texa s nu r s e s .o rg
TEXASNURSING M A G A Z I N E
NURSING
Reimagined Leading the Way with Innovation and Foresight
T N A : E m p o w e r i n g Te x a s N u r s e s t o a d v a n c e t h e p r o f e s s i o n | I s s u e 2 , 2 0 2 2
ISSUE 2, 2022 Volume 96, Number 2 EDITOR IN CHIEF: Julia Menegay MANAGING EDITOR: Lisa Maxwell COPY EDITORS: Gabi Nintunze
BOARD OF DIRECTORS OFFICERS: Tamara “Tammy” Eades, DNP, MSN, RN, President eades@uta.edu Joyce Batcheller, DNP, RN, NEA-BC, FAONL, FAAN, President-elect jbatcheller7@yahoo.com
4807 Spicewood Springs Rd., Bldg 3, Suite 100, Austin, TX 78759-8444 P: 800.TNA.2022 or 512.452.0645; F: 512.452.0648
Colleen Marzilli, PhD, DNP, RN, CNE, NEA-BC, Secretary cmarzilli@uttyler.edu
tna@texasnurses.org | texasnurses.org
MISSION Empowering Texas Nurses to advance the profession
Steven J. Jewell, BSN, RN, CEN, CPEN, USN (ret.), Treasurer jst4jstn@gmail.com DIRECTORS: Patricia Freier, MSN, RN-BC, CPHQ pfreier@covhs.org Lucindra Campbell-Law, PhD, ANP, APRN, PMHNP, BC campbel1@stthom.edu Edtrina Moss, PhD, RN-BC edtrina@comcast.net
VISION Nurses transforming health TEXAS NURSING (ISSN 0095-36X) is published quarterly— Winter, Spring, Summer, Fall—by the Texas Nurses Association, 4807 Spicewood Springs Rd., Bldg. 3, Suite 100, Austin, TX 78759-8444 Periodical postage is paid in Austin, Texas. One-year subscriptions: $25 (nursing schools, libraries, hospitals, non-nurses, out-of-state nurses), foreign $30; single copy $2.50. Subscription is not available to non-member Texas nurses. Some back issues may be viewed online at texasnurses.org. PUBLISHING PARTNER Monarch Media & Consulting, Inc. P: 512.680.3989 or 512.293.9277; F: 866.328.7199 monarchmediainc.com | chellie@monarchmediainc.com Advertising inquiries: call Chellie Thompson at 512.293.9277. TEXAS NURSING is indexed in The Cumulative Index to Nursing and Allied Health Literature and in the International Nursing Index. 16mm, 35mm microfilm, 105mm microfiche, article copies available from University Microfilms International: 1.800.521.3044. Statements of fact and opinion are made on the responsibility of the authors alone and do not imply an opinion on the part of the officers or the membership of TNA. POSTMASTER Send address changes to TEXAS NURSING, 4807 Spicewood Springs Rd., Bldg. 3, Suite 100, Austin, TX 78759-8444. ARE YOU MOVING? Need to change your address? If so, provide it quickly and easily in the Members Only section of the TNA website, texasnurses.org. Or mail your new address—at least six weeks prior to your move— to Texas Nurses Association headquarters. We’ll make sure your TEXAS NURSING makes the move with you. FEEDBACK EMAIL OR LETTER GUIDELINES TEXAS NURSING will select emails/letters on the basis of readership interest and relevance to current nursing/health care events. TEXAS NURSING reserves the right to edit all letters. Guide: Limit to 200 words; focus on single issue; include writer’s name, mailing address, and daytime phone. Send to: editor@texasnurses.org.
Brandon “Kit” Bredimus, DNP, RN, CEN, CPEN, CNML, NE-BC, CENP, NEA-BC kit.bredimus@midlandhealth.org Mary Vitullo, BA, BSN, RN-BC vitullo.mary@yahoo.com CHIEF EXECUTIVE OFFICER: Cindy Zolnierek, PhD, RN, CAE
TNA DISTRICT PRESIDENTS Dist.1:
Teresa Acosta, RN shadowmon@sbcglobal.net
Dist. 3:
K. Renee’ Yarbrough-Yale, DNP, APRN, ACCNS-AG, CDCES tnad3president@gmail.com; District office: Jamie R. Rivera, JamieRivera@texashealth.org
Dist. 4:
Ruben Castillo, RN, MSN, CCRN, NE-BC 817-229-6478, tnad4.nursingnetwork.com
Dist. 5:
Michael Turturro, MBA, MHSA, MSM, BSN, RN-BC President.TNAd5@gmail.com, tna5.org
Dist. 7:
Lisa Kelly, lisakelly0212@yahoo.com tnadistrict7@gmail.com
Dist. 8:
Donna R. Wallis, MBA, MSN, RN tna8.org
Dist. 9:
Renae Schumann renaeschumann20@gmail.com; District office: Melanie Truong, RN, Executive Secretary, tna9@tnadistrict9.com, tnadistrict9.com
Dist. 17:
Mari Cuellar, NEA-BC, MSN, RN mgrace2329@yahoo.com
Dist. 18:
Janice L. Miller, MSN janice.miller@umchealthsystem.com
Dist. 19:
Anita Lowe, RN alowe@uttyler.edu
Dist. 35:
Karen Koerber-Timmons, PhD, RN, CLNC, CNE, NEA-BC, CCRN, RN-BC mkkoerbertimmons@gmail.com
At-Large: Contact TNA, 800-862-2022, ext. 129 brichey@texasnurses.org
Copyright 2022 © Texas Nurses Association
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Nursing
Surveillance Focus for Nursing
15
Designing the
Future Nurses:
Health Care Heroes? 12
20
Contents IN EVERY ISSUE
ARTICLES AND FEATURES
5
7
8
19
PRESIDENT’S NOTES
TNA NEWS What's New and Next
PASSING THE LEADERSHIP TORCH
ALLEVIATING THE NURSE SHORTAGE IN TEXAS
Headline
TNA Transitions, New Strategic Plan, New Leadership
6 TNA MEMBER NEWS On the Move, In Memoriam, Kudos
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How TNA is Working to Effect Change
Read more at texasnurses.org. TNA members receive stories, news, and practice tips every Tuesday in the Check Up e-newsletter. If you haven't been getting your Check Up, see your email spam filter or contact us at tna@texasnurses.org.
