Spence, 2014). It is for these reasons that the New York State Nurses Association requires each volunteer and team to develop several written plans of action aimed at returning independence and power back to the local community health workers and healthcare system. In keeping with the NYSNA mission statement and overarching goals, the following are examples of the action plans that were required by NYSNA from the volunteering healthcare professionals in preparation for and strategizing about the health conditions that were encountered during the STMM (see figures 1-6).

Nysna Medical Mission Statement For Stmm The NYSNA, in coordinating short-term medical missions, aims to develop a plan of action to build, sustain, and improve the state’s capability to prepare for, protect against, respond to, recover from, and mitigate disaster-related hazards.

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Ethical and Legal Guidelines for Short-Term Medical Missions Post Natural Disaster

NYSNA Overarching Goals for STMM


and health needs following disasters. o develop and train CHWs who are members of the community T (affected by the disaster).  To teach RNs how to prepare CHWs to enhance public health and contribute to community resilience.  To train RNs to train CHWs in disaster-related components aimed at mitigating risks, minimizing impacts, and speeding the process of community recovery.

o optimally prepare the volunteer RN and NYSNA as an organization T as a resource for effective performance in rapid response to disaster.  To serve underresourced communities affected by large-scale disasters and that are at high risk for adverse outcomes due to pre-existing disparities in health, access to service, and environmental health.  To make the community aware of the sequential steps that could be taken at individual and organizational levels to respond to disasters

NYSNA Health Care Practitioner Action Plan Templates: Puerto Rico Figure 1: Community Needs Assessment

What Are the Overall Needs of the Community Social Determinants of Health: No refrigeration, electricity, poverty high, literacy low, single-mother households Common Risk Factors to Adverse Health: Hurricane causes damage to infrastructure, water access, and increases stress/PTSD, depression, anxiety, roads, housing, food Access to Clean Water: Limited, sewage in oceans Electrical Services: Major outages Garbage Disposal: Disrupted/vermin present, mosquitos, major pile-ups Roadways: No traffic signals, roads eroded, flooded during rain, blockages Access to Food Supplies: Fast food only

Figure 2: Community Health Assessment Plan

What are the Healthcare Conditions of the Populous within the Community

Figure 3: Community Barriers Assessment Analysis

What are the barriers to Addressing the Healthcare Conditions of the Populous within the Community

Primary issue: Storm damage to infrastructure

Primary Issue: Lack of continuity of care/coordination of care

Cardiovascular Diseases and Hypertension: High incidence in adult population/obesity

Cardiovascular diseases and Hypertension: Poor food choices due to lack of refrigeration

Diabetes: High incidence in adults/children

Diabetes: Primary injectable insulin not available, no refrigeration

Cancers (Breast, Cervix, Prostate, Colon): Lack of screening (mammography, colon, PAP)

Cancers (Breast, Cervix, Prostate, Colon): No screening cites post disaster

Asthma/Respiratory: Low ICS/controller use

Asthma and Other Respiratory issues: Molds and airborne triggers due to storm

Obesity: Prevalent due to lack of fresh foods

Obesity: Lack of access to low cost fruits, veg.

Tobacco: Increased use due to stress/PTSD, depression

Tobacco: Increased use due to PTSD, stress

Alcohol: Increased use due to stress/PTSD, depression

Alcohol: Increased use due to PTSD, stress

Conjunctivitis: Higher incidence in children

Conjunctivitis: Contaminated water

Skin Integrity: Rashes, cuts, fungal infections

Skin Integrity: Pollutions, molds, contaminated water

Other: Home pts with comorbidities/domestic violence

Other: Oral care, no dentists, sugary foods

Nutrition: Salty, sugary foods; poor dentition

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n Ethical and Legal Guidelines for Short-Term Medical Missions Post Natural Disaster

Figure 4: Community Follow-Up Plan What Patient Intake Handouts (Exhibit F) Were Provided to the Community Members? Social Determinants of Health: See other Cardiovascular Diseases/HTN: Non-compliance with medication protocols, see other Diabetes/Nutrition: See other Cancers (Breast, Cervix, Prostate, Colon): see other Asthma/Respiratory: See other Obesity: Limited access to fresh food, see other Tobacco: Poor dentition, see other Alcohol: See other Conjunctivitis: See other Skin Integrity: Eczema, ringworm, scabies, bedsores, fungal infections, foot care Other: Access to follow-up care was assured via affiliation with the University of Puerto Rico schools of nursing, MD, Pharmacy, CHWs, and visiting mobile units. Churches provided food.

Figure 5: Indigenous Healthcare Worker Plan Indigenous Healthcare Worker Methods for Improving Patient Access to Recommended Healthcare Condition Resources ďƒ† Teaching the populous how to navigate & access community services and other resources (Exhibits A, C) Primary Issue: NYSNA engages with CHWs, University of Puerto Rico, local churches, makes provisions for mobile vans Cardiovascular diseases/HTN: Mobile vans Diabetes: Mobile vans, churches, clinics Cancers: Mobile vans equipped with X-rays Asthma and Other Respiratory Issues: Counseling Obesity: Counseling Tobacco: Counseling Alcohol: Counseling

Figure 6: Educational Materials to Patient Plan Resources Recommended for the Healthcare Condition Primary Issue: FEMA, CHW, SON Cardiovascular Diseases and Hypertension: Counseling, NYSNA flyers*, student RNs/MD/Pharm. Diabetes: NYSNA flyers, nutrition, DM Cancers (Breast, Cervix, Prostate, Colon): Mobile van X-ray units Asthma/Respiratory: Billboards on major roadways, TV ads, counseling Obesity: NYSNA flyers Tobacco: Posters in clinics, billboards Alcohol: Posters in clinics, billboards Conjunctivitis: NYSNA flyers, handwashing, counseling Skin Integrity: NYSNA flyers Other: Public health dentists lists, schools, community centers, women’s shelters Nutrition: Counseling, NYSNA flyers


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*NYSNA informational flyers were distributed on the following topics: handwashing, sterilizing water, portable water, foods and their benefits, physical vs. emotional hunger, foods for diabetics, benefits of carrots, how to read a food label, conjunctivitis, mosquitos, Zika, influenza, impetigo, and head lice.

One of the participants also included the following thoughts: “If you can’t live in the rough, you will be miserable. You will be living in primitive facilities; the climate was hot and humid with no air conditioning. You can’t be a prima donna and survive this STMM.”

Characteristics of the Volunteering Healthcare Professional in the Role of Practicing Professional

Characteristics of the Volunteering Healthcare Professional in the Role of Leader

When an organization, such as NYSNA, wants to take on a humanitarian mission, it needs competent (see exhibits B, C) volunteers. Organizations need to clearly define requirements for people who want to volunteer and to provide training that helps members of the medical mission not only understand what to expect in the host country, but to build cultural competency skills that will enable them to help the host community build its own capacity (Stuard & Grippon, 2016).

Generally speaking, there are three main types of leadership styles: (a) Directive (also known as autocratic, or “the boss” type); (b) Participative (sometimes referred to as inclusive, or the “I’m in there with you” type); and (c) Delegative (also known as laissez faire, or the “I assign it out, I don’t do this” type).

