texa s nu r s e s .o rg
TEXASNURSING M A G A Z I N E
Innovation & Foresight Creating a Shared, Preferred Future
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 4 , 2 0 2 1
ISSUE 4, 2021 Volume 95, Number 4 EDITOR IN CHIEF: Cindy Zolnierek, PhD, RN, CAE MANAGING EDITOR: Lisa Maxwell COPY EDITOR: Gabi Nintunze 4807 Spicewood Springs Rd., Bldg 3, Suite 100, Austin, TX 78759-8444 P: 800.TNA.2022 or 512.452.0645; F: 512.452.0648
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
Colleen Marzilli, PhD, DNP, RN, CNE, NEA-BC, Secretary cmarzilli@uttyler.edu
Nelson Tuazon, DNP, DBA, RN, NEA-BC, CENP, CPPS, CPHQ, FANP, FACHE, FAAN, Treasurer Nelson.Tuazon@uhs-sa.com
tna@texasnurses.org | texasnurses.org
MISSION Empowering Texas Nurses to advance the profession
DIRECTORS: Patricia Freier, MSN, RN-BC, CPHQ pfreier@covhs.org
VISION
Lucindra Campbell-Law, PhD, ANP, APRN, PMHNP, BC campbel1@stthom.edu
Nurses transforming health
Edtrina Moss, PhD, RN-BC edtrina@comcast.net
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
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.
CHIEF EXECUTIVE OFFICER: Cindy Zolnierek, PhD, RN, CAE
TNA DISTRICT AND PRESIDENT 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
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.
Dist. 17: Mari Cuellar, NEA-BC, MSN, RN mgrace2329@yahoo.com
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.
Dist. 35: Karen Koerber-Timmons, PhD, RN, CLNC, CNE, NEA-BC, CCRN, RN-BC mkkoerbertimmons@gmail.com
Dist. 18: Janice L. Miller, MSN janice.miller@umchealthsystem.com Dist. 19: Anita Lowe, RN alowe@uttyler.edu
At-Large: Contact TNA, 800-862-2022, ext. 129 brichey@texasnurses.org
Copyright 2021 © Texas Nurses Association
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INNOVATION IN PRACTICE
Nurses As Agents of Change
Foresight, Futures, and Innovation
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12
Questioning
Pioneering Wellness
the Question Reducing Stigma Toward People with Mental Health Conditions
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Contents IN EVERY ISSUE
ARTICLES AND FEATURES
5
9
14
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PRESIDENT’S NOTES
TNA NEWS
Writing on the Wall
What's New and Next
Texas Nurses Shape History
Professional Regulation, Peer Review, and Safety:
Innovation and Foresight
The Nurse Leader's Role
6 TNA MEMBER NEWS Kudos and Appointments
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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.
I S S U E 4 , 2 0 21 | T E X A S N U R S I N G M AGA Z I N E
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President’s Notes Tammy Eades, DNP, MSN, RN
INNOVATION AND FORESIGHT What Lies Ahead for the Most Trusted Profession AS WE HEAD into the changing seasons of 2021 and the new year of 2022, we as nurses need to focus on innovation and foresight to meet the needs of our patients and peers. Innovation will be crucial in continuing the success of TNA and keeping up with the evolving landscape of our profession. Foresight will enable us to predict what is necessary for the future of Texas nurses. Both innovation and foresight can empower us as nurses to create a brighter future. As we see the numbers of nursing faculty and practicing nurses decline across Texas, we must strive to promote the true image of nursing and what we do as nurses. First, we need to stop saying we are “just” a nurse. Instead, proudly say “I am a nurse!” We have been called the most trusted profession for a reason, and we should be proud of that. Always be ready to take advantage of opportunities to promote nursing. Educating the public about a nurse’s job is extremely important to prevent misconceptions. Most importantly, do not suppress your enthusiasm about being a nurse. Sincerely
accept gratitude from people, because you do make a difference. Regarding legislation, we need to communicate to our state and local lawmakers the importance of maintaining our nursing shortage reduction and faculty loan repayment funding. Each year we lose more money for support of these critical jobs. We need to think outside the box about how we can increase the number of practicing nurses and nursing faculty. This is where innovation comes in—be creative and proactive. Be a voice for nursing and nurses and get involved in different ways organizationally, legislatively, and within your community to create change in our profession. The future holds many opportunities for nurses as change makers, and we need to have the foresight to be prepared for what our future as nurses in Texas holds. Be ready to step up to meet those changes. I wish every one of you a very happy holiday season. Please spend some time for yourself and with your loved ones. I sincerely and personally thank you for all you do. i
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TNA MEMBER NEWS SPOTLIGHT ON YOU KUDOS Dr. Mari Tietze, PhD, RN-BC, FHIMSS, FAAN has been selected for the Myrna R. Pickard Endowed Professorship at The University of Texas at Arlington. Tietze will also be an affiliate of the Multi-Interprofessional Center for Health Informatics on behalf of nursing. Tietze is a recognized expert in psychosocial nursing, holistic patient needs, and expansive health services distribution. As an experienced nursing educator and researcher, Tietze will also work closely with faculty in the College of Nursing and Health Innovation (CONHI) to advance interprofessional research and innovation in technology, health informatics, and nursing education. She will play a critical role to UTA in advancing health informatics education by supporting its upcoming Health Informatics Master’s in Nursing specialty, and associated interprofessional certificates. Sarah J. Williams, PhD, DNP, NPD-BC, CNE, ANEF, was recognized as a recipient of the Distinguished Alumni Award during the annual Baylor University’s Louise Herrington School of Nursing 2021 Reunion. Dr. Williams celebrated 50 years of practicing nursing. She is currently Professor Emeritus with the Ila Faye Miller School of Nursing, University of the Incarnate Word where she served for 14 years on faculty and as director of the RN-BSN-MSN nursing program. A proud veteran of the USAF, she served for 30 years in a variety of nursing roles. Since retirement, she continues to give back to the profession through volunteering and sharing her expertise within various professional organizations.