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President’s Notes Tammy Eades, DNP, MSN, RN
PAST REFLECTIONS AND NEW BEGINNINGS Your and TNA's Future
WHEN I BECAME TNA PRESIDENT in July 2020, we were full blown into the COVID-19 pandemic. We went from looking forward to celebrating “2020, The Year of the Nurse” to shutting down our country and not knowing what lay in store for us. I became the first virtual president in the history of TNA, and we had to introduce new and virtual programming to support nurses through a whole new challenge. Two years later, we have learned many things, including how to live with COVID-19. I just returned from the AONL conference and you could hear and feel the excitement in everyone’s voice about being able to meet in person again. We listened to Northwell Health Nurse Choir (I recommend you look them up online) sing their inspirational song “Don’t Give Up On Me.” There probably was not a dry eye in the room. It reminded me that we should never give up on having our voices heard—and amplified—through TNA. I heard Dan Pink speak on his book, The Power of Regret: How Looking Backward Moves Us Forward, understanding how we can turn our regret into positive thinking to help us move forward. How can the members of TNA take the lessons we learned during the pandemic and move forward into the future of nursing? We can do this by completing our work and mission, taking the chances when presented to us, always doing the right thing, and reaching out when our colleagues need us. As we approach the 2023 legislative session, we need to keep our vision and mission in mind and be ready to be the voice of Texas nurses. Get involved at
How can the members of TNA take the lessons we learned during the pandemic and move forward into the future of nursing? We can do this by completing our work and mission, taking the chances when presented to us, always doing the right thing, and reaching out when our colleagues need us. the grassroots level. Do not let the 88th Legislative session pass thinking ‘I could have done more.’ Be proactive and take chances. I am so proud to be a part of TNA. I want to thank you, my colleagues, who inspire me. I will continue to be a voice for Texas nurses.
association as well as finding the next CEO. The right leader always emerges at the right time and I have great faith that Joyce and the TNA board will find the right person to lead us into the future. Tammy Eades, DNP, MSN, RN i
Springtime is always a refreshing time as the bluebonnets and Indian paintbrushes remind me of the opportunity to start fresh. So, I would like to take this opportunity to introduce you to your next TNA president, Dr. Joyce Batcheller. As president, Joyce will be leading the
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TNA MEMBER NEWS SPOTLIGHT ON YOU ON THE MOVE
IN MEMORIUM
KUDOS
Candi ConstantineCastillo, MSN, RN, is the new CEO of Prime Healthcare’s Harlingen Medical Center. Constantine-Castillo was on the original team when the hospital first opened in 2002 as the education coordinator, and now, 20 years later, is becoming the CEO. Over her career, Constantine-Castillo held several leadership positions to prepare her for her new role.
Eleanor Lillian Hammonds, passed away on January 18, 2022, at the age of 98. Hammonds was a member of the Cadet Nurse Corp when she was transferred to Winter General Army Hospital. There she met her future husband while giving him stitches. Hammonds served as Director of Nurses at Nix Hospital in San Antonio from 1959-1970. Under her direction, the hospital created a childcare center for working mothers in an unused room. She was later recruited to hold the same position at Northeast Baptist Hospital. Hammonds was the chairman of the nursing section for the American Cancer Society; a member of the Board of Directors for ACS Bexar County and TNA District 8; President of TNA District 8; and President of Alamo Area Directors of Nursing organization.
Michael Pickett, MSN, APRN, CPNP, is one of the recipients of the 2022 ANA Innovation Awards. Pickett and a team of frontline nurses from Texas Children’s Hospital developed the RediStik Wearable Simulation Task Trainers. The award recognizes exemplary nurse-led innovations that improve patient safety and health outcomes. i
Kathleen R. StevensHamilton, EdD, MS, RN, ANEF, FAAN, and her husband, Alexander B. Hamilton, gifted UT Health San Antonio’s School of Nursing with a nine-foot bronze statue of Florence Nightingale. The couple met with the late Texan sculptor Rick McCumber and Dean of the School of Nursing, Eileen T. Breslin, PhD, RN, FAAN, to plan the statue’s details. Stevens-Hamilton said that there is no larger image in modern healthcare and nursing than Florence Nightingale.
If you are a TNA member and you’ve, been promoted, received an award, or been elected or appointed to a board or community organization, we’d like to hear from you. Please send submissions to editor@texasnurses.org.
NursingComplaintHelp.com
PROTECT YOUR LICENSE If you have received: • A Letter of Investigation from the Texas Board of Nursing • Notice of Peer Review
Registered Nurse and Attorney
This site is for nurses in ANY STATE and provides videos, advice, suggestions, and downloadable real responses to use as guides in responding to any BOARD COMPLAINT or INVESTIGATION.
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NursingComplaintHelp.com
CALL TODAY! Joyce Stamp Lilly RN JD
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TNA NEWS WHAT'S NEW AND NEXT REGISTER NOW!
TNA REPRESENTS YOU! In the past quarter, TNA represented you with:
June 24−25, 2022
TNA Annual Meeting
Foresight, Futures and Innovation Reimagine Nursing
TEXA S N URSES
ANNUAL MEETING
ASSOCIATIO N
2022
June 24-25
Georgetown, TX
FORESIGHT, FUTURE & INNOVATION
› › › ›
ED/CEO Executive Enterprise Meeting Presidents/ED Call Statement on Racial Reckoning Special Meeting of the Membership Assembly
›
Policy/Government/Practice/Ethics/HNHN Call
HRSA
RWJF Future of Nursing Report
TBON
THA
APRN Alliance
TPHC Steering Committee
TADDPNP
THECB
AARP CCNA:
Sheraton Hotel and Conference Center Georgetown, TX Learn a new model for future thinking and help envision a better world for nurses with futurist Daniel Pesut, PhD, RN, FAAN. Join us at the annual business meeting for updates on finances, policy and programs and to give input on issues within TNA's policy development process.