Medical volunteers are primarily agents of change. Entrepreneur Michael Lindenmayer (2013), the cofounder and CEO of Toilet Hackers, a social enterprise focused on securing 100% sanitation for the 2.6 billion people living without a toilet or water, sanitation, and hygiene (WASH) skills, articulates the following: The standard volunteer is insufficient. Mediocrity is lethal. It erodes persistent problem-solving, disruptive innovation and tenacity. More dangerous than the standard volunteer are the ones that either suck up your time and energy or those that show-up without generating any results. (p. E1) In keeping with Lindenmayer’s (2013) seven criteria for awesome volunteers, NYSNA’s written application (see exhibit G) and individual interviews were structured to ensure that each volunteer possessed the following attributes: 1. Be results driven (the ability to achieve results without complaint or excuses); 2. mix professionalism with passion (the ability to bring enthusiasm and professionalism to the cause in the face of diversity and limited resources); 3. have a collaborative tribal mindset (the ability to look for and include each other and other organizations/people in on the partnership); 4. be committed (the ability to say what you are going to do and then make it happen); 5. be a constant champion (the purpose and passion for the mission insinuates into their every thought, word, and action); 6. b e energetic (others feel pumped up when in their presence); and 7. have the right motivation (the ability to think less about what they personally can get from the experience of volunteering and more about what they can contribute to the mission). Following a post-mission interview, the participants of the Puerto Rico mission added the following list of characteristics needed from the volunteer practitioner: ood clinical skills G The ability to follow the directions of the leader without conflict  Self-esteem  The ability to take risks and make decisions without asking permission  Competence in working on a multigenerational team (Umapathi et al., 2015)  

One leadership style, the autocratic or directive style, has repeatedly been shown in the literature to be the least successful and the least productive. Reasons for the autocrat’s less-than-optimal leadership abilities are numerous. Perhaps it’s because autocrats are usually perceived as arrogant, bossy people; sometimes, however, they may simply be new and eager to impart change and set the world on fire. Other times, autocrats think they will be able to quickly command respect based upon their station in life, but the reality is that respect usually needs to be earned and, of course, earning anything worthwhile takes time, time that is usually unavailable on STMMs (Becker’s Hospital Review, 2015). The participants of the Puerto Rican medical mission confirmed these sentiments. One person said, “Frankly, it’s the nurses who should be leading these teams. The MDs think they are the boss because they’re doctors, but they don’t have what it takes to lead these teams. This work needs a holistic perspective; MDs are just not trained in that perspective.” Another participant added, “MDs are elitist and they wear blinders regarding social and behavioral determinants of health. They just don’t get that you have to incorporate these, along with holistic care strategies and principles, into the healthcare of the population.” The literature supports the notion that nurses as leaders have developed their own particular style of leadership: an integrated, “whole health” approach to care (Soltis-Jarrett et al., 2017). “Rather than viewing the healthcare from a body system or organ perspective, nurses traditionally conceptualize individuals as human beings that are more than the sum of their bodies and parts” (Soltis-Jarrett et. al, 2017, p. 436). Viewing the person as a whole and as a part of the family and community, nurse leaders will assess and care for a patient rooted in a physical, psychological, sociocultural, and spiritual perspective (Soltis-Jarrett et al., 2017). David Norris (2016), an anesthesiologist and CEO of the Center for Professional Business Development, offers the following as key characteristics for a successful mission leader: Effective decision-making. Effective leaders don’t procrastinate and they aren’t worried about making a bad decision.  Mission and purpose driven. Each and every decision or action is based upon the “what and why” of their mission and purpose.  Set valid goals and objectives.  Find and solve the real problems and have laser-like focus. Good leaders do not let superficial issues distract them. They continually reassess where their focus is and whether or not they have taken their eye off the ball. 

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ave a growth mindset. Effective leaders recognize they might H not have all the answers. They will approach problems with an open mind, refraining from making assumptions, and use questions to either confirm or reject what they objectively observe.

Following a post-mission interview, the participants of the Puerto Rican mission added the following list of characteristics needed from the volunteer taking on the role of lead practitioner. “They need (a) strong organizational skills; (b) to be able to relate to the patient; (c) to be a calm person; (d) to be able to match the volunteer healthcare professional to the task at hand; (e) to be willing to take the lead and do the work as well; (f) to have the strategic skill set to organize what should be done at any given time; (g) to be able to build relationships with local agencies and organizations; and (h) to be able to treat other team members as equals.”

FINDINGS Analysis of the participant’s accounts of the Puerto Rico STMM during the post-mission interviews revealed the following sequential themes: 1. Scope of practice concerns 2. Team building concerns 3. Resource concerns 4. Feeling anxious: adjusting to cultural and environmental differences concerns 5. Ethical concerns

Addressing Scope of Practice Concerns “I was worried about what I could and could not do. I’m an RN, and when I was triaging, I wondered if I could initiate treatment before the patient was seen by the DNP or MD from our group. The orientation we received taught us what our practice boundaries are,” said one RN. “I relied on the collective expertise of the other members of my team when I was unsure about my role, meds, dosages, and management of complex cases. There was no access to any online resources in most areas,” said another STMM volunteer. Providers with narrow scopes of practice in their home countries could potentially see a medical mission environment as an appropriate opportunity to practice more generally or to gain new skills. Significant harm can result when visiting medical teams assume that any medical care they provide is better than what the local community can provide or is better than no intervention (Frellick, 2018; Stuart, 2015). Local leaders and patients do not perceive the need to inquire about credentials. One


approach for medical providers might be to ask themselves, “Would I do this at home?” (Stuart, 2015). Although most countries hosting visiting medical teams do not have the resources to ensure compliance, volunteers on the Puerto Rico mission were practicing in a territory of the United States. Therefore, U.S. tort law, healthcare law, and standards of practice inure. Practitioners must remember that NYS Board of Regents Rules and the NYS Health Law coins it to be unprofessional conduct/professional misconduct for practitioners to violate any state law from any U.S. region. However, when the need is urgent enough to raise consideration of exceeding one’s scope (for example, when the practitioner’s personal experience is adult care, and the mission requires caring for children), careful forethought and informed consent are required at a minimum (Frellick, 2018).

Addressing Team Building Concerns “There were multiple strong personalities in this group. I was worried about how well we would work together as a team, who would take the lead role, who had the right experience, who had the right personality to lead,” said one interviewee. “I really liked that NYSNA had us develop a plan of action to help team members develop roles and responsibilities. I especially liked the requirement that we establish rules for our team. Our team rules were to: (a) be prompt so we could all arrive on time and leave at a reasonable time; (b) be responsible for the supplies and equipment that we would need that day; and (c) respect the decision of the team leader, but speak up if you had a better idea,” said a Puerto Rico STMM volunteer. “The orientation and debriefing sessions were the most helpful part of the NYSNA mission to help correct problems before they escalated. I especially liked the role playing on optimizing conversations with CHWs, patients, and with team members,” said a NYSNA team member. Team orientation not only includes sharing with the team logistics of the trip (see exhibit H), it requires orientation regarding respect for local laws, informed consent, codes of conduct, resource allocation, authority for decision-making, pre-deployment community assessments, equipment and supply review, cultural awareness, conflict resolution (see exhibits D, E), and how to empower the host country’s local staff (Stuard & Grippon, 2016). Along with 10-hour mandatory educational sessions, NYSNA required of each volunteer the following strategic/action plans (see figures 7-10) and Self-reflection/competency forms (see exhibits A-E).

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Figure 7: Development of Team Mission and Goals Mission and Goals of the Team Mission: To develop a plan of action to build, sustain, and improve the state’s capability to prepare for, protect against, respond to, recover from, and mitigate disaster related hazards Goal 1: To meet the immediate health needs of the community Goal 2: To meet the immediate health needs of the client Goal 3: T o facilitate the community healthcare worker to empower the population and promote independence Goal 4: To develop linkages with the community setting to provide for continued care Goal 5: To provide culturally specific healthcare Goal 6: T o value the customs of the country/refrain from imposing western values on the population

Figure 8: Development Consensus on Role of Team Members Team Member Roles Healthcare Worker: To help identify community needs, to keep a list of clients visited, to help navigate systems, to coordinate follow-up care. RN: To identify psychosocial needs, triage patients for NP/MD, perform primary assessments and health histories. Advanced Practice RN: To perform secondary health and physical assessments, provide treatments, prescribe medications. MD: To diagnose, treat, and prescribe medications. Psychologist provided individual sessions to populous.