Dr. Cynthia Stinson, PhD, RN-BC, JoAnne Gay Dishman School of Nursing associate professor and department chair, has been appointed by Gov. Greg Abbot as a member of the Texas Health Services Authority Board of Directors. Stinson is a member of the Texas Nurses Association, American Nurses Association and Sigma Theta Tau International Honor Society. She is also a member of and medical educator for the Gift of Life program. With 47 years of experience in the field, Stinson serves as the only nurse on the board.
APPOINTMENTS
TNA welcomes Director of Communications Lisa Maxwell to the staff! Maxwell is a fifth-generation Texan and a proud graduate of the University of Texas at Austin, with degrees in Journalism and English. Her previous roles include marketing and communications work at a variety of nonprofit organizations. Welcome Lisa!
Awards Committee Belinda Gallegos, Chair Christi Candelaria Jennifer Cook Nisha Jobin Mathews Alaina Tellson Marcella Upshaw Lisa Velasquez
[ CAREGIVER ] CARE FOR THE
In disaster situations, nurses must care for others while caring for themselves and their family. Texas Nurses Association and Texas Organization of Nurse Executives, with support from Johnson & Johnson, developed Care for the Caregiver to help nurses before, during and after disasters.
Watch videos, download free resources, and get more information on preparedness, resiliency, and self-care.
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At their July 2021 meeting, Texas Nurses Association Board of Directors finalized appointments to the following structural committees: Audit/Finance Committee Nelson Tuazon, TNA Treasurer, Chair Richard Bays Kimberly Curtin Stephanie Foster Katherine Kreis Gloria Loera Colleen Matzke Casey Power Barbara Walker Patti White
Bylaws Committee Phalassa “Lasi” McArthur, Chair Naoshia Carroll Jenni Rogers More Member News on page 8
Member News continued from page 6 Joicy Thomas Deborah Tran Communications Committee Edtrina Moss Joyce Bernardo-Uhlmer Lisa Boss Sorayah Bourenane Miguel Charon Cory Church Elizabeth Clark Kimber Cockerell Sarah Graff Ashley Holmstrom Amy McCarthy Susan McKee Opeyemi Ogunniyi Antonia Perez Christine Roberts Chasity Shaw Governmental Affairs Committee Todd Bailey, Chair Belinda Alvalos Amy L. Anderson Lauren Gaudette Monica Jimenez Laura Kidd Kinya Mitchell
Patricia “Pat” Morrell Olusola “Sola” Oyewuwo Sarah Perry Evan Porter Steven Powell Tracey Ramsey-Abbott Richard Sambrook Ruth Whitehead Kelley Renee Yarbrough-Yale Policy Council Colleen Harris Marzilli, Chair Jim Allard Lori Batchelor Richard Beard Lisa Campbell Nancy Crider Tonya Fagan Nancy Fahrenwald Lori Hull-Grommesh Stephanie Morgan Dru Riddle Catherine Robichaux Poldi Tschirch i Please send member news (e.g., promotions, awards, board or committee appointments) to editor@texasnurses.org.
PAC DONATION
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HAVE YOU MET THE $20 CHALLENGE YET? TEXAS NURSE PAC is the officially sponsored political action committee (PAC) of the Texas Nurses Association. We contribute to candidates on both sides of the aisle. Help TNA refresh its financial PAC resources to help candidates who support nursing and health care. If every member donated just $20, we could have a fighting chance at the Capitol!
Give at texasnurses.org/PAC. Contributions to TEXAS NURSE PAC are not deductible as charitable contributions for federal tax income purposes.
TEXAS
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TNA NEWS WHAT'S NEW AND NEXT SAVE THE DATES!
TNA REPRESENTS YOU!
Mark your calendar for the following TNA events!
In the past quarter, TNA has:
February 15, 2022 Leaders & Legends of Texas Nursing nominations due The Leaders and Legends event honors nurses who have advanced the profession through their involvement with TNA. We welcome nominations of exceptional nurses across Texas.
Provided testimony to the House Appropriations and Senate Finance Committees re: funding to address the nursing shortage
June 24−25, 2022 TNA Annual Meeting Follow TNA on Twitter. @TexasNursesAssn
Represented you at Texas Board of Nursing
House Public Health Committee re: health care access in border communities – elimination of barriers to APRN practice and funding to address the nursing shortage
Texas Center for Nursing Workforce Studies
DSHS Expert Vaccination Allocation Panel
DSHS Schools Testing Program and funding School Nurses
TNA Wants You!
HHSC Quality Providers
TNA is looking for volunteers, committee members and issue advisors to participate in programs and policy work.
Value-Based Payment Quality Improvement Advisory Council
Texas Health Care Industry Strike Force
Whether you want to learn something new, have a voice in nursing policy and practice or meet other nurses from across the state, there's an opportunity for you.