ANA
› ›
Access to Care Initiative Hot Topic Discussion: Staffing Ratios
›
Hot Topic: Violence Against Nurses
DSHS › ›
Monthly Vaccine Updates TCNWS – WPV Task Force
›
TCNWS Advisory Committee
HHSC Texas Health Steps Advisory Panel
Capital Area Trauma Regional Advisory Council
Texas Nurses Rally at Capitol
TEXAS PEER ASSISTANCE
Purchase tickets to the Leaders and Legends Awards gala to honor some of the most influential nurses in Texas history. Join us at 5 p.m. for cocktails and bid on some fantastic items in the silent auction. The awards program begins at 6 p.m. For more details and to register, visit texasnurses.org/mpage/ AnnualMeeting.
PROGRAM FOR NURSES
Volunteer for TPAPN
BECOME A PEER SUPPORT PARTNER Texas Peer Assistance Program for Nurses (TPAPN) peer support partners provide an empathetic listening ear to TPAPN participants.
REGISTER TODAY For more information on program, tickets or sponsorship, visit texasnurses. org or follow this link. Silent Auction and Banquet require a separate ticket.
Start advocating today!
tpapn.org PAGE 7
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PASSING THE LEADERSHIP TORCH By Dr. Joyce Batchellor, DNP, RN, NEA-BC, FAONL, FAAN, TNA President 2022-2024
If you have been a member for a while, you expect a transition to occur in the office of President at this time of year. This is also the time the board creates a new strategic plan. This year, we will have a new executive leader. Below are words from President-Elect Joyce Batcheller about each of these changes.
TRANSITIONS I AM EXCITED to begin my two-year commitment as the President of the Texas Nurses Association. I would like to begin by thanking all nurses in all practice settings for the incredible work you do and the differences each of you have made and continue to make in so many people’s lives. I commonly hear nurse leaders say, “It would be great to get back to normal.” I admit I tend to think, “What we really need to do is create a new normal.” Prior to the pandemic, we had a high percentage of nurses who were experiencing moderate burnout and exhaustion. Additionally, caring for increasingly complex patients, working in stressful environments, experiencing staffing shortages, health inequities, and faculty shortages grew worse during the pandemic. Other examples of what we endured include an increase in the number of “early” retirements, workplace violence, and travel nurse assignments that were and are offering
higher pay and greater flexibility. These examples illustrate that it is time to shape the nursing profession for the future and create a “new normal.” I have always believed that nurses have the answers, and that belief continues to be validated through some of my national work. I recently served as a reviewer of proposals for the Johnson & Johnson Nurses Innovate QuickFire Challenge: Healthcare Transformation through Nurse-led Tech. It was inspiring to read about the amazing ideas many nurses have and are being funded to create. I am working with colleagues who are exploring new models of care and others who are using virtual technology to assist with admissions and discharges to decrease the workload of the nurses and assure smooth hand offs. All of these have a potential for TNA to spread that work and create new opportunities.
NEW STRATEGIC PLAN The TNA Board is beginning the strategic planning process and development of goals that will span the next two years. A series of TNA Nurse Chats have been set up as opportunities for nurses in the state to share what is on their mind about nursing. The sessions have been facilitated by one of us on the Board and supported by the TNA staff. This is one strategy for us to hear from all of
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you. We also encourage you to become involved in your local district meetings and/or serve on a committee. Visit texasnurses.org/MemberZone for more information.
NEW LEADERSHIP During this past year, I had the privilege of working with Dr. Tammy Eades, the board, TNA staff and the CEO, Dr. Cindy Zolnierek. As you know, Dr. Zolnierek will resign at the end of May to begin her retirement. She continues to provide mentoring and consultation to several TNA staff members. She has accomplished a lot during her tenure and is committed to assuring a smooth transition. Julia Menegay, who has been at TNA since 2010 and is currently chief operating officer, has agreed to serve as the acting CEO until the appointment of the next CEO is official. I would like to assure all of you that you are in good hands as we continue to move forward while a search committee is interviewing candidates for the position. As you can see, this is a lot of transition. We, your board, are paying particular attention to securing a new CEO, to creating the plan to carry us forward, to being responsive and visionary for nursing in Texas, and to attending to the numerous policy issues critical to advancing health and nursing in the state of Texas. I’m here to serve. Join me! i
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Foresight, Futures and Innovation Reimagine Nursing
TEXA S N URSE S
ANNUAL MEETING
ASSO CIATIO N
2022
June 24-25
Georgetown, TX
WHO SHOULD DETERMINE THE FUTURE OF NURSING? Since the onset of COVID-19, nurses have been challenged in new ways. Existing weaknesses in the system broke down entirely. At the same time, necessity resulted in innovation. While the future of nursing is less certain than ever, the opportunity for nurses to take the lead is here. How do you plan for the unknown? At the TNA Annual Conference, you’ll experience interactive learning, lively discussion, and leave having built tangible skills of foresight leadership. Join us in Georgetown, June 24 and 25, and begin the journey.
Speakers
DANIEL PESUT, PHD, RN, FAAN
ORIANA BEAUDET, DNP, RN, PHN
Principal Consultant at Strategic Foresight Consulting and Coaching
Honors
VP of Innovation ANA Enterprise
THURSDAY, JUNE 23 5:00 – 7:00 p.m.
Welcome Networking Reception
FRIDAY, JUNE 24
REGISTER TODAY For more information on program, tickets or sponsorship, visit texasnurses. org or follow this link. Silent Auction and Banquet require a separate ticket.
7:00 a.m. Breakfast Buffet 8:00 a.m. Welcome, Daniel Pesut Presentation 11:30 a.m. Annual Meeting and Lunch 1:30 – 4:00 p.m. Presentation, continued 5:00 p.m. Cocktails and Silent Auction 6:00 p.m. Leaders & Ledgends of Texas Nursing Foundation Gala
SATURDAY, JUNE 25 8:00 a.m.
Oriana Beaudet
Considering nurses as health care heroes led me to ensure that I had a foundational understanding: What is a “hero”? WHEN ASKED TO PROVIDE THE KEYNOTE address at a recent event, I found myself struggling with the theme: “Celebrating Health Care Heroes.” At the onset of the pandemic, nurses had initially embraced public celebrations of their contributions. But as each new wave hit, we became more exhausted and “hero” became a shallow echo that did not compensate for the trauma nurses experienced. How could I address this group about health care heroes without telling them they got it wrong? The following is a summary of my address. Considering nurses as health care heroes led me to ensure that I had a foundational understanding: What is a “hero”? Merriam-Webster provided this definition: 1.