Figure 9: Developing a Team Action Plan How the Team Carried Out the Mission and Goals Each team consisted of prescribers, practitioners who are bilingual and fluent in Spanish, practitioners with many years of mission work experience, and drivers who were bilingual and able to serve as liaisons among CHWs, patients, and volunteers. CHWs had lists of clients for STMM members to visit in various residential communities and helped the team navigate the areas. CHWs introduced team members to clients and their families or caretakers and advocated in some cases for clients who were not on visitation lists, but were in dire need of medical attention. Each RN was responsible for teaching CHWs what they need to know to continue the care of the patient.

Figure 10: Development of Conflict Resolution Plan and Debriefing Schedule How the Team Debriefed and Addressed Conflict Issues Team members came together each evening after dinner to share experiences. The team leader facilitated each debriefing by focusing on the positive aspects of site visits (e.g., total number of patients treated, desired outcomes that were met, alliances developed with CHWs and community leaders). Conflict is a challenge, especially within a large, diverse group of healthcare professionals. Strong leadership skills of the team leader are crucial. The team leader for the Puerto Rico STMM was wise enough to know that through collaborating to achieve a mutual goal, we would learn to trust one another and respect each other’s point of view and life skills and experiences. We started as “strangers on a mission” and soon became a family made up of intergenerational, multicultural members. Journal of the New York State Nurses Association, Volume 46, Number 1


n Ethical and Legal Guidelines for Short-Term Medical Missions Post Natural Disaster Addressing Resource Concerns “Conflicts were minimal due to all of our strategic planning and orientation, but revolved around division of labor. This included two runs each day for more supplies. This issue remained a constant source of stress and conflict for the team,” said one interviewee. “Trying to find the appropriate meds or supplies as quickly as possible was very difficult and time consuming because we had not taken the time before day-one to organize and sort them the day before our visit,” added one of the participants. “Trying to get online resource information for pharmaceutical guidance as well as diagnostic and treatment parameters on our cell phones was difficult in view of the lack of electricity and cell service in the places we traveled to,” said one practitioner. “Setting up our work area and assigning our roles and tasks prior to starting the health screenings helped decrease confusion and kept the lines of communication amongst all team members open and positive,” said one STMM volunteer. “Mainlanders like me take too much for granted. We have to contact our representatives in the public arena and voice the needs and concerns of our fellow American citizens and advocate for them. Mission trips must continue with the financial support of private and public sectors,” said one participant. Some researchers have found that it is more cost effective and less of a regulatory risk to purchase needed medicines in the host country from reputable pharmacy sources. It supports the local economy and avoids the confiscation of drugs and heavy tax levies that teams risk when transferring medicines across international borders. Of course, transporting medications from the United States may be necessary due to issues of drug quality, lack of resources, or access issues in the service area to which the volunteer team is traveling. In such cases, the organization/coordinator should arrange in advance of the trip a team meeting to repackage medicines into small, individual, dispensable quantities, appropriately pre-labeled (Johnson, Alsharif, Rovers, Connor, White, & Hogue, 2017). Additionally, the organization/coordinator should arrange in advance for the provision of resource materials, such as a Physicians’ Desk Reference, The Practitioner’s Pocket Pal: Ultra Rapid Medical Reference, by Jim Hancock, and Pediatric Emergent/Urgent and Ambulatory Care: The Pocket NP, by Sheila Sanning Shea, Karen Sue Hoyt, and Kathleen Jordan.

Addressing Anxiety, Cultural, and Environmental Concerns Working in underresourced communities can be very chaotic for volunteering participants who have never been to a post-disaster community. A team member’s emotional reaction to encountering poverty, disorder, lack of access to fresh food and clean water, and security concerns can distress participants and even jeopardize a mission’s safety and success (Stuart & Grippon, 2016). “There is great disparity in what is received on the U.S. mainland versus what is available here. I personally felt I was no longer on American soil. It felt like when I visited third world nations,” said one volunteer. “This was a long day. Vega Baja has had little aid for recovery efforts. There is debris, dirt, and garbage all over. Starving horses and dogs roam


the beaches. Children are barefoot. Most homes are uninhabitable. The beaches are being polluted by the lack of facilities. People are depressed,” observed an STMM participant. “The saddest thing I witnessed was when a client could only receive one vial of insulin because his insurance would not approve more,” said an interviewee. “We had to have meetings into the night about ways to keep going and how to soothe our minds and spirits,” shared one team member. The experience of performing humanitarian work in the wake of a natural disaster helps healthcare practitioners to mature personally and professionally. It facilitates an understanding of political, socioeconomic, cultural, and environmental differences, along with providing numerous opportunities for problem-solving, such that the experience overall is rewarding in a profoundly different way from nursing in their own workplaces (Lal & Spence, 2016).

Addressing Ethical Concerns “Technology is overrated. What I believe this mission is about is following your heart, your gut, and your instincts. Use your head to guide your hands,” said one respondent. Post-disaster medical missions present unique ethical challenges. These missions must take into consideration relationships with local communities, needs assessment, professional standards, and capacity building. Facilitating affiliated relationships drives mission success as much as the offering of voluntary healthcare provider skills. The majority of services provided on short-term medical missions are designed to meet immediate, ongoing community needs, such as nutrition and clean water, routine infectious disease treatments and immunizations, general behavioral/mental health interventions, maternal-child health, and chronic disease counseling. A genuine desire to help does not imply authority to determine priorities in distant communities or to take action. Local leadership must drive mission priorities. Visiting practitioners must give honest assessments of their ability to meet the needs of the population they are serving. The temporary nature of most medical missions requires unpretentiousness in service; introducing unsustainable technology and expertise often will lead to disappointment and harm (Stuart, 2015). For NYSNA as an organization, understanding that short-term medical mission team’s visit and work by invitation and in partnership with local stakeholders is central to achieving a sustainable and quality outcome. Formulating affiliations with organizations from local congregations that work in the communities, as well as with local universities with nursing, medical, and pharmacy schools that incorporate student internships into their programs, local community health workers, and local unions were key work components of the voluntary contingent. Concerns regarding effectiveness and collaboration in affiliated relationships was addressed prior to deployment and during the orientation phase of the mission process.

Evaluation of the Outcomes Outcomes are difficult to collect in short-term medical mission settings and are among the least commonly reported data in the published literature pertaining to STMMs. Patient populations are often transient due to unstable social conditions; and since many travel long distances to obtain much-

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needed care, returning for a follow-up evaluation may not be feasible and even potentially dangerous in many cases (Malay, 2017). Detailed outcomes data is necessary for consistent, ongoing communications with local providers assigned with the task of following the patients after the mission volunteers have left the host country. A more detailed follow-up program should entail additional documentation, communications between mission and host country providers and patients, and provisions for patient transportation (Malay, 2017). NYSNA accomplished this goal by developing standardized assessment and treatment documents (see exhibit D) that were transferred to host community colleges of medicine, nursing, pharmacy, and outpatient clinics. These alliances were formed before the medical volunteers were deployed through the assistance of local unions and faith centers. Practitioners from indigenous organizations made follow-up arrangements for the patient population treated by the volunteer practitioners. The hope of the medical team was that these documents will be utilized to generate descriptive data sets to guide follow-up missions and policy initiatives with local hosts. In addition, NYSNA continuously engages in critical analysis of its programs and missions in accordance with the World Health Organization’s model depicted in its report, “Partnerships for safer health service delivery: Evaluation of WHO African Partnerships for Patient Safety 2009-2014.”