In-person meeting with White House Vaccinations Coordinator Dr Bechara Choucair
RWJF/CCNA Campaign for Action
Texas Public Health Coalition
Visit our website to learn more:
Texas Medical Board invitational meeting on pain management
texasnurses.org/page/Involved
Responded to 28 press inquiries about nursing shortage and staffing. i
If you have received: Letter of Investigation from the Texas Board of Nursing Notice of Peer Review
Joyce Stamp Lilly RN JD Registered Nurse and Attorney
713.759.6430 jslilly@me.com www.nurse-lawyer.com
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Foresight, Futures, and Innovation By Cindy Zolnierek, PhD, RN, CAE CEO, Texas Nurses Association
FORESIGHT IS A “SYSTEMATIC, MULTI-STEPPED PROCESS for discerning, analyzing, and acting on potential futures.”1. It is a process of considering the future. Organizations typically use some level of foresight processes in strategic planning efforts. The traditional strengths, weaknesses, opportunities, and threats (SWOT) analysis is a popular model. Yet such models are limited by focusing on the current state, rather than anticipating the future.
identifies a preferred future that can be planned for and acted on to become a reality.
Drivers of change represent trends that enable forecasting, or the imagining of a range of possibilities and potential futures. Envisioning then identifies a preferred future that can be planned for and acted on to become a reality.
Ten out of the 50 current drivers of change, as identified by the American Society of Association Executives Foundation, include:2
Another environmental scanning approach considers drivers of change, internal and external factors likely to shape the future. Factors may comprise social, technical and scientific, economic, political, and business (STEPB) domains. Drivers of change represent trends that enable forecasting, or the imagining of a range of possibilities and potential futures. Envisioning then
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Our peri-pandemic world has disrupted all STEPB domains, accelerating change and innovation in unimagined and unrealized ways.
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Automating work: innovative robotics, affective computing Diversity, equity, and inclusion: increased diversity against backdrop of polarization Ethical consumption: younger generations’ concerns about social and environmental issues Healthcare disruption: more retail-like experience, unbundling, nontraditional actors Hybrid meetings: developing technologies create new modes of interactions Immigration driven demography: reshaping demographics, values, attitudes New forms of work: freelance, gig, contract, temporary work Next-gen professionals: next-gen and Gen-Z differ in outlooks
Socializing reshaped: digitally mediated social interaction A world reshaped by COVID-19: patchwork of regressing and accelerating trends
Foresight is not limited to strategic planning. it is key to innovation. Imagining a desired future— whether that involves access to care of rural communities, public health emergency preparedness, an antiracist culture, or personal retirement—involves foresight, and opens the door to ideas for a new, creative, better way to get there. Foresight is not limited to strategic planning. it is key to innovation. Imagining a desired future—whether that involves access to care of rural communities, public health emergency preparedness, an antiracist culture, or personal retirement—involves foresight, and opens the door to ideas for a new, creative, better way to get there. Innovation is not the same thing as original thinking; rather, it often involves repurposing an idea from one domain to another.3 How can nurses use foresight to spark innovation and create a new reality for practice, education, and policy in our shared future? Consider what nurses are already doing:
You Care.
n n n
n
New higher starting salaries for RNs Health and retirement benefits Paid vacation leave and up to 15 paid holidays a year Shift differential pay
Contracting directly with health care organizations for the shifts, days, and rates they choose, such as with the Nurseify app or travel nursing hub Trusted Health.
Delivering care through hospital at home programs as with the American Hospital Association.
Educating through high fidelity virtual reality simulations like SimX
Expanding telehealth and telemedicine avenues and payment policies
TNA’s Board of Directors will be learning more about foresight competencies as they develop a new strategic plan and envision a better future for the association in 2022. TNA members are invited to join us in this work. In addition, watch for notice of our 2022 annual meeting targeting Foresight, Futures, and Innovation as you plan what comes next! i REFERENCES 1. Rhea, M. (2017). Why associations need foresight. ASAE Foundation. https://www. asaecenter.org/publications/109498-why-associations-need-foresight 2. ASAE Foundation (2021). Drivers of Change: Summaries and Forecasts. https:// www.asaecenter.org/publications/109508-drivers-of-change-summaries-of-41-keytrends-identified-by-asae-foresightworkspdf 3. Boynton, A. & Fischer, B. (2011). The Idea Hunter: How to Find the Best Ideas and Make Them Happen. San Francisco: Jossey-Bass.
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Many of us chose the nursing profession because we wanted to make a difference, and so we look for ways to make that happen. Nurses are natural innovators. When we see a problem, we solve it. When we imagine a better way to implement a procedure or protocol, we do it. We are creative, time driven, and patient centric. But it’s more than that—innovation means taking a good idea and turning it into a process that can be implemented to improve health care or patient care outcomes.
INNOVATION IN PRACTICE
Nurses As Agents of Change
THE IDEA This year, recognizing the need for mental health support after the challenges educators and health care workers faced personally and professionally in the last two years, the University of Texas at Tyler started the Free Virtual Visit Mental Healthcare Outreach Project. Initially, the program was targeted at East Texas educators; however, due to surges in the pandemic and cries for help from so many in health-related fields, we knew we had to expand our outreach to include all health care workers.
By Barbara Chapman, DNP, APRN, FNP-C, EBP-C, NHDP-BE, PMHNP-BC as told to Gabi Nintunze
Through the program, students of the school of nursing’s postmaster’s certification program in psychiatric-mental health provide free telemedicine mental health services to professionals in the North and East Texas regions. The program has allowed us to combine both the need for student face to face clinical experiences, while also increasing access to mental health care for those dealing with increased stress, anxiety, or other issues. Patients receive resources and support, and students receive valuable practice.