A mythological or legendary figure often of divine descent endowed with great strength or ability;
2.
An illustrious warrior;
3.
A person admired for achievements and noble qualities;
Nurses:
4.
One who shows great courage;
5.
The principal character in a literary or dramatic work.
By Cindy Zolnierek, PhD, RN, CAE
Heroic actions are supererogatory — that is, they go beyond the person’s duty or obligation. Nurses have a duty of care to their patients, so how is what they did during COVID-19 heroic? While all heroic actions are supererogatory, not all supererogatory actions are heroic. Giving
Health Care Heroes?
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None of those definitions seemed to capture what we have witnessed from health care workers, especially nurses, during the pandemic. So, I looked to the academic literature and found a discussion differentiating heroism from altruism.1
money to charity may be supererogatory, but this is not a heroic action. Heroism is differentiated from altruism in that it involves voluntary engagement with an acknowledged degree of personal risk to help others (p. 510). Nurses have a duty of care to their patients—a special, positive moral duty that arises from the relationship between the nurse and patient. Such special duties are grounded in a social contract in which the profession has access to certain privileges, such as trust and self-regulation. In return, nurses have a duty to treat, which involves accepting a certain degree of personal risk.2 The duty to treat and the level of risk is limited. Provision 5 of nurses’ Code of Ethics3 states: The nurse owes the same duties to self as to others, including the responsibility to promote health and safety [and to] preserve wholeness of character and integrity (p. 19).”
Nurses have a duty of care to their patients—a special, positive moral duty that arises from the relationship between the nurse and patient. Such special duties are grounded in a social contract in which the profession has access to certain privileges, such as trust and self-regulation. In return, nurses have a duty to treat, which involves accepting a certain degree of personal risk. Reciprocity is an important component of the social contract. In return for accepting some personal risk in fulfilling their duty to treat, health care workers expect support in working in difficult conditions. What were the risks nurses faced that made their actions heroic? 1.
The very real risk of becoming infected and ill with COVID-19 or transmitting the virus to vulnerable family members, especially young children or elderly parents in the home. The fear of exposure was
Reciprocity is an important component of the social contract. In return for accepting some personal risk in fulfilling their duty to treat, health care workers expect support in working in difficult conditions. aggravated by inadequate and unavailable personal protective equipment while transmission of the virus was poorly understood. Nurses endured the emotional and financial cost of living apart from family for extended periods while working. 2.
3.
4.
Nurses encountered physical and mental exhaustion as they cared for increasing numbers of patients with severe illness and worked extended hours and days without adequate rest periods. Nurses were stretched thin caring for an increasing number of intensively ill patients, unable to meet their own ethic of care, and witnessing the delay or denial of care due to lack of staffed beds, all of which left many of them morally distressed. Nurses reported never experiencing so much death—especially the death of so many young and “healthy” people. Despite all their caring and attentiveness, nurses observed the same trajectory toward death over and over again. When family and friends were denied visitation at end of life, nurses became surrogates, holding hands and comforting patients as they passed. Many suffered compassion fatigue as a result. Finally, some nurses lost their health or lives due to COVID-19. Others mourned the loss of their colleagues—physicians, nurses, other health care workers—who succumbed to the illness itself or its sequelae, ranging from leaving the profession to suicide.
The pandemic resulted in dire working conditions for nurses in which they experienced not just risks but harm. Society did not live up to its side of the social
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contract: providing supportive working conditions. Initially the public celebrated nurses as heroes. Signs outside hospitals, nursing homes, and community clinics announced, “Health care heroes work here.” New York communities gathered in the evening with lights and noise makers to pay tribute to front-line workers. Businesses offered discounts or giveaways to nurses. TNA distributed thousands of yard signs to nurses proclaiming their heroism.
Nurses don’t want to be called heroes, nor do they see themselves as victims or martyrs. But they have suffered. But as the pandemic persisted, wave after wave, public sentiment changed. No longer were nurses celebrated. Instead, they often bore the brunt of the public’s frustration and anger manifesting in harassment and outright violence. Once again, reciprocity of the social contract failed. Nurses don’t want to be called heroes, nor do they see themselves as victims or martyrs. But they have suffered. Many experienced post-traumatic stress, anxiety, and depression. Some have become disillusioned with nursing and have left the profession, temporarily or for good. Others have found new purpose and meaning in their suffering and feel energized to act by:
Reassessing priorities and rebalancing their lives accordingly.
Working to improve their practice environment.
Achieving more decision-making authority to address safe staffing, workplace violence, and the design and use of technology.
Recognizing the importance of personal well-being and helping to eliminate the stigma associated with self-care and mental health.
So, what is the message for us nurses, educators and students? It is important to acknowledge that
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Nurses should insist on reciprocity from health care organizations for the social contract they share.
ADVANCE YOUR
EDUCATION. BECOME AN AGGIE NURSE.
nursing.tamu.edu
@tamunursing
It is important for nurses to reflect on Provision 5 of our Code of Ethics. Nurses have a responsibility to care for themselves. Such self-care includes seeking help and supporting others who seek help, including mental health support, without judgement. the pandemic has caused suffering— among patients, families, communities, and nurses. It is not my intention to glorify suffering; however, I believe there is purpose and meaning to be found in the experience of suffering. It can be transformative.4 Take stock of your experience, consider where and how you may have suffered, and consider what gift— what understanding or purpose—lies within that experience that is uniquely yours to embrace. I think it is important for nurses to reflect on Provision 5 of our Code of Ethics. Nurses have a responsibility to care for themselves. Such self-care includes seeking help and supporting others who seek help, including mental health support, without judgement. Educators—
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teach this value to your students. Part of nursing’s professional responsibility is to care for the profession. We do that by advocating for positive practice environments that provide nurses the opportunity to provide quality and effective patient care. Staffing levels driven by direct care nurses, strong violence prevention initiatives, and adequate rest periods are key. Nurses should insist on reciprocity from health care organizations for the social contract they share. Nursing is a noble profession with a strong tradition grounded in an ethic of care. We must always honor our duty to the patient and act in their best interest, to the best of our ability given our circumstances. It’s not about being heroes. And we must support our colleagues in this endeavor as well. i FOOTNOTES 1. Cox., C. (2020). ‘Healthcare Heroes’: problems with media focus on heroism from health care workers during the COVID-19 pandemic. Journal of Medical Ethics, 46: 510-513. 2. American Nurses Association (2010). Nursing’s Social Policy Statement: The Essence of the Profession. American Nurses Association, Silver Spring, MD. 3. American Nurses Association (2015). Code of Ethics for Nurses With Interpretive Statements. American Nurses Association: Silver Spring, MD. 4. Frankl, V. E. (1946). Man’s Search for Meaning. Beacon Press: Boston.