Addressing Medical Supply Concerns The team recognized that there needed to be a greater concentration on the sorting and packaging of essential supplies. In addition, there was a lesson learned about the types of medical supplies that were most important in providing daily care. “Preparation of your supplies must take place each night before the next day’s visits. You first need to know what type of patients you will be seeing and the setting for the assessment, then you need to marry the right supplies and medications for that visit,” said one team member. “We learned you don’t have to bring everything that was donated. We packed only those common, available medications that we knew the patient would be able to access and continue to take after we left,” said another.

Addressing Post-Traumatic Stress Disorder The team recognized that more than 75% of the patients that were seen suffered from post-traumatic stress disorder. This caused great concern among the team members because there were not enough practitioners with the knowledge and skills to treat this disorder. “Every night, we relied on the training from our one mental health RN and our one clinical sociologist to talk us through how to communicate with these patients and instill hope and a psychological sense of safety,” said one participant. Ensuring patients with the essential elements to promote positive psychological thought processes requires a concentration on the following: 1. promoting a psychological sense of safety,


2. promoting calming,


3. promoting a sense of self-efficacy and collective efficacy,




4. promoting connectedness; and 5. instilling hope. (Vernberg et al., 2016) GAP/ASSET ANALYSIS

Addressing Continuity of Care The team was also concerned with the personal trauma of separation from the mission.




Resource: http://www.chausa.org/docs/default-source/international-outreach/ short_term_medical_mission_survey_results.pdf?sfvrsn=0.

LESSONS LEARNED Analysis of the Puerto Rico mission participants’ accounts of the STMM during the post-mission interview revealed the following themes requiring greater emphasis and concentration: 1. Medical supplies 2. Post-traumatic stress disorder 3. Continuity of care

“I felt panicked that the most vulnerable and sickly of the patients we saw would not receive follow-up care, even though we transferred information to the community health workers,” said a volunteer. “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,” admitted a practitioner. It may be helpful to address these concerns using the very same principles identified by Vernberg (2016). Team members should incorporate specific strategies for coping, which include relaxation exercises, calming self-talk, meditation, journaling, and talking with peers for support. The medical team accomplished this by encouraging patients to share feelings, express emotions, identify past and current strengths and potential future successes, and learn new stress reduction activities, such as yoga.

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n Ethical and Legal Guidelines for Short-Term Medical Missions Post Natural Disaster

CONCLUSION Short-term medical missions currently fill an important function in addressing global health crises. They also provide opportunities for students in service learning, along with other healthcare providers, to develop their skills and a greater appreciation of the healthcare beliefs and practices of different cultures.

values that steered them toward a healthcare career in the first place. Finding an ethical balance between the ideal and the pragmatic is a dilemma at the heart of all medical decision-making and STMMs. Critical assessment and peer review of patient outcomes should be welcomed as an opportunity to collaborate on addressing the deficiencies and building on the evidencedbased strengths of STMM care.

Ethical motivations that drive volunteerism in STMMs play a restorative role for seasoned practitioners by reconnecting them with the altruistic


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n References American Medical Association Principles on Ethics. (2001). AMA Code of Medical Ethics. Retrieved from https://www.ama-assn.org/sites/ default/files/media-browser/principles-of-medical-ethics.pdf American Nurses Association. (2015). Code of Ethics with Interpretative Statements. Nursingworld. Retrieved from http://www.nursingworld. org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/ Code-ofEthics-For-Nurses.html Becker’s Hospital Review. (2015). Five Important Qualities for a Medical Leader (and One to Avoid). Beckershospitalreview. Retrieved from https://www.beckershospitalreview.com/hospital-managementadministration/5-important-qualities-for-a-medical-leader-and-oneto-avoid.html Colduvell, K. (2017). How Nurses Can Get Involved with Medical Mission Trips. Nurse. Retrieved from https://nurse.org/articles/get-involvedwith-nursing-medical-mission-trips/ Elgafi, S. (2014, November 11). Medical Liability in Humanitarian Missions. The Journal of Humanitarian Assistance. Tufts. Retrieved from https://sites.tufts.edu/jha/archives/2111 FEMA. (2013, July 1). Hurricane Sandy FEMA After-Action Report. Retrieved from https://www.fema.gov/media-library-data/201307261923-25045-7442/sandy_fema_aar.pdf

2013/06/03/7-traits-of-amazing-volunteers/#549d2aa1220f/ Maines, A. (2018, May 16). 2017 Atlantic hurricane season by the numbers: An extremely active season. Weatherbug. Retrieved from https:// www.weatherbug.com/news/2017-Atlantic-Hurricane-Season-By-TheNumbers-An Malay, P. B. (2017, March/April). Short-term medical missions and global health. The Journal of Foot and & Ankle Surgery, 56(2), 220-222. Retrieved from https://www.jfas.org/article/S1067-2516(17)30031-5/ fulltext Martiniuk, A. L. C., Manouchehrian, M., Negin, J. A., & Zwi, A. B. (2012). Brain Gains: a (sic) literature review of medical missions to low and middle-income countries. BMC Health Serv Res, 12: 134. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3474169/ Mongelard, E. (2006, September). Corporate civil liability for violations of international humanitarian law. International Review of the Red Cross, 88(863). Retrieved from https://www.icrc.org/eng/assets/files/ other/irrc_863_mongelard.pdf Morse, J. M., & Field, P. A. (1996). Nursing Research: The Application of Qualitative Approaches. Basingstoke: Macmillan. Morse, J., & Richards, L. (2002). Read me first for a user’s guide to qualitative method. Thousand Oaks, CA: Sage.

Frellick, M. (2018, March 26). Ethical Guidance for Volunteer Medical Trips Issued by ACP. Medscape Medical News. Retrieved from https:// www.medscape.com/viewarticle/894450

Muse, M. V. (2018). Ethical and legal issues. National Commission on Correctional Health Care. Retrieved from https://www.ncchc.org/ cnp-ethical-legal

Hassler, D. A. (2017, January/February). Serving others through mission trips. Journal of Trauma Nursing, 24(1), 57-60. https://journals.lww. com/journaloftraumanursing/Abstract/2017/01000/Serving_Others_ Through_Mission_Trips.14.aspx

Rich, S., Graham, M., Taket, A., & Shelly, J. (2013). Navigating the terrain of lived experience: The value of lifeworld existentials for reflective analysis. International Journal of Qualitative Method, 12, 498-510. Retrieved from file://C:/Users/cesposito/Downloads/12269-Article%20 Text-50537-1-10-20130926.pdf

Hawkins, J. (2013, October/December). Potential pitfalls of short-term medical missions. Journal of Christian Nursing, 30(4), E1-E6. https://www.nursingcenter.com/cearticle?an=00005217-20131200000023&Journal_ID=642167&Issue_ID=1602350 Hensley, R. D. (2016). Does theory translate in the trenches of short-term mission work? Online Journal of Health Ethics 12(2), 1-12. https:// aquila.usm.edu/cgi/viewcontent.cgi?referer=https://www.google.co m/&httpsredir=1&article=1178&context=ojhe Johnson, K. L., Alsharif, N. Z., Rovers, J., Connor, S., White, N. D., & Hogue, M. D. (2017). Recommendations for planning and managing international short-term pharmacy service trips. American Journal of Pharmaceutical Education, 81(2), 23. https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC5374912/

Shipp Hilts, A., Mack, S., Eidson, M., Nguyen, T., & Birkhead, G. S. (June, 2016). New York State public health system response to Hurricane Sandy: Lessons from the field. Disaster Med Public Health Prep., 10(3):443-53. Retrieved from doi: 10.1017/dmp.2016.69 Silva, M. C., & Ludwick, R. (1999, July 2). Interstate nursing practice and regulation: Ethical issues for the 21st century. Online Journal of Issues in Nursing, 4(2), Retrieved from www. nursingworld.org//MainMenuCategories/ANAMarketplace/ ANAPeriodicals/OJIN/TableofContents/Volume41999/No2Sep1999/ InterstateNursingPracticeandRegulation.aspx

Lal, S., & Spence, D. (2016). Humanitarian nursing in developing countries. Journal of Transcultural Nursing, 27(1), 18-24. https://doi.org/ 10.1177/1043659614536585

Smith, J. D., Holland, R. P., Phillips, J. D., & Falkenheimer, S. A. (2016, November). Mobilizing and training academic faculty for medical mission: Current status and future directions. Christian Journal for Global Health, 3(2), 168-175. Retrieved from http://134-1-1560-2-1020161107.pdf

Laverty, S. (2003). Hermeneutic phenomenology and phenomenology: A comparison of historical and methodological considerations. International Journal of Qualitative Methods, 2(3), 1–29.