THE PROCESS Educators and health care workers each present their own specific challenges, allowing for students to have real-time live telehealth encounters in a preceptor-supervised environment. Numerous patients have been seen since the project launched last summer. Students can select their availability using our appointment site, and participants can register for a slot that suits them, thereby keeping the process streamlined and accessible. This project uses technology in a successful and adaptable system. We are now working on inter-collaborative efforts between the coming medical school and psychiatry program at the Health Science Center at UT Tyler; the East Texas hub for the Child Psychiatry Access Network (CPAN); and the Texas Child Access Through Telemedicine program (TCHATT). Following this crisis, health care will never be delivered in the same way. More importantly, schools will be expected to teach health care students how to deliver this type of care. We are starting now.
THE TAKEAWAY “OFTEN, INNOVATION COMES FROM A POSITION OF NEED. Being an agent of change is not always easy. It requires grit, dedication, and passion. The burden the last two years has placed upon health care workers is immeasurable. I myself battled and beat breast cancer in the middle of a pandemic and, while undergoing treatment, kept working on outreach programs and child/adolescent rotations in a since-completed PsychiatricMental Health Nurse Practitioner (PMHNP) program. I focused on what I loved and looked to the future.” - Barbara Chapman
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Nurses accomplish change in both research and clinical settings using creative thinking to improve patient outcomes. This innovation drives our profession forward. I encourage my fellow nurses to do what they love. If you have a passion, follow it. If you see something that needs changing, work to make it happen. If you hear the word ‘no,’ take it as a sign to explore the next option. In the words of Aristotle: the only way to avoid criticism is to do nothing, say nothing, and be nothing. Do not give up on your idea or dream. Even the small steps you take today can move the rest of us—and our patients—forward into a better tomorrow. i
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Writing on the Wall Texas Nurses Shape History
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It was in 1907, while I was Superintendent of Nurses at St. Joseph Hospital in Houston, that I received a circular letter from Fort Worth asking me to come to a meeting for the purpose of organizing a State Association. This was one of a group of letters to every superintendent and graduate in the State. I was only one of many to receive a copy. I paid no attention to that letter except to read it, and consign it to waste basket, but I was not to get off so easily. I was called on by Miss Virginia Perkins and by her persuaded to attend the local meeting of the Nurses’ Association of Houston. At that meeting I was unanimously chosen to be the delegate to the Fort Worth meeting, February 22, 1907, to which meeting Miss Perkins accompanied me, and, traveling all day together, we very naturally discussed the prospective meeting and what it was for, and incidentally or accidentally, I mentioned the fact that I had attended a meeting in Denver, Colorado, when they were discussing their bill (creation of the Colorado Board of Nursing), and that I had a copy of that bill somewhere in my possession. Excerpted from The History of the Graduate Nurses’ Association of Texas 1907 to 1931, Chapter I, by Mrs. Jennie Cottle Beaty, RN, the first president of the Texas Graduate Nurses Association.
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creating TNA Nineteen nurses gathered in 1907 were instrumental in passing legislation that created the Texas Board of Nurse Examiners, thus impacting the future of all Texas nurses who followed, and how the association, now standing at 16,000 members, continues to shape nursing practice and advocacy today.
J.L. Brown
Memorial Fund Donors Jeff Dorian, District 2 President, (years unknown) Margie Dorman-O’Donnell, President, 2011-2016 Roberta Eacott, Treasurer, 1998-2002, 2004-2006 Michael Evans, President, 1989-1991 Alexia Green, President, 1999-2001
And the rest, as they say, is history. In August 2021 TNA mounted a 100-year historical timeline on the wall outside of the A. Louise Dietrich Training Room. The timeline shows how 19 nurses gathered in 1907 were instrumental in passing legislation that created the Texas Board of Nurse Examiners, thus impacting the future of all Texas nurses who followed, and how the association, now standing at 16,000 members, continues to shape nursing practice and advocacy today.
Ferne Kyba, Director 1986-1988, TNF President 1987-1992 Betty Skaggs, President, 1981-1985 Susy Sportsman, President, 2007-2011 Ruth Stewart, President, 1977-1978 Anna Valadez, Director, 1990-1994
The beautiful timeline was made possible by donations from past and present TNA presidents and board members which honored the legacy of John Levis “J.L.” Brown. Brown began working at the Texas Nurses Association in 1972 as the director of communication and retired in 1996 as the associate executive director. During those 24 years, J.L. founded TNA’s official Texas Nursing magazine in 1973 and served as its editor until his retirement. He also served as the staff liaison to many TNA committees and task forces including the Council on Workplace Issues, the Bylaws Committee, the Nominating Committee, and the Economics and General Welfare Committee. Brown also wrote the “History of the Texas Nurses Association” for the Texas
Pat Yoder-Wise, President, 1995-1999
Thank you State Historical Association Handbook of Texas in 1995, which continues to be used with periodic updates. TNA Members and visitors are welcome to view the timeline, rich with photos from publications and events of TNA’s long history, at the association’s headquarters in Austin. i
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Pioneering Wellness
MOVING TOWARDS A
Healthier
WORKPLACE by Gabi Nintunze, TNA and Kristina Heath, BSN, RN, TPAPN
We’re here for you and your mental wellness. Nurses burn out; don’t let it happen to you!