Nursing
Surveillance Focus for Nursing By Shery Wachtel, PhD, RN, CNS-CC, CCRN-K
NURSING SURVEILLANCE is a term defined for Nursing Intervention Classification (NIC) in 1995 (Bulecheck &McCloskey) as “purposeful and ongoing acquisition, interpretation and synthesis of patient data for clinical decision making. As this definition purports, nurses are actively and continually pulling vital and often critical information on each patient in their care in order to determine the best course of action. This is not a passive activity and carries the weight of nurse-sensitive indicators (NSI) determined to be directly responsible for patient outcomes dating back to mid1990s. Burston, Chaboyer and Gillespie (2013) conducted a review of the literature to identify NSIs studied more than a decade prior. This review identified 43 NSIs; the top 14 included falls, sepsis, shock and mortality. Pressure ulcers, central line infections,
If patient outcomes are the product nurses sell, why would anyone pay for a poor-quality product? pneumonia, urinary tract infections, wound infections and failure to rescue top out those earliest identified (19982002). In October 2014, the Centers for Medicare and Medicaid Services (CMS) began reducing Medicare reimbursements by 1% to hospitals in the bottom quartile of performance for hospital-acquired conditions (HAC). Not surprising, today’s HAC include conditions still attributed to nursing care. Though this penalty seems appropriate for underperforming hospitals, the focus of the HAC and NSI remains the nurse. If patient outcomes are the product
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nurses sell, why would anyone pay for a poor-quality product?
FOCUS ON THE NURSE Using nursing surveillance as the premise for quality patient outcomes requires several assumptions:
Continuous data acquisition, interpretation and synthesis yields better decision-making
Nurses will have all the information all of the time
Nurses will make the right decision every time
Nurses will act based on the right decision
Actions taken will be the right action for the decision
The concept is now complicated by, at best, five points of failure for the nurse.
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A closer look at the day in the life of nursing may provide very convincing insight on the “human factor.” What, if anything, has been done to mitigate these fail points? The last two decades have seen numerous initiatives to mitigate surveillance and decisionmaking fail points with little improvement seen in patient outcomes, specifically length of stay and unexpected cardiac arrests (Cochrane Review, 2007; updated 2021). These include such initiatives as Critical Care outreach (McArthurRouse, 2001), Early-warning systems (Cardona-Morrell, Prgomet, Turner, Nicholson & Hillman, 2016; Cochrane Review, 2021; Downey, Tahir, Randell & Jayne, 2017; Le Lagadec & Dwyer, 2016), and Rapid Response Teams (DeVita, Smith, Adam, Adams-Pizarro, Buist, Bellom, et.al, 2010; Sandroni, D’Arrigo & Antonelli, 2015). The most common factors identified as contributors to results of these initiatives were crisis recognition (DeVita, Smith, Adam, Adams-Pizarro, Buist, Bellomo, et. al, 2009) and human factor. The human factor component reported Al-Moteri, Plummer, Cooper and Symmons (2018) specifically identified the human factor component as delays in recognition and response with a lack of improvement despite training. In this study, they reported that while 81% of deteriorating patients could be identified early just 12% of nurses had concerns. In 43% of the patients with abnormalities, the staff was unaware of deterioration. Final discussion
suggested human behavior and ward culture were the underlying reasons for failure to interpret signs of deterioration and a choice not to escalate. Have any of the initiatives introduced over the last two decades to assist nurses in actively performing nursing surveillance successfully improved quality patient outcomes or made an impact on the assumptions for successful surveillance? To answer this, we must include key factors identifiable in the clinical environment today. Factors that must be considered include staffing levels, skill mix for existing staffing matrices, daily workloads, and the practice environment.
WORK ENVIRONMENT A closer look at the day in the life of nursing may provide very convincing insight on the “human factor.” Between 2009-2015, total medical/surgical capacity in the acute care setting approximated 75%-82% of all hospital beds (Wallace, Angus, Seymour, Barnato, Kahn, 2015). In these units, vital signs (VS) have become a standard of care for assessment of patient condition and stability. Repeated studies for almost two decades show this standard to be incomplete. In one of the earlier studies, Ludikhuze, Smorenburg, Rooij and de Jonge (2012) reviewed 2,688 sets of VS and found most recorded to
Picture 1. Visual display of integrated monitoring with data-fusion to produce an index of patient instability.
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Picture 2. Maintaining the visual graphic of patient stability using integrated monitoring with data-fusion to produce an index of patient instability.
be incomplete containing only one or more parameters. Even in patients with a Modified Early Warning Score (MEWS) ≥ 3, respiratory rate (RR) and pulse oximetry (SpO2) was documented in only 30%-66% of VS assessments. If Certified Nursing Assistants (CNA) are routinely taking VS, are they reporting abnormalities to the RN immediately upon taking? Or, is their workflow to take readings from 10 or more patients assigned to them and only then document them? How long is the delay between taking VS and documenting or notifying the nurse? If the focus continues to point to nursing, why would a nurse not be able to identify patient instability? If we give them tools to identify patient instability, why would a nurse choose not to act? If we educate them on how to act when a specific event is identified, why would they make a wrong decision about subsequent actions? Dall’Ora, Griffiths, and colleagues (2019) reviewed VS taken every four hours in relation to nurses and CNAs working 12hour shifts across 32 inpatient acute care units. They reported 53% of the VS were delayed (> 1.3 hours) and 44% missed (≥ 2.6 hours) and VS were more likely to be delayed when increased CNA hours were part of 12-hour shift. Yen, Kelly, Saha, Loversidge, Chipps, Gallagher-Ford and Buck reviewed nursing activity in a 12-hour shift. The shifts were divided into four-hour blocks for review. The study reported the highest interruptions were from 7:00 a.m. to 11:00 a.m. with the average nurse receiving 124 communications in four hours. If you
Three types of technological solutions have emerged over the last decade: machine-learning, deep learning and integrated monitoring using data-fusion for predicting the instability before serious events occur. break that down, it is equivalent to 31 communications per hour or essentially every two minutes. In that same fourhour block, the nurse performed 208 hands-on tasks with multi-tasking occurring 131 times (39.5%). The duration of the multi-tasking events ranged from 14.6 minutes to 109 minutes with the average time for multi-tasking being 45 minutes per occurrence.