Stuart, K. (2015, July). Ethical concerns with medical missions abroad. Ethics Matters. Retrieved from https://www.chausa.org/docs/defaultsource/hceusa/stuart–formatted.pdf?sfvrsn=10

Lindenmayer, M. (2013, June 23). 7 traits of amazing volunteers. Forbes. Retrieved from https://www.forbes.com/sites/michaellindenmayer/

Stuart, K., & Grippon, C. (2016, September-October). Implementing recommendations for short-term medical missions. Journal Of

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n Ethical and Legal Guidelines for Short-Term Medical Missions Post Natural Disaster the Catholic Health Association of the United States. Retrieved from https://www.chausa.org/publications/health-progress/article/ september-october-2016/implementing-recommendations-for-shortterm-medical-missions Uejima, T. (2011, February). Medical missions and medical malpractice: The current state of medical malpractice overseas. American Society of Anasthesiologists, 75(2), 22-24. Retrieved from http://depts. washington.edu/asaccp/sites/default/files/pdf/Click%20here%20 for%20_105.pdf Umapathi, T., Choon Yong, B., Lan Yong, S., & Teik Lee, S. (2015, August 12). International guidelines for the successful organisation (sic) of humanitarian medical missions (HMMs) during peacetime. Proceedings of Singapore Healthcare, 24(3), 181-187. Retrieved from http://journals.sagepub.com/doi/full/10.1177/2010105815598453#arti cleCitationDownloadContainer


United Nations Volunteers Report, prepared for the UN General Assembly Special Session on Social Development, Geneva (2001). Retrieved from http://www.ocva.org.uk/sites/ocva.org.uk/files/Definitions%20 of%20volunteering%2009.pdf Van Manen, M. (2002). Phenomenology online. Retrieved from http:// www.phenomenologyonline.com/ 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), 13331347. World Health Organization. (2018). Ethical principles. World Health Organization. Retrieved from http://www.who.int/about/ethics/en/

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EXHIBIT A: Self-Assessment Competency Sheet for Training CHW RN Self-Evaluation Competency Sheet for Training the Community Health Worker Name of RN: Date:

RN Self- Evaluation Scale

Strongly Disagree




Agree Strongly

2 3 4



I believe I met the programs “In the Aftermath of Maria� objectives. I was able to use the program content and resources to train the community workers. I was encouraged to contribute ideas and perspectives to the team-building discussions. I was able to ask questions and participate in team-building discussions. I had a collaborative relationship with the community health worker(s). The program handouts were useful to me. The materials gave me relevant teaching strategies to help me train community workers.

The community health worker met action plan goals. Please complete the following statements: My favorite part of the experience was My least favorite part of the experience was Please share any comments/feedback/suggestions on the content, format, or logistics of the training.

Thank you for your time!

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Exhibit B: Evaluator Daily Competency Checklist and Feedback Form RN Teaching of CHW and Practice Protocols Evaluator:________________________ Location:_________________________ RN-Participant/Learner:__________________________ 5 The RN’s field performance demonstrates excellent progress, consistently beyond basic competence. 4 The RN’s field performance demonstrates very good progress. 3 The RN’s field performance demonstrates competence and meets expectations. 2 The RN’s field performance demonstrates some progress, requires improvement. 1 The RN’s field performance did not meet required expectations.

Best Practice Competency Standards

Observation 1 Date:

Content Knowledge: The RN understands the concepts and methods of culturally competent adult instruction while training community health workers (CHW). Human Development and Learning: The RN trainer understands how adults learn and based training on individual CHW’s experience. Planning: The RN understands instructional concepts and structures their teaching based upon the goals of the program to build alliances and to mitigate health risks. Instructional Delivery: The RN understands and uses a variety of instructional strategies to develop problem solving, and reflective thinking on the part of the community health worker. Communication: The RN uses knowledge of effective written, verbal, and nonverbal techniques to foster active inquiry, collaboration, and supportive interaction during their trainings of community health workers. Evaluation: The RN understands assessment strategies and uses them to support continuous development of the community health worker and alliances built.

Additional Comments:


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Observation 2 Date:

Observation 3 Date:

Ethical and Legal Guidelines for Short-Term Medical Missions Post Natural Disaster


Exhibit C: Field Service Competency Form Field Service Self-Reflective Feedback and Facilitator Feedback Competency Form RN Participant/Learner Name: Evaluator Name:

Part One: To be filled out by the RN Learner What Parts of the Program Were Helpful?

What Parts of the Program Should Be Done Differently?

Part Two: To be filled out by the Facilitator RN Learner Skill Checklist: The RN  Gives clear instructions to the patient  Does not just “give out answers”—encourages self-reflection of patient  Draws on the experience of the patient  Provides culturally competent nursing care to all patients  Summarizes issues, ideas, questions, answers, and solutions for the patient

 Builds relationship between CHWs and patients  Asks questions that will stimulate discussion and critical thinking of the CHW  Facilitates collaborative and concerted discussions with the patient D raws solutions, ideas, questions, and answers from the CHW  Provided appropriate assessments, services, assistance to distressed patients

Part Three: To be filled out by the RN How was the Evaluator Helpful to Me?

What Should Evaluator Do Differently?

To be filled out by the RN Evaluator Skill Checklist: My Evaluator/Facilitator  Gave me clear instructions  Facilitated collaborative discussions  Encouraged my independence in practice  Drew on my previous experience  Summarized issues, ideas, questions, answers, and solutions for me

 Built agreement among team members around key points and issues  Asked questions that stimulated discussion and critical thinking  Drew solutions, ideas, questions, and answers from all RN participation

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EXHIBIT D: Outcomes Assessment Form Mandatory Notes and Comments for Outcomes Determination Name: Directions: At the conclusion of the program, please provide a statement that reflects 1. Who assumed the leadership role on the team for (1) the team building action plan exercise and (2) in the field?

2. Was the leader chosen, elected, or self-proclaimed in each area described above?

3. Did the leader encourage group discussion on the team building action plan exercise and independence in practice in the field? If not, how did that make you feel? What actions did you take, if any?

4. Was your assigned evaluator the same person as the leader?

5. Were team rules developed? Why or why not? What were they? Were the rules helpful? Why or why not?

6. Were team members respectful of the experience and expertise of one another? Please describe.

7. Were the team goals met? Why or why not?

8. Were the identified team goals relevant once you entered the field? Why or why not?

9. What became the most important issue in the field? Please describe.

10. Was the identified mission relevant? Please explain.

11. What did you learn from this experience?

12. What did you notice was the difference between the delivery of healthcare to U.S. citizens on the mainland and U.S. citizens on U.S. island territories? 13. Did the opportunity to examine another culture within a service-learning experiential framework provide a platform to learn about health disparities, social services, and socioeconomic issues in greater depth? Please explain fully.