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NEARLY TWO YEARS after the start of a global pandemic, anecdotal reports indicate nurses are leaving their employment, often marking mental and physical burn out as the cause. In a Delphi study run by the Association for Leadership Science in Nursing (ALSN) and the American Organization for Nursing Leadership Foundation (AONL-F) researchers identified nurses’ well-being, resilience, and safety in the workplace as a top priority.1 As research regarding the effect of the pandemic and resultant work conditions on nurses’ wellbeing grows, the need for strategies to improve the work experience of frontline nurses and nurse leaders is becoming more and more evident. Frontline staff must experience support from their employers and leaders in actions and words. In the past two years nurses have experienced moral, physical, and emotional distress; burnout syndrome; compassion fatigue; secondary trauma and more.2 Ensuring the wellbeing of nurses requires immediate action. The creation and implementation of programs has led to healthier workplaces with better retention and staff that feels more capable and actively supported.
CREATING PARTNERSHIPS Health care organizations in Texas have implemented workplace wellness programs to provide support for nurses’ mental health, substance use, and other concerns. Some organizations have partnered with external organizations, while others have created in-house programs to support their staff. Pam Bradshaw, DNP, RN, FAONL, NEA-BC, CCRN-K, Chief Operating and Nursing Officer of Shannon Medical Center (SMC) in San Angelo, Texas, is actively engaged in raising mental health and substance use awareness of employees by providing a safe space to seek help and educating and improving the knowledge of current and new nursing leaders. Dr. Bradshaw invited the Texas Peer Assistance Program for Nurses (TPAPN) to the SMC leadership meeting in August to provide an overview of the TPAPN program. After the presentation, TPAPN created a partnership that was tailored to the needs of the facility. Materials were created for organizational use, including mental health and substance use resources. Support information was
Thriving , Not Surviving Baylor Scott and White Health created their own wellness program to support their nurses and staff members. Their “Thrive Wellness” Program is included in their benefits package for all employees. included in nursing orientation materials. “TPAPN is a great resource that is underutilized by all of us,” Bradshaw said. “Being able to recognize when a nurse needs help and then encouraging them on their road to recovery is both great for the organization and great for the nurse, as they can hopefully practice safely for many more years.”
INTERNAL PARTNERSHIPS Baylor Scott and White Health (BSWH) created their own wellness program to support nurses and staff members. The “Thrive Wellness” Program is included in their benefits package for all employees. Sally Gillam, DNP, MAHS, RN, NEA-BC, Regional Vice President and Chief Nursing Officer for the BSWH Austin-Round RockHill Country region, is actively engaged in raising mental health and substance use awareness within the BSWH system. She also serves as theTexas Organization for Nursing Leadership (TONL) representative on TPAPN’s Advisory Committee. “COVID-19 and its variants have pushed healthcare to its limits,” Gillam said. “The unsurmountable weight that clinical staff have had to navigate has been overwhelming at times. This heavy burden has been physical, mental, spiritual, and all other aspects impacting the human condition.” The Thrive Wellness Program includes data collection on five pillars of health: physical, emotional, social, financial, and professional. The data is used to improve the content and delivery of the program to staff, as well as to better understand the type of partnerships that will meet staff needs. “Nurses and all others in health care must assure that they engage themselves in self-care,” Gillam said, noting the importance of the role organizations play in providing opportunities for selfcare to be both possible and encouraged. “I am forever grateful that our teams have multiple avenues to direct their needs. The stress is near intolerable
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at times. Staff must know they are the center of our world, and that their health is critical to support.”
OUTSIDE SOURCES External resources play an important role in supporting nurses. Health and wellness initiatives such as the American Nurses Association’s Well-Being Initiative, the Gratitude Practice for Nurses (a joint effort of the American Nurses Foundation and the Greater Good Science Center at the University of California, Berkley), and the Moodfit Mobile App are examples of resources that instruct nurses on practices to build resiliency, provide tools to overcome stress, and deepen nurses understanding of mental and emotional wellness. Texas Health and Human services provides online resources tailored to specific state regions and pediatric and adult needs. Counselling services, medication management, skills training and development, detoxification from substances, and referral services for substance use treatment are all available to the public at large. Nurses are experiencing tremendous stress due to the working conditions brought on by the pandemic. While encouraging selfcare and mental health awareness is a positive development, employers of nurses have a responsibility to support nurse wellness. Organizations have successfully developed their own internal programs as well as established relationships with community partners to address issues. Find the resources that fit with your organization and culture to support nurse wellness. i REFERENCES 1. Chipps, E. M., Joseph, M. L., Alexander, C., Lyman, B., McGinty, L., Nelson-Brantley, H., Parchment, J., Rivera, R. R., Schultz, M. A., Ward, D. M., & Weaver, S. (2021). Setting the Research Agenda for Nursing Administration and Leadership Science: A Delphi Study. The Journal of nursing administration, 51(9), 430–438. https://doi.org/10.1097/ NNA.0000000000001042 2. Bumpus, S. (2021). Nursing Burnout in Texas. Texas Nursing Magazine, Issue 1, 2021, 21.