INNOVATIVE SOLUTIONS With this very enlightening evidence on the continued bombardment of data, communication, and interruptions, is there any wonder why nursing surveillance has shown little change in patient outcomes? This patient care environment with increasing shortages in the workforce calls for solutions that can impact patient care delivery and technology that can accumulate and interpret data readily, to clearly present a nurse with evidence of patient deterioration. Three types of technological solutions have emerged over the last decade: machine-learning, deep learning and integrated monitoring using data-fusion for predicting the instability before serious events occur. Machine-learning uses VS data compiled from documentation to learn patterns
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and relationships of various parameters (Muralitharan, Nelson, Di, et al, 2021). The limitation here is the source of the VS. If VS are manually entered in an electronic EMR, the trends and relationships are dependent on recording of all parameters and the accuracy of the parameters entered. On the other hand, if electronically captured the accuracy improves but only if all parameters are captured for the correct patient and time. Deep learning takes VS data acquisition and evaluation a step further to learn relationship of VS trends or patterns to specific events such as cardiac arrest (Kwon, Lee, Lee & Park, 2018) or mortality. Again, this model is as accurate as the source of the VS data and how it was acquired in the medical record. The final and likely the most innovative solution is integrated monitoring. This method pulls bio-physiologic data or VS directly from the patient monitoring systems without the need for manual data entry. VS are retrieved directly from the point of care monitoring systems with accurate patient identification, often through the use of barcode scanning the patients’ armband, and submitted in real-time for analysis. The analysis uses a method known as data-fusion to evaluate each parameter trend individually in addition to the relationship between parameters. This relationship is displayed as an index from zero (little to no instability) to five (high level of instability. A final component of integrated monitoring is the learning of patient parameters so that changes are individualized to each patients’ bio variability. This allows alerts and warnings to be reflective of each unique patient and not dependent on the standard alarm defaults found in
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vendor proprietary systems applied to all monitored patients (VISENSIA, OBS Medical). The index can be displayed on a continuous tracker (Patient Watch, Hillrom) for a clear visual warning system depicting change in patient stability all in real time. The graphic in pie graph format allows the care providers to see the VS parameters contributing to the index changes (Picture 1).
SUMMARY Implementation of innovative solutions that can essentially ”tap a nurse on the shoulder” as notification of significant changes in patient conditions creates an ideal tool to enhance nurse surveillance in today’s hectic environments with constant interruptions and continued staffing challenges. i REFERENCES Bulecheck, G.M., McCloskey, J. C. (1995). Nursing interventions classifications (NIC). Medinfo. 8 Pt 2, 1368. Cardona-Morrell, M., Prgomet, M., Turner, R. M., Nicholson, M., Hillman, K. (2016). Effectiveness of continuous or intermittent vital signs monitoring in preventing adverse events on general wards: a systematic review and meta-analysis. International Journal of Clinical Practice. 70(10), 806-824. Dall’Ora, C., Griffiths, P., Redfern, O., Recio-Saucedo, P. M., Ball, J. (2019). Nurses’ 12-hour shifts and missed
Implementation of innovative solutions that can essentially ”tap a nurse on the shoulder” as notification of significant changes in patient conditions creates an ideal tool to enhance nurse surveillance in today’s hectic environments with constant interruptions and continued staffing challenges. or delayed vital signs observations on hospital wards: retrospective observational study. British Medical Journal.8; 1-6. DeVita, M. A., Smith, G. B., Adam, S. K., Adams-Pizarro, I., Buist, M., Bellomo, R., Bonello, R., Cerchiari,E., Farlow, B., Goldsmith, D., Haskell, H., Hillman, K., Howell, M., Hravnak, M., Hunt, E. A., Hvarfner, A., Kellett, J., Lighthall, G. K., Lippert, A…Winters, B. (2010). Identifying the hospitalized patient in crisis – A consensus conference on the afferent limb of Rapid Response Systems. Resuscitation. 81, 375-382. Downey, C. L., Tahir, W., Randell, R., Brown, J. M., Jayne, D. G. (2017). Strengths and limitations of Early Warning Scores: a systematic review and narrative synthesis. International Journal of Nursing Studies. 76, 106-119. Kwon, J., Lee, Y., Lee, Y., Lee, S., Park, J. (2018). An Algorithm Based on Deep Learning for Predicting In-Hospital Cardiac Arrest. Journal of American Heart Asssociation. 13(10).
Lukikhuize, J., Smorenburg, S., de Rooij, S., de Jonge, E. (2012). Identification of deteriorating patients on general wards; measurement of vital parameters and potential effectiveness of the Modified Early Warning Score. Journal of Critical Care. 27. 424.e7-424.e13. Muralitharan, S., Nelson, W., Di, S., McGillion, M., Devereaux, P.J., Barr, N., Petch, J. (2021). Machine Learning-based Early Warning Systems for Critical Deterioration: Systematic Scoping Review. Journal of Internet Research. 23(2). McArthur-Rouse, F. (2001). Critical care outreach services and early warning scoring systems: a review of the literature. Journal of Advanced Nursing. 36(5), 696-704. Sardoni, C., D’Arrigo, S., Antonelli, M. (2015). Rapid response systems: are they really effective? Critical Care. 19:104. Wallace, D., Angus, D., Seymour, C., Barnato, A., Kahn, J. (2015). Critical Care Bed Growth in the United States. American Journal of Respiratory Critical Care Medicine. 191(4). 410-416. Yen, P, Kelley, M., Lopetegui, M., Saha, A., Loversidge, J., Chipps, E., Gallagher-Ford, L., Buck, J. (2018). Nurses’ Time Allocation and Multitasking of Nursing Activities: A Time Motion Study. AMIA Annual Symposium Proceedings. 1137-1146.