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EXHIBIT E: Daily Debriefing Form Mandatory Daily Journaling of Team Building Sessions Directions: Use this area to provide a daily journal of team debriefing, conflicts/issues that arose, and how the conflict/issue was resolved.

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

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EXHIBIT F: Patient Intake Form (Provider Form) Site Name:___________________________________________________________ Date of Exam:______________________________ Patient Name: _____________________________________________ Age:_____________ Weight: Kg/lbs_______________________ History: What is your major health problem or concern at this time? ____________________________________________________________________________________________________________ Hx. Of illnesses:________________________________________________________________________________________________ V/S: BP:_________________________ mmHg____________ HR:_____________ RR:________________ T:____________________

Body System Results

Describe Abnormalities

General Survey  Fever, chills  Weight change  Fatigue and weakness  Generalized pain Integumentary (skin)  Rashes  Lesions  Changes in pigmentation Ears, Nose, Mouth and Throat and Neck  Hearing loss, earache, tinnitus  Dizziness and vertigo  Epistaxis  Sore throat  Swollen glands Eyes  Change in vision (blurred vision, loss vision, floaters, flashing lights)  Eye pain, redness or tearing  Double vision Respiratory  Chest pain  Shortness of breath (dyspnea)  Cough  Hemoptysis Cardiovascular and Peripheral  Chest pain  Palpitations  Pain or weakness in the arms or legs  Edema  Cold, numbness, pallor in legs 28

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Treatment Provided

Ethical and Legal Guidelines for Short-Term Medical Missions Post Natural Disaster

Body System Results

Describe Abnormalities


Treatment Provided

Gastrointestinal  Abdominal pain  Indigestion, nausea, vomiting, hematemesis, loss of appetite  Dysphagia and/or odynophagia  Change in bowel function  Diarrhea, constipation  Jaundice Genitourinary  Suprapubic pain  Dysuria, urgency or in urination  Urinary incontinence  Hematuria  Flank pain and ureteral colic Musculoskeletal  Joint pain  Neck pain  Low back pain Neurological  Headache  Dizziness or vertigo  Weakness  Numbness, abnormal or absent sensation  Syncope  Tremors or involuntary movements Behavior and mental status  Changes in attention, mood or speech  Changes in insight, orientation, or memory  Anxiety, panic, phobias  Delirium, dementia Recommendations:

Provider Signature:

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Patient Intake Form (Patient Form) Nombre Direccion Numero de teléfono Contacto de emergencia


Edad Peso M/F

Perfil del paciente ¿Tiene alergias? __________________________________________________________________________________________________ ¿Estás embarazada? ____________________________ ¿Cuántos meses? __________________ ¿Problemas? ________________________

Síntomas / Condición de salud Asma_______________________________ Sinusitis _____________________________ Problemas Respiratorios__________________ Presión Alta___________________________ Baja ________________________________ Problemas Cardiacos____________________ Azucar Alta___________________________ Baja ________________________________ Diabetes_____________________________ Condición Estomacal_______________________________________ La Diarrea ______________________________________________ Problemas con los riñones__________________________________________________________________________________________ Condición de la piel ______________________________________________________________________________________________ Depresión, ansiedad, insomnio, otra___________________________________________________________________________________ ¿Mareo o desmayo? ________________________________________ ¿Cuándo? ______________________________________________ Condición oftálmica ______________________________________________________________________________________________ Condición neurológic _____________________________________________________________________________________________ ¿Ha estado recientemente en el hospital? ¿Por qué? ________________________________________________________________________ ¿Ha tenido cirugía?_________________________________________ ¿Cuándo?_______________________________________________

Hora_________________ BP___________________ Pulse________________ 30

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Temp________________ Resp___________________

Ethical and Legal Guidelines for Short-Term Medical Missions Post Natural Disaster


Autorizo al Dr./Dra. _________________________________________ a ofrecerme tratamiento para la condiciรณn de salud arriba descrita y reconozco que dicha consulta se me ofrece de forma voluntaria y gratuita. Firma _________________________________________________________________________________________________________

Perfil del Paciente Nombre:_________________________________________________


_______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________

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EXHIBIT G: Healthcare Practitioner Volunteer Application Thank you for signing up as a volunteer for deployment with the New York State Nurses Association. This will be a challenging deployment with specific requirements. If you are found to be a match, we will contact you to discuss the next steps. Thank you for being willing to volunteer your time and expertise! * Required 1. Name* 2. Home Address (Street, City, State, ZIP)* 3. Do you have a current passport?* Yes  No  • If yes, please indicate issuing country. 4. Phone number* 5. Email* 6. Job Title (Staff RN, Educator, Nurse Manager, etc.)* 7. Employer/Hospital System* 8. Department/Unit* 9. Are you interested in receiving Continuing Education Units (CEUs) or Contact Hours (CHs) for volunteering?* Yes  No  • Please check all titles that apply to you. *  Registered Nurse  Nurse Practitioner  Medical Doctor  Physician’s Assistant  Emergency Medical Technician/Paramedic  Social Worker  Psychiatrist  Other: 10. Please provide your license/registration number(s) if applicable, and the state of licensure. 11. Do you have prescription writing privileges?*

Yes  No 

12. Do you have experience in any of the following areas? *  Pediatrics  ER  ICU  Public Health  No experience


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13. Please list any other units you are comfortable working in. 14. If you are an NP, what is your area of specialty?  Family  Adult  Pediatrics  OB/GYN  Other: 15. Do you have prior disaster relief experience? *

Yes  No 

• If yes, please indicate where and with what organization(s). 16. Do you speak any foreign languages? *

Yes  No 

• Please indicate which languages you speak. 17. Are you a member of a union?*  NYSNA  1199/SEIU  CWA  NYSUT-AFT  TWU  None  Other: 18. Are you able to work in difficult conditions for up to two weeks without a day off?* 19. Are you able to work either day or night shifts?* 20. Are you able to run a mile?*

Yes  No 

Yes  No 

Yes  No 

21. How many times per week do you exercise? *  Zero  Once  Twice  Three or more

22. How long do you exercise per workout?  30 mins or less  30-60 mins  60-90 mins or more 23. Are you able to be out of contact with family or friends during the mission?*

Yes  No 

24. Do you have any food allergies?* Yes  No  • If yes, please list them.

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n Ethical and Legal Guidelines for Short-Term Medical Missions Post Natural Disaster 25. Do you have any dietary restrictions?*  Vegan/Vegetarian  Kosher  Gluten-Free  Lactose-Free  None  Other: 26. Are you willing/able to forgo this restriction during the medical mission?*

Yes  No 

• If no, please explain. 27. Are you able to easily set aside personal feelings to focus on the task at hand?*

Yes  No 

28. Are you comfortable taking direction from medical mission staff/leaders and following the chain of command during the medical mission? *  Very comfortable  Somewhat comfortable  Somewhat uncomfortable  Very uncomfortable 29.Please provide at least one emergency contact (name, relationship, phone, and email).*


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Journal of the New York State Nurses Association, Volume 46, Number 1



Effects of Dental Hygiene on Cognition

The team from left to right: Jose Domenech is a TWU member and served as one of the team’s drivers; Marc Alan Minick, PhD, LMSW, Clinical Sociologist; Hector Rivera, RN, is a NYSNA member who concentrates in PACU and the catheterization lab; Pietro Henao, RN, is an 1199SEIU member who concentrates in medical nursing; Lucille Contreras Sollazzo, RN, is the Associate Director, Nursing Education and Practice, NYSNA; Michael Touger, MD, is an emergency medical provider; Eileen Hadley, RN, is a NYSNA member who concentrates in medical nursing. Grace Otto, RN, is a NYSNA member who concentrates in psychiatric mental health nursing; Emiliano Padilla is a TWU member and served as one of the team’s drivers; Raquel Womble-Ortiz, RN, is from Massachusetts and concentrates in pediatric nursing; Carole Ann Moleti, DNP, is a NYSNA member who concentrates in maternal-child health.