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PROFESSIONAL REGULATION, PEER REVIEW, AND SAFETY:
The Nurse Leader’s Role
By Cindy Zolnierek, PhD, RN, CAE, CEO Texas Nurses Association
There is a social contract between society and the profession. Under its terms, society grants the profession’s authority over functions vital to itself and permits them considerable autonomy in the conduct of their own affairs. In turn, the professions are expected to act responsibly, always mindful of the public trust. Self-regulation to assure quality and performance is at the heart of this relationship. It is the authentic hallmark of the mature profession.1 (Donabedian, 1976, p. 8 as cited in ANA)
PROFESSIONAL RESPONSIBILITY FOR SELF-REGULATION Peer review provides a process for selfregulation. The American Nurses Association first defined nursing peer review in 1988: …the process by which practicing registered nurses systematically access, monitor, and make judgements about the quality of nursing care provided by peers as measured by professional standards of practice… Peer review implies that the nursing care delivered by a group of nurses or an individual nurse is evaluated
by individuals of the same rank or standing according to established standards of practice.2 In Texas, Nursing Peer Review (NPR) is a distinct provision in the state’s Nurse Practice Act (NPA) that covers the “evaluation of nursing services, the qualifications of a nurse, the quality of patient care rendered by a nurse, the merits of a complaint concerning a nurse or nursing care, and a determination or recommendation regarding a complaint.” NPR Law applies the principles of peer evaluation to two specific situations:
SAFE HARBOR (SH) NPR AND INCIDENT-BASED (IB) NPR. Both types of NPR are intended to engage nurses in professional self-regulation. Texas NPR is consistent with a professional governance structure that promotes ownership of nursing practice —one in which nurses have authority and accountability for practice, competence, and quality.3 Nurse leaders are responsible for supporting professional governance by establishing empowering structures—that is, systems and processes that provide nurses with access to information, sup-
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port, resources, and opportunities—within organizations.4 Nurse leaders of organizations meeting statutory requirements for providing NPR are responsible for establishing the process within their organizations, informing nurses of related policies and procedures, and ensuring the NPR Committee (NPRC) is functioning accordingly.
SAFE HARBOR NURSING PEER REVIEW SHNPR is one such empowering structure. It provides a process for nurses who question whether an assignment or “requested conduct” would violate their duty to a patient or constitute unprofessional behavior. SH is intended to support nurses’ efforts to raise concerns about possibly and potentially unsafe situations and to articulate their concern in a manner that invites problems solving. Nurses invoking SH must go beyond declaring something to be “unsafe.” They must describe in detail how the requested conduct or situation would cause the nurse to violate the NPA. The nurse must invoke SH in good faith, with sincere and honest intent, supported by a factual and legal basis. continued on page 20
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If you, a coworker, or a family member need help with a substance use or mental health issue, call the Texas Peer Assistance Program for Nurses. TPAPN case managers provide guidance, support, and monitoring to help nurses recover and maintain their licenses. And TPAPN peer advocates provide an empathetic listening ear. You and those you care about are not alone!
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CONDUCT SUBJECT TO REPORTING IS CONDUCT THAT…
continued from page 18 The ability to invoke SH is a nurse’s right. A nurse leader who refuses to accept a nurse’s request for SH is acting in bad faith and is in violation of the NPA. Additionally, retaliating against a nurse invoking SH is illegal. Unfortunately, some nurse leaders may interpret an SH request as an indictment of their leadership, rather than an alert of a possible systemic flaw requiring intervention to ensure patient safety. A leader should want to know when a nurse feels unsafe—whether due to perceived lack of skills, resources, understanding of the assignment, or any other reason. Once aware, leaders can respond by teaching, shuffling resources, or clarifying expectations. Organization leaders who embrace a safety culture welcome reports of situations with the potential for error so that they can respond to prevent occurrence, investigate to understand causes, and implement prevention strategies.5 Just as reports of near misses should be encouraged as opportunities to prevent errors that cause harm, SH requests should be welcomed in the same spirit of patient safety. Ideally, the situation for which SH is invoked can be resolved in the moment, and the supervisor requesting the conduct or making the assignment and the nurse invoking safe harbor are able to come to an understanding of each other’s perspectives and achieve an acceptable solution. There are circumstances that preclude solutions, like the severe shortage of critical care nurses during the pandemic. In such situations, SH affords nurses protections from disciplinary action by the Board of Nursing (BON) for errors related to the SH request.* Nurse leaders should support their staff’s ability to access these protections even though they cannot fix the staffing situation. Whether or not the situation is resolved to the nurse’s satisfaction, the decision to proceed with a NPRC review and determination regarding the assignment belongs to the nurse who invoked SH.
INCIDENT-BASED NURSING PEER REVIEW Like SHNPR, IBNPR is couched within a framework of professional regulation and safety. The BON participates in pro-
Violates the NPA or BON rule and contributed to the death or serious injury of a patient. Indicates the nurse’s practice may be impaired by substance use. Constitutes abuse, exploitation, fraud, or a violation of professional boundaries. Indicates that the nurse lacks knowledge, skill, judgment, or conscientiousness to such an extent that the nurse’s continued practice of nursing could reasonably be expected to pose a risk of harm to a patient or another person, regardless of whether the conduct consists of a single incident or a pattern of behavior.
fessional regulation through processes to ensure that “each person holding a license as a nurse in the State of Texas is competent to practice safely.”6 This is accomplished through licensure and complaint investigation processes. Nurses are required to report peers whose practice may pose a risk of harm to patients. In lieu of making a report to the BON, the nurse may and is encouraged to make the report to the NPRC. A well-functioning NPRC may be better equipped than the BON to investigate a practice situation due to their familiarity with the environment, proximity to information including witnesses, timeliness of response, and simplified due process requirements. The NPRC also understands organizational capacity for providing any remediation the nurse may need to address identified needs to assure patient safety. The extent to which external factors, such as system issues beyond the nurse’s control, may have contributed to the nurse’s practice breakdown must be evaluated by the NPRC. Organizations embracing a safety culture are less interested in assigning blame and more interested in understanding process breakdowns because they appreciate that prevention of future incidents requires recognizing and correcting systemic issues.5 Thus, even when the NPRC determines the nurse’s conduct is subject to reporting to the BON (including when the nurse is terminated before NPR), the external factor analysis should be completed so that the organization can identify and respond to contributing system issues.