Dr. Sheryl "Shery" Wachtel has more than 40 years of nursing experience from staff nurse to supervisor. She now works with hospital leadership on clinical issues that require technology solutions and participates in product research studies. She enjoys spending time with her four children and seven grandchildren.
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ALLEVIATING THE NURSE SHORTAGE IN TEXAS: HOW TNA IS WORKING TO EFFECT CHANGE1 By Jack Frazee, JD IT IS NO SECRET that Texas, like other states, is facing a nursing shortage. This shortage is making it difficult to fully staff clinical practice settings across the state. During the peak of past COVID-19 waves, heavily hit regions of the country needed nurses to travel from across the country to support their response. As a result, those who stayed home were spread thin, serving large numbers of patients. This phenomenon impacted nearly every aspect of nursing practice from workload to wages. The underlying problem is one of supply and demand. Texas already had a shortage of nurses prior to the pandemic that the state had been working to ameliorate. In 2001, the Texas Legislature passed Senate Bill 572, which found that, “Texas is experiencing a significant shortage in the registered nurses it needs [and] it is necessary to increase the number of registered nurses in the state to protect the health, safety and welfare of the public.” According to the nurse supply and demand projections published by the Texas Center for Nursing Workforce Studies in 2020, Texas will have a deficit of 57,012 registered nurses (RNs) in 2032.2 The findings of the Legislature and the Center recognized a problem even before the pandemic took a further toll on the nursing workforce. The shortage has become worse as nurses experience unbearable workplace pressures and leave the hospital setting. The Texas Center for Nursing Workforce Studies will provide additional information about the nursing shortage after conducting a new survey later this year. Meanwhile, TNA has been working with state officials to alleviate the shortage. On December 20, 2021, Governor Abbott announced that he would allocate $25 million from the Governor’s Emergency Education Relief Fund to “support Texas nurses through loan repayment, financial aid for nursing students, and to accelerate innovation in nursing education.” Since his announcement, TNA briefed the Governor’s staff and agency employees on how these funds could be used most efficiently. TNA is pleased to say the state is hard at work to distribute these
This moment in nursing presents challenges and opportunities. The pandemic has revealed weaknesses in the healthcare system and even threatened to break an already strained workforce. However, those weaknesses may also be seen as opportunities to innovate and improve. funds and boost the supply of nurses in Texas. These emergency funds are only the first step required to train more nurses and alleviate the nursing shortage in Texas. New data from the Center for Nursing Workforce Studies, due to be published later this year, will tell us how significantly the pandemic exacerbated the existing shortage. TNA will use this data to inform requests for additional funding of nursing education in the coming session. This moment in nursing presents challenges and opportunities. Working short-staffed is clearly a strain on nurses. The pandemic has revealed weaknesses in the healthcare system and even threatened to break an already strained workforce. However, those weaknesses may also be seen as opportunities to innovate and improve. This provides an opportunity to imagine a better future for nurses. Now is the time for nurses to consider what lessons they want to impart on the next generation of nursing professionals, to consider what kind of leaders they want to be, and to consider the value of their mentorship to others. Now is the time for Texas nurses to manifest the future they desire. TNA will continue to inform its membership of funding developments and opportunities as the state works to address the shortage it faces. i FOOTNOTES 1. Senate Bill 572, 77th Texas Legislature (2001). 2. “Updated Nurse Supply and Demand Projections 2018-2032,” Texas Health and Human Services – Texas Department of State Health Services (July 2020), available at: Updated Nurse Supply and Demand Projections 2018-2032 (texas.gov)
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Designing the Future Improving Bedside Training from Houston to the World By Lisa Maxwell with Michael Pickett, MSN, APRN, PNP-BC
Nurse innovator Michael Pickett, MSN, APRN, CPNP developed a line of RediStik Wearable PIV, Port and CVC Simulation Task Trainers to improve the experience of teaching nurses procedural skills for all skill levels.
WHEN THE AMERICAN NURSES ASSOCIATION announced the 2022 Innovation Team Award (sponsored by Stryker) winners, TNA member Michael Pickett, MSN, APRN, CPNP was at the top of the list. Pickett, along with a group of colleagues at Texas Children’s Hospital and Baylor College of Medicine, was awarded the Nurse-Led Team Award for the development of a line of RediStik Wearable PIV, Port and CVC Simulation Task Trainers, which use realistic materials initially developed in Pickett’s own laundry room and finalized into production designs with Sawbones, to improve the experience of teaching nurses procedural skills for all skill levels. Pickett, who has been a pediatric nurse practitioner for more than 20 years, gradually became more interested in the idea of product development. In 2016 Texas Children’s Hospital (TCH) instituted an intellectual property policy which opened the door for employees to pursue development of new products or processes that could potentially deliver revenue back to both the organization and the employee. “I was interested in product development and the innovation process,” said Pickett, “but I did not anticipate how much work it was going to be.” A mentor advised Pickett to do a needs assessment and he quickly identified a need for better clinical simulation training tools for procedures. For the first project, Pickett decided to build a better peripheral IV (PIV) trainer. Pickett talked to end users about what they needed compared to what existed at the time. “Simulation trainers weren’t very realistic,” said Pickett, “and skills videos were too long and not filmed from the nurse’s perspective.” Based on feedback from the Simulation Center and nurse educators, Pickett determined that creating a wearable trainer would be more effective by providing opportunities to learn positioning techniques and add versatility at the same time because it can be worn on a person, mannequin or used
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as a table-top trainer. He also thought the trainers needed to feel more like the real thing when visualizing and palpating the skin and still look new after hundreds of needle sticks.