Judith Sheridan-Gonzalez, MSN, RN, FNP NYSNA President NYSNA Mission Co-Coordinator


Journal of the New York State Nurses Association, Volume 46, Number 1


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 46, Number 1


n what’s new


Effective Pain Management in Older Adults with Dementia

In the context of pain management, research reports several strategies that can optimize decision-making capacity of the older adult with dementia: 1. Designate and document one person as the proxy decision-maker (the agent) and/or medical power of attorney (i.e., family, trusted friend, caregiver if recognized in your state) (medical power of attorney is not recognized in New York State) to consistently attend health appointments and provide decision support for the older adult with dementia. The roles of the older adult with dementia, agent, and each interdisciplinary team member should be clearly delineated. 2. Introduce conversations with older adults when they are not experiencing moderate or severe pain or under the influence of pain medication in order to improve their capacity to make informed decisions (American Nurses Association, 2010). 3. Initiate discussions (a) early in the dementia trajectory and (b) during times when the older adult is more lucid and cognitive ability is


most reliable, as evidenced by a brief cognitive assessment and clinical judgment. 4. Provide modest amounts of information at any given time. 5. Use a culturally sensitive approach, respecting cultural values related to pain and utilizing interpreter services when needed.

References Staja, B., Booker, R. D. (2018). Shifting paradigms: Advance care planning for pain management in older adults with dementia. Gerontologist, 58(3), 420-427, as cited in Medscape – June 19, 2018. https://www. medscape.com/viewarticle/896728_4 American Nurses Association. (2010). Position statement: Registered nurses’ roles and responsibilities in providing expert care and counseling at the end of life. Silver Spring, MD: ANA.

Journal of the New York State Nurses Association, Volume 46, Number 1

n The

Association Between Dementia and Risk of Hospital Readmission: Does the Effect of Dementia on Hospital Readmission Vary According to Primary Diagnosis? In a retrospective cohort study, individuals aged 65 and older diagnosed with one of the 30 most common diagnoses and discharged from 987 hospitals between April 2014 and September 2015 (N = 1,834,378) were studied to assess the association between dementia and risk of hospital readmission and to evaluate whether the effect of dementia on hospital readmission varies according to primary diagnosis. The 30 diagnoses appear in the Table. The individuals’ overall prevalence of dementia was 14.7% and varied according to primary diagnosis, ranging from 3.0% in individuals with prostate cancer to 69.4% in those

with aspiration pneumonia. Overall, individuals with dementia had a higher risk of hospital readmission (8.3%) than those without (4.1%), although diagnostic category substantially modified the relationship between dementia and hospital readmission. For hip fracture, dementia was associated with greater risk of hospital readmission; this risk was decreased for cholecystitis. Participants with dementia had a higher risk of emergency readmission (3.9%) than those without (1.5%), although the relationship between dementia and emergency readmission was substantially different according to diagnostic category.

Table Thirty most common diagnoses Acute Myocardial Infarction

Cerebral Infarction

Heart Failure

Peripheral Arterial Disease

Angina Pectoris


Hip Fracture


Aspiration Pneumonia


Inguinal Hernia

Prostate Cancer

Bladder Cancer

Chronic Kidney Disease

Intestinal Disease

Rectal Cancer

Bowel Obstruction

Colon Cancer

Intracranial Injury

Spinal Stenosis


Diabetes (Type 2)

Kidney Infection


Breast Cancer

Gastric Cancer

Liver Cancer


Gastrointestinal Inflammation

Lung Cancer

The study had two major findings. First, in 17 of the 30 most common diagnostic categories, participants with dementia were more likely to be readmitted to acute care hospitals than those without dementia. Second, the influence of dementia on readmission varied according to diagnostic category. Given the greater risks of readmission for some primary diagnoses, routine screening for dementia in individuals with those diagnoses could help predict their risk of readmission. This information could help healthcare providers adjust post discharge care to minimize the likelihood of readmission of older adults with dementia.

References Sakata, N., Okumura, Y., Fushimi, K., Nakanishi, M., & Ogawa, A. (May, 2018). Dementia and risk of 30-day readmission in older adults after discharge from acute care hospitals. J Am Geriatr Soc., 66(5), 871-878, as cited in Medscape – June 19, 2018. https://www.medscape.com/ viewarticle/897337_1

Journal of the New York State Nurses Association, Volume 46, Number 1


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Efficiency of Using Safe Patient Handling Equipment in Older Adults and Adults with Dementia Dementia is a progressive clinical condition that is experienced as an array of symptoms, including memory loss, difficulty expressing language, impaired communication, and ability to reason effectively. Patients with dementia in the acute care setting are more likely to experience negative clinical incidents such as falls (Butcher, 2018). The demented patient is four to five times more likely to fall than older adults who do not have cognitive impairment. For those who fall, the risk of sustaining a fracture is three times higher than for cognitively well people (Alzheimer Society of Manitoba, 2014). The study by Kanaskie and Snyder (2018) demonstrates the complexity of decision-making among care providers in the use of safe patient handling and mobility (SPHM) technology. Inter-professional team approaches to patient assessment and care are important components of confident decision-making. Special considerations and frequent reassessments are required for people with dementia.

Barriers to Use

Perceived Risk

Coordination of Care

Physical barriers

Patient risk

Patient related characteristics

Knowledge and skill

Perceived risk to self

Assessment of patient needs and abilities

Unit culture

Interprofessional collaboration

The qualitative analysis of the Kanaskie and Snyder (2017) study revealed three major themes pertaining to the use of SPHM technology: barriers to use, perceived risk, and coordination of care.

Barriers to Use Physical barriers include inability to access equipment, limitation in storage space, and inadequate space to maneuver equipment into patient rooms. Physical barriers constitute a major deterrent to using life equipment. The research suggests the inability to access equipment, limitations to storage space, and inadequate space to maneuver equipment into patients’ rooms as barriers to use. Knowledge and skill in using lift equipment is a reported barrier. Although nurses may have been trained on SPHM technology and equipment, without consistent use and ongoing practice, RNs and NAs described decreased confidence in their skills. This was attributed to the subsequent decline in use of SPHM equipment. Unit culture was described as accepted practices related to the delivery of basic nursing care and included assisting patients with meals, bathing, and other activities of daily living. Coordination of care and 40

routines on a unit were noted as creating a challenge during mealtime, bathing, and nursing assessments. Additionally the researchers noted that when new hires transitioned onto a unit and SPHM equipment was not used by incumbent nurses, there was a positive correlation of non-use by the new hire.

Perceived Risk Nurse’s perception of patient risk was described as connected with the need for ample preplanning in order to safely and appropriately ambulate patients who are at risk for falls. Patient fatigue often required the use of an assistive device to help the patient return to bed. Without proper preplanning, the use of assistive devices was described as difficult. Patients and family members’ fears also contributed to nurses’ decisions about whether to use SPHM equipment. Patients who experienced a previous fall were noted as particularly fearful of using SPHM equipment. Self-risk as a potential negative outcome for the RN was described as a motivator by some nurses; however, potential risk to self was not always a driving force, because while in the moment, nurses described more frequently choosing the path that seemed the fastest approach and one that did not require peer assistance.