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CONCLUSION Peer review is commonly understood as a process professions utilize for self-regulation. The Texas Nursing Peer Review Law, within its Nursing Practice Act, provides for two specific types of peer review processes consistent with empowering structures of professional governance systems. Nurse leaders in Texas are legally and professionally responsible for establishing peer review processes that support patient safety. Patients are best served when nurses feel comfortable raising safety concerns, reporting errors and near misses, and supporting safe practices of peers. Patient safety is the ultimate goal shared by all. i * see Sec. 303.005.(c)(3) and (4)
REFERENCES 1. Donabedian as cited in ANA Nursing’s Social Policy Statement (need to check citation) 2. Haag-Heitman, B. (2011). Nursing peer review: principles and practice. American Nurse Today, 6 (9) 3. Porter-O’Grady & T., Clavelle, J. T. (2021) Transforming shared governance toward professional governance for nursing. Journal of Nursing Administration, 51 (4) 206-211. DOI: 10.1097/ NNA.0000000000000999 4. Moura, L. N., Camponogara, S., Dos Santos, J. L. G., Gasparino, R. G., Da Silva, R. M., & Freitas, E. D. O. (2020). Structural empowerment of nurses in the hospital setting. Rev Lat Am Engermagem, 28: e3373. https://dx.doi.org/10.1590%2F1518-8345.3915.3373 5. ECRI. Culture of safety: an overview. Health Syst Risk Manage 2019 Jun 14. https://www.ecri.org/ components/HRC/Pages/RiskQual21.aspx 6. Texas Board of Nursing Agency Mission https:// www.bon.texas.gov/about_mission_and_values.asp
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NURSES PUT YOUR NURSING SKILLS IN OFFICE
The to TO WORK INRoad OFFICE
wide variety of roles, working with Texas ing, and other health organizations.
Representation
The Nurses in Office initiative aims to encourage and support registered
NURSES IN OFFICE
olitics, such as getting people out to vote running for elected offices, starting locally—school boards, city ter testifying for and nurses against legislative ne Mitchell, the RN in Winkler County councils, and justice of the peace—and growing eventually to the state er for reporting an incompetent physician and national “not guilty,” vindicated for doing the right levels. Reaching this goal will require local and statewide leadership, teamwork, and individual engagement. I HAVE BEEN IN NURSING for 60 years in a wide variety of roles, working with Texas aw and the Code of Ethics for Nurses.
Nurses in Office is the Nurses Association (TNA), the Board of Nursing, and other health organizations. brainchild of Lolly members of the legislature. We want her footsteps andschool perhaps 2040 we will a nurse governor! Lockhart, PhD,more RN. nurses to forfollow hospital bonds during high and by later testifying forhave and against legislative bills. In 2010 I was the expert witness for Anne Mitchell, the RN in Winkler County Here she recounts ave nurses in To get nurses in officewho across Texas, webrought need yourherhelp: had criminal charges against for reporting an incompetent physician how she was inspired When I saw Dr. Billye to the Texas Medical Board. She was found “not guilty,” vindicated for doing the right Brenda Cleary: Women to build Consider running for office or encourage a colleague to run. this initiative. thing for patient safety, consistent with the law and the Code of Ethics for Nurses.
Rep.engaged Donna Practice Act. I was actively in Howard inspired this initiative. She first ran for school board, then was elected to the state House. She built on tate run and win. In addition, while on the running a campaign and serving in an elected office to become one of the most influential and valuable her experience Even at a young age I was engaged in local politics, such as getting people out to vote violence.
hool board, I realized es. In a few years, they Getting more nurses evin Stewart, Texas ctor of practice.
Volunteer to do research for candidates.
As TNA staff for several years in the 1960s, I helped amend the Nursing Practice Act. I was actively engaged in campaigns Get voters registered andincluding to the Rep. polls. for several candidates, Lloyd Doggett’s first state run and win. In addition, while on the Taskon Force, I helped develop the current statement on workplace violence. ANA Serve a campaign team.
Nursing Canvass for or otherwise promote a candidate that you believe in. Representatives Needed
Looking at our landscape, I am concerned we do notcould have nurses in an interest group of nurses Tell TNA if you (or a peer) are running forcurrent office.political If you don’t have anyone to run, you create leadership roles such as elected and appointed positions of authority. When I saw Billye in 2021 and 2022. to find a strong nurse candidate. This is the time to check if there will be openDr. positions Brown for her 103rd birthday, she insisted I read a book by her student Brenda Cleary: Women In Politics. I could not put it down. Visit texasnurses.org/nursesinoffice for more information.
“As a registered nurse and a your community member of thein Texas House of Representatives, I use the nursing process daily to analyze complex public policy issues. The nursing process is a great framework for solving complex problems. Nurses are experts in solving problems. We need more problem solvers running for office.” — Representative Stephanie Klick
Thinking of how Representative Donna Howard started on the local school board, I realized that was the key. Get early and mid-career nurses to run for local offices. In a few years, they would be ready for the Legislature, and then for Governor or Congress. Getting more nurses ready to run needs a concerted campaign. I started strategizing with Kevin Stewart, Texas PAGEand 21 Ellen Martin, TNA ISSU E 4 , 2of 0 21 | T E X A S N U R S I N G M AGA Z I N E School Nurses Association general counsel, director practice.