A mentor advised Pickett to do a needs assessment and he quickly identified a need for better clinical simulation training tools for procedures. For the first project, Pickett decided to build a better peripheral IV (PIV) trainer. Pickett talked to end users about what they needed compared to what existed at the time. Pickett approached the Innovation Department at TCH and secured a small amount of funding. With that, he began experimenting with prototypes in his laundry room at home. After researching how silicone stage makeup is made, and using his kids as models, he went through multiple iterations to get the right feel and resistance of the trainer tissue. With his self-developed model in hand, Pickett then coldcalled a few companies to learn more about what was involved in creating a more polished prototype suitable for testing. One such company, Sawbones, specializes in developing orthopedics and other custom medical simulation products. Pickett spoke to the president of new product development and a few months later visited Sawbone’s factory to demonstrate his prototypes and discuss design goals and a budget. A match was made, and Sawbones became the development and distribution partner for RediStik. With next generation prototypes in hand, Pickett then convened a small focus group of seasoned professionals to test the device and used their input to refine the designs, which went through more than 20 iterations.
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Rather than let cost become a barrier, Pickett got creative. After dialing in his tissue formula for the PIV trainer, he asked medical device company Angiodynamics for expired port catheters and double lumen central line catheters to use for product development in the RediStik Port and CVC Trainers, and looked to other hospital departments, including respiratory therapy, biomed and “all the supply chain people in the innovation council,” for supplies.
A study performed by Global HOPE found only 19% of IVs were successful after three or fewer sticks. After training with Redistik PIV trainer, that number increased to an amazing 96%. The Global HOPE team published their results in the Journal of Pediatric Nursing. Although Pickett was the driving force behind RediStik's development, he received support from across the hospital, including:
TOP LEFT: Nurse successfully starting IV while the RediStik Wearable PIV trainer is worn on a mannequin. BOTTOM LEFT: Flushing newly placed IV on RediStik Wearable PIV Trainer, accessing RediStik Wearable Port Trainer and confirming correct needle placement with blood aspiration, Sterile dressing placed on RediStik Wearable CVC Trainer. ABOVE RIGHT: Nurses in Malawi learning how to place an IV on the RediStik Wearable Trainer.
The legal department helped with compliance and developing contracts with outside vendors.
The product engineers at Sawbones helped to improve the product.
Frontline clinicians provided crucial input throughout the development process regarding usability and other requirements.
A multidisciplinary team in the Innovative Solutions Council that helped him test and roll out the products.
The Business Innovation department that provided mentorship and startup funds.
The Quality Improvement team, from whom he learned how to build and administer surveys.
Nurse educators who brought their expertise in writing set-up instructions for the trainers and helped produce the skills videos developed while using the trainers.
Once RediStik Wearable Trainers were created, they were piloted in 14 clinical areas at TCH in Houston and through the Global HOPE cancer clinics in sub-Saharan Africa for use in chemotherapy administration via peripheral IVs. A study performed by Global HOPE found only 19% of IVs were successful after three or fewer sticks. After training with Redistik PIV trainer, that number increased to an amazing 96%. The Global HOPE team published their results in the Journal of Pediatric Nursing.
The marketing department, where he learned about script writing and video editing and production. They also assisted him with building a website.
The TCH Nurse Residency Program in Houston implemented peripheral intravenous (PIV) skills training using the RediStik PIV Trainers. Prior to training, only 15% of these new nurses said they
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ABOVE: "Nurses in Nurse Residency program at Texas Children’s Hospital learning how to place an IV on the RediStik Wearable Trainers. ABOVE RIGHT: Michael Pickett, MSN, APRN, PNP-BC.
felt confident in inserting a PIV. After completing training, 96% said they now felt confident in inserting a PIV. Pickett said that although he received support from his supervisors, colleagues, and the institution, it was ultimately his own determination that kept the project moving forward. Since receiving the 2022 ANA Team Innovation award, he now can give back to the units who helped pilot and implement the RediStik PIV, Port and CVC Trainers, and the RediStik team will continue to drive quality improvement initiatives with a global impact.
Since receiving the 2022 ANA Team Innovation award, Pickett now can give back to the units who helped pilot and implement the RediStik PIV, Port and CVC Trainers, and the RediStik team will continue to drive quality improvement initiatives with a global impact.
The RediStik Wearable Trainers are being used globally and are available via Sawbones website. The trainers are finding additional uses as well; Pickett was recently invited to attend a trade show where an IV filter line vendor used RediStik trainers to demonstrate their own product and have plans to use them at all their shows both in US and abroad. Global HOPE in subSaharan Africa and TCH in Houston are realizing the trainers’ value in training both patients and parents on how to perform venipunctures and accessing ports to administer lifesaving medications in high-risk patient populations. Pickett’s advice to other nurse innovators:
He hopes that hospital administrations see the value in such projects and continue to make it easier for nurses to innovate. “It’s easy to inspire frontline staff to come up with new ideas,” he said. “Barriers tend to be time and money, although a big hurdle for nurse-led innovation is that nurses are trained to avoid risk. Creating and testing a new idea comes with some risk that could be financial or just the perception of looking stupid if it does not turn out great.”“We have all these missed wins because good ideas aren’t brought to light due to fears that the idea may not be amazing or the person with the idea does not know where to start. There is a ton of lost opportunity. My hope is, the more innovative accomplishments that are highlighted by frontline clinicians, leadership and businesses will see the value in supporting frontline innovation.”
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Pickett is proud of RediStik and its growth as a product line. “My favorite part continues to be finding the need and then making a product that exceeds the need and design goals. It was also an opportunity for my two teenage boys to see the value of not giving up.”
Find out if your employer has a structured innovation department or program and an intellectual property policy in place that might allow you to share in potential profit.
Do research to make sure your idea doesn’t already exist.
Build rough prototypes at first to get user feedback. This helps garner momentum and support of your concept
Get feedback from qualified people
Have a script in place that works well so that end users understand what you are hoping to achieve, and so that they know what you need and can answer relevant questions.
Most importantly, Pickett said, just start. Don’t succumb to analysis paralysis. i FOOTNOTES Improving Peripheral Intravenous Catheter Care for Children with Cancer Receiving Chemotherapy in Malawi. Published in the Journal of Pediatric Nursing, November 2020 https://doi.org/10.1016/j.pedn.2020.09.019 To learn more about the RediStik Wearable Trainers, including teaching videos and presentations, visit: www.sawbones.com/catalog/training-models/redistik.html and www.texaschildrens.org/redistik Feel free to email Michael Pickett at mtpicket@texaschildrens.org with questions.
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