Coordination of Care Patient related characteristics such as diagnosis, physical and cognitive abilities, pre-existing conditions, motivation, and de-conditioning since admission constituted barriers to the use of SPHM devices. Patients and families sometimes viewed the use of SPHM equipment as a negative message or insult as it related to the patient’s size or weight. Assessment of patient needs and abilities was a skills concern described by both RNs and NAs. Because a patient’s cognitive and physical abilities changed on a daily basis, practitioners found it difficult to discern if the patient had the strength and capacity to utilize SPHM equipment. Practitioners were fearful of status changes in patients and errors in judgment. Interprofessional collaboration with physical and occupational therapy staff was identified as an asset in assisting with the determination of the chosen method of ambulation and whether to use SPHM equipment.

References Alzheimers Society of Manitoba Dementia Care & Brain Health. (2014). Reducing risk of fall for people with dementia. Retrieved from https:// www.alzheimer.mb.ca/wp-content/uploads/2013/09/2014-DementiaFall-Risk-Checklist-template.pdf Butcher, L. (2018). Caring for patients with dementia in the acute care setting. British Journal of Nursing, 27(7), 358-362. Kanaskie, M. L., & Snyder, C. (2017). Nurses and nursing assistants decision-making regarding use of safe patient handling and mobility technology: a qualitative study. Science Direct, 39, 141-147. doi: 10.1016/j.apnr.2017.11.006 https://www.sciencedirect.com/science/ article/pii/S0897189717304329

Journal of the New York State Nurses Association, Volume 46, Number 1

n Faulty

Electronic Health Records May Support a Malpractice Claim

Research and analysis of patient safety reports indicate that the use of electronic health records (EHRs), and even certain aspects of EHRs themselves, may be linked to potential patient harm and increasing malpractice actions. Researchers analyzed patient safety reports from 2013 through 2016 from the Pennsylvania Patient Safety Authority database. Safety reports, written by nurses, describe the safety event, contributing factors, what effect the event had on a patient, and whether that effect meant more healthcare services were needed. The study included reports where one of the top-five EHR vendors or products was mentioned in the report and if the report indicated that the event caused the patient possible harm. Of 1.735 million reported safety events, 1,956 (0.11%) included the

name of an EHR vendor or product and were reported as possibly causing patient harm, and 557 (0.03%) contained language “explicitly suggesting” that use of the EHR contributed to possible patient harm. Of those 557 reports that cited the use of EHRs as contributing to patient harm, harm levels were broken into four categories. Categorical occurrences were as follows: potentially required monitoring to prevent harm (84%, n = 468), potentially caused temporary harm (14%, n = 80), potentially caused permanent harm (1%, n = 7), and could have required intervention to save a life or could have resulted in death (<1%, n = 2). Researchers divided usability factors into seven categories, with data entry, alerting, and interoperability more frequently linked to potential harm than others (see table).

Table of Usability Factors

Usability Category

Number of Events

Events %

Data entry









Visual display



Information accessibility



System automation/defaults



Workflow support



The researchers also tracked when EHR usability problems occurred, and found that most occurred in order placement (38%) or when giving medication (37%), followed by reviewing results (16%), and documentation (9%). The authors noted research limitations: “Patient safety reports contain limited information making it difficult to identify causal factors and may be subject to reporter bias, inaccuracies, and a tendency to attribute blame for an event to the EHR.” Although only a small percentage of potential harm events were linked to EHR usability, the study numbers may be reportedly conservative because the incidents reported are only a fraction of the events that happen and the study only included reports that mentioned specific vendors or products.

References Howe, J. L., Adams, K. T., Hettinger, A. Z. et al. (2018, March 27). Electronic Health Record Usability Issues and Potential Contribution to Patient Harm. JAMA, 319(12), 1276-1278. doi:10.1001/jama.2018.1171 as cited in EHRs May Be Tied to Potential Patient Harm, Study Suggests – Medscape – Mar 27, 2018. https://www.medscape.com/ viewarticle/894465?src=WNL_infoc_180627_MSCPEDIT_hospmed &uac=215663EV&impID=1667064&faf=1

Journal of the New York State Nurses Association, Volume 46, Number 1


n CE Activity: Effects of Dental Hygiene on Cognition Thank you for your participation in Effects of Dental Hygiene on Cognition, a new 0.5 contact hour continuing education (CE) activity offered by NYSNA. NYSNA members and non-members are invited to take part in this activity, and 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 80% or better on the post-test. This activity is free to NYSNA members and $10 for non-members. Participants can pay by check (made out to NYSNA and please include CE code 1B9157 on your check) or credit card. The completed answer sheet and evaluation form may be mailed or faxed back to NYSNA; see the evaluation form for more information. The New York State Nurses Association is accredited as a provider of continuing nursing education 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/authors involved with the development of this independent study have declared that they have no vested interest. NYSNA Program Planners and Authors declare that they have no conflict of interest in this program.

GOAL Studies indicate poor dental health and gum disease may be linked to Alzheimer’s disease and dementia. Although past studies have suggested a link between oral health and dementia, new research pinpoints a specific gum disease bacteria in the brain. Everyday activities like eating and tooth brushing, and some dental treatments, could allow the bacteria to enter the brain. Failure to floss and engage in oral care results in long term inflammation, which, in turn, causes nerve cell death and possibly memory loss, premature aging, and disease. According to a report at the International Society of Vascular Behavioral and Cognitive Disorders, poor dental health increased the likelihood of dementia by 30-40% over a 32-year period, regardless of cardiovascular status.

OBJECTIVES By completion of the article, the reader should be able to: 1. Summarize the research that indicates that lack of oral hygiene results in dementia. 2. Understand the importance of teaching patients that flossing and brushing habits may result in better cognition for all adults. 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 0.5 contact hours for this program will be offered until July 22,2021. 1) Cognitive impairment is common in the geriatric population and, according to some studies, may lead to dementia and Alzheimer’s disease. a. True b. False 2) The disease process of Alzheimer’s is thought to consist of edema and an abnormal accumulation of plaque in the brain. a. True b. False 3) According to the National Center for Biotechnology Information, Alzheimer’s accounts for 40% of all dementias. a. True b. False 4) Alzheimer’s is a part of the normal aging process, and advanced age is a major risk factor for Alzheimer’s disease. a. True b. False 5) Researchers have found that one-in-nine people over 65 years of age develop Alzheimer’s and that 81% of people older than 75 years of age have Alzheimer’s. a. True b. False 6) The NCBI found that African Americans are twice as likely, and Hispanics are one-and-a-half times as likely, to develop Alzheimer’s than white Americans. a. True b. False 7) According to the National Institute of Dental and Craniofacial Research, a division of the National Institute of Health, 70.1% of adults 65 years and older have periodontal disease. a. True b. False 8) Loss of teeth and the apolipoprotein E�4 allele is related to memory loss and tooth loss is associated with loss of cognitive function. a. True b. False 9) Adults with the highest level of P. gingivalis tend to have the least cognitive deficits. a. True b. False 10) Decreases in cognition occur within six months of the onset of poor oral hygiene. a. True b. False

Journal of the New York State Nurses Association, Volume 46, Number 1

The Journal of the New York State Nurses Association, Vol. 46, No.1

Answer Sheet Effects of Dental Hygiene on Cognition Note: Contact hours for this program will be offered until July 22, 2021. 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): E-mail: Profession:

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

NYSNA Member # (if applicable):

License #:

License State:

ACTIVITY FEE: Free for NYSNA members/$10 non-members PAYMENT METHOD Check—payable to New York State Nurses Association (please include “Journal CE” and your CE code 1B9157 on your check). Credit card:




American Express

Card Number:

Expiration 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 fax to: 212-785-0429

Journal of the New York State Nurses Association, Volume 46, Number 1


Learning Activity Evaluation Effects of Dental Hygiene on Cognition Please use the following scale to rate statements 1-7 below:




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?


Journal of the New York State Nurses Association, Volume 46, Number 1

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