Resources to Run
Questioning
the Question Reducing Stigma Toward People with Mental Health Conditions
By Kanaka Sathasivan, MPH
SEVERAL YEARS AGO, the Board of Nursing (BON) added a simple question to the licensure renewal form: “In the past five years, have you been diagnosed with or treated for schizophrenia or other psychotic disorder, bipolar disorder, paranoid personality disorder, antisocial personality disorder or borderline personality disorder, which impaired or does impair your behavior, judgment, or ability to function in school or work?” While the question was intended to protect public welfare and was considered standard and used by other licensing entities at one time, it reinforced stigma and perpetuated discrimination against certain health conditions. “It was unfair and frustrating,” recalls Andrea Knott, BSN, RN, CPN. Following the birth of her daughter, Knott experienced postpartum psychosis, which led to a diagnosis of bipolar disorder. She worked carefully with her doctor to find a treatment that worked for her and had been doing fine at work. She was applying for renewal a year after her diagnosis. “At
first, I saw the question and thought ‘I get it. I get that they want a letter from my doctor.’” After she applied to renew her license in July 2019, answering the question honestly, she was stunned to receive a letter from the BON requesting documentation and proof of compliance with the Nursing Practice Act.
THE LETTERS “I felt like I had done something wrong,” Knott said. “But in reality, there was nothing I could do to control what I went through. The only thing I could control was seeking treatment.” Knott immediately complied with the request, providing documentation and information including work history and year-end evaluations; a resume; a letter outlining the circumstances of her hospitalization; and a response to the allegations of violating the Nurse Practice act to the BON. She also consulted an attorney who shared stories of other nurses who face similar barriers. Some had to wait
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months for their license to be reinstated, during which time they could not work. However, Knott was confident she had done nothing wrong and that legally, there would not be grounds to remove her license. Then the second letter came. On Aug. 13, 2019, the BON requested even more information. Knott began to ask more questions. She hired an attorney, and with their help put together a response packet that included yearly evaluations from manager and coworkers, letters of reference from community members, family, and her pastor attesting to her character. “With the help of my doctor, I felt safe and confident to not just be a mom but also a health care provider. The packet included great reviews from my peers— they would be the first people to speak up if they were concerned,” she said. Her peers also reinforced that she was doing the right thing by being honest. However, the BON’s response was discouraging: “They wanted me to be seen by one of their doctors.”
THE EVALUATION Confused and upset, Knott decided to call the BON and talk directly to her case manager to understand their rationale. She learned that refusal to comply with evaluation could lead to administrative hearing. So, she tried to use their list of doctors to set up an appointment. “I called a number of the pre-approved providers in the Dallas–Fort Worth area,” she explained. “The evaluation would have been $800. But when I asked them who they normally evaluated, it was usually nurses with substance use disorder. I asked specifically if they had any experience with bipolar or postpartum psychosis and none of them did. I know it’s my right to see someone that specializes what I need.” Since Knott was not comfortable seeing any of their providers, she went back to her attorney at beginning of October. In addition, she sought support from her colleagues and employer. “I’m so blessed to have an amazing support system, bosses, coworkers—able to talk about feelings and feel supported. Not everyone has that.” Knott also served on the committee for mental health in the med-surg unit, where she worked alongside former Texas Nurses Association (TNA) Board Director Shakyryn Napier, DHSc, RN, CPN, NEA-BC. She shared her situation and her frustration: “I did nothing wrong, and I felt like I was being interrogated like a criminal.” Napier, also chair of the TNA Policy Council, immediate brought the issue to the attention of TNA, including the council members, Chief Executive Officer Cindy Zolnierek, PhD, RN, CAE, and lobbyist Kevin Stewart, JD. In a heartfelt letter in January 2020, Knott explained how problematic the question had become. Crucially, she wrote: “[The BON’s] actions serve only to encourage nurses to hide their mental health issues and not seek medical care for fear of losing their license.”
THE CHANGE Zolnierek and Stewart agreed that the question created undue hardship for nurses and further perpetuated stigma against people with mental health conditions. Jumping into action, they alerted the BON regarding Andrea’s experience speaking directly with the BON general counsel and executive director
Treatment Without Fear
BON approved replacing the question with “Are you currently suffering from any condition for which you are not being appropriately treated that impairs your judgment or that would otherwise adversely affect your ability to practice nursing in a competent, ethical, and professional manner?” asking them to remove or change the question. TNA’s efforts paid off. First, in early 2020, Knott’s case was closed—the evaluation by Andrea’s treating provider should have been adequate. There had been a breakdown in the BON’s processes, and they clarified their investigation procedures to prevent further occurrences. The BON also acknowledged that the question on their application and renewal forms regarding mental health issues was not aligned with the Americans With Disabilities Act and agreed to research more appropriate language. At its July 2020 quarterly meeting, the BON approved replacing the question with “Are you currently suffering from any condition for which you are not being appropriately treated that impairs your judgment or that would otherwise adversely affect your ability to practice nursing in a competent, ethical, and professional manner?” “I don’t want any nurse to go through what I’ve been through,” Knott said. “It was not just demeaning, but stressful to have to relive that traumatic event and worry that my livelihood and license could be on the line.”
When Knott learned through a coworker that the question had changed, she almost started crying. “I was so thankful no one else would have to go through that, and I knew that if I had a relapse or needed hospitalization, I wouldn’t have to go through it again. I have control over my medications, see my therapist regularly, and take care of my health, but something could happen later that meant seeking treatment or hospitalization again.” The change in the question meant that Knott and others would now be able to seek treatment without fear of losing their license. “I’m so glad it changed at that time,” she said. “With COVID, there has been an increase in nurses needing help and now they don’t have to fear getting it. I want to erase the stigma behind people with mental health conditions. You can still be a productive and giving member of society.” i For nurses who need help with a mental health condition or substance use disorder, visit tpapn.org to learn more about the Texas Peer Assistance Program for Nurses.
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