texa s nu r s e s .o rg
TEXASNURSING M A G A Z I N E HURRICANE
HARVEY
IN THE EYE OF THE STORM
YOUR INVOLVEMENT WITH TNA PEER REVIEW
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 | F a l l 2 0 1 7
FALL 2017 Volume 91, Number 4 EDITOR-IN-CHIEF: Cindy Zolnierek, PhD, RN MANAGING EDITOR: Nadia Tamez-Robledo 8501 North MoPac Expressway, Suite 400, Austin, TX 78759-1292 P: 800.TNA.2022 or 512.452.0645; F: 512.452.0648 tna@texasnurses.org | texasnurses.org
MISSION Empowering Texas Nurses to advance the profession
BOARD of DIRECTORS OFFICERS: Jeff Watson, DNP, RN-BC, NEA-BC, NE-BC, CRRN, President Kim Belcik, PhD, RN-BC, CNE, Vice President Kleanthe Caruso, RN, MSN, NEA-BC, Secretary Gayle Dasher, RN, PhD, ANP-BC, Treasurer DIRECTORS: Rhonda Winegar, DNP, RN, FNP-BC, CCRN, CPN Tamara “Tammy” Eades, DNP, MSN, RN Pam Greene, PhD, RN Patricia Freier, MSN, RN-BC, RCIS Shakyryn Napier, DHSc, MSN, RN, CPN EXECUTIVE DIRECTOR: Cindy Zolnierek, PhD, RN
TNA DISTRICT AND PRESIDENT
VISION Nurses Transforming Health TEXAS NURSING (ISSN 0095-36X) is published quarterly – Winter, Spring, Summer, Fall – by the Texas Nurses Association, 8501 N. MoPac Expy., Ste 400, Austin, TX 78759-8396 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, 8501 North MoPac Expy., Suite 400, Austin, TX 78759-8396 ARE YOU MOVING? Need to change your address? If so, provide it quickly and easily in the Members Only section of the TNA web site, texasnurses.org. Or mail us 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.1:
Clarissa Silva, clarissa2277@att.net
Dist. 3:
Linda Dunn, ladynurse101@aol.com, District office: 817-249-5071, tna3@usapathway.com, tna3.org
Dist. 4:
Jackie Michael, michaels@uta.edu, District office: Pat Pollock, P.O. Box 764468, Dallas, TX 75376; 972-435-2216; d4tna@flash.net; tnad4.org
Dist. 5:
El Burley, president.tnad5@gmail.com
Dist. 7:
Patricia Phelps, psphelps1993@gmail.com, District office: P.O. Box 1482, Belton, TX 76513
Dist. 8:
Linda Juenke, 830-739-7028, ljsoaringeagle3@gmail.com
Dist. 9:
Lisa Boss, lisa.boss@uth.tmc.edu, District office: Melanie Truong, 7324 Southwest Freeway, Suite 2-1453, Houston, TX 77074; 713-523-3619; tna9@tnadistrict9.com; tnadistrict9.com
Dist. 10: Anita Farrish, 254-421-9797, anitafarrish2001@yahoo.com Dist. 11: Paula Parks, 940-224-3533, wfparksdept@gmail.com Dist. 12: Heidi Wolf, 409-853-5900, HWolf@iasishealthcare.com Dist. 13: Nannette Kelley, nannettekelley@msn.com Dist. 15: Andrea Kerley, 325-670-4230, akerley@hendrickhealth.org Dist. 17: Cindy Keese, 361-332-1643, cakeese@aol.com Dist. 18: Darla Smith, darla.smith3@stjoe.org Dist. 19: Colleen Marzilli, cmarzilli@uttyler.edu Dist. 21: Jessica Tully, 432-254-1949, jessica.tully@midland-memorial.com Dist. 22: Toni McDonald, 936-544-8823, t.mcdonald323@yahoo.com Dist. 35: Chrystal Brown, 903-434-8302, cbrown@ntcc.edu Dist. 40: Contact TNA, 800-862-2022, ext. 129, brichey@texasnurses.org.
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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. Copyright 2017 © Texas Nurses Association
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IN THE EYE OF THE STORM Surviving Hurricane Harvey
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COVER: photo courtesy Adobe/NASA
NURSING PEER REVIEW
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PRESIDENT’S NOTES
CHERYL KEE: 1959 – 2017
Healing from Harvey
Remembering Cheryl
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TNA MEMBER NEWS
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19
EXPERT ADVISORS NEEDED FOR TNA POLICY COMMITTEES Contribute in 2017
YOUR INVOLVEMENT WITH TNA
20
22
INNOVATIVE SOLUTIONS FOR NURSE STAFFING
UTILIZING THE NPA WEBSITE TO THE FULLEST
TNA LEADERSHIP CONFERENCE
Help TNA Collect Information on Innovative Solutions for Nurse Staffing
Quality Online Resource
2017 Leadership Conference Recap
23 TEXAS NURSES FOUNDATION NEWS
Thank You, On the Move, Elections, Appointments, Kudos, and In Memoriam
First Research Grant Nurses Helping Nurses
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BECOME AN AGGIE NURSE ADVANCE YOUR CAREER with RN to BSN • Flexible Online • Comprehensive • Affordable nursing.tamhsc.edu
President’s Notes Guest Columnist, Pam Greene, PhD, RN Member, TNA Board of Directors
HEALING FROM HARVEY How Storytelling Can Play a Role in Supporting Storm Survivors
IN THIS GUEST COLUMN, TNA Director Pam Greene, PhD, RN, shares a journal of her experience riding out her third hurricane and what it’s been like moving forward. Thursday, June 1, 2017: As usual, emergency supplies were collected and put in place in our Corpus Christi home at the beginning of hurricane season. Thursday, Aug. 24: The pre-cut plywood, labeled for each window and door, was pulled from storage and screwed in place. Tropical storm Harvey was upgraded to a Category 1 hurricane. It was on track to make landfall in Corpus Christi. Friday, Aug. 25: At 4:21 p.m., power went out, and we were in absolute darkness. We had our emergency supplies and were prepared for power loss. Harvey had escalated to a Category 4, but we were not prepared for that. It was too late to evacuate. We waited. Texts poured in from across the country. Dozens of family and friends expressed care, concern, encouragement, and prayers. The impact of those connections was profoundly comforting. Saturday, Aug. 26: At 5 a.m., we checked the local weather app. (We were rationing cell phone use to extend our ability to communicate as long as possible.) Harvey had not hit Corpus Christi directly. While there were still rain and wind gusts, we were able to venture gingerly into the darkness, flashlights in hand, and survey the immediate damage. Lots of tree limbs, debris, and downed fences, but we were spared. What a sense of gratitude and almost disbelief! Our neighbors just 30 miles to the north had not fared nearly as well. Harvey battered them with winds at speeds well
Healing and recovery is a collective effort, and we can all find ways to contribute. I know “Texas Strong” is more than a T-shirt slogan. above 100 mph and was accompanied by flooding, leaving a path of massive destruction and devastation. At this point, you know Harvey did not stop for days. He circled around and stalled in place at times. Harvey continued to pummel communities and dump unprecedented amounts of rain, taking homes, closing hospitals and schools, destroying businesses, and robbing individuals of their shelter and their livelihoods. Some lives were taken, others forever changed by Harvey. There were and continue to be countless humanitarian acts resulting in lives being saved. Nurses waded in chest-high water in the pouring rain to care for fragile, elderly residents in a long-term care facility. Teams formed to rescue those in danger, later to prepare and feed hundreds at a time in small, hard-hit communities like Aransas Pass. Groups banded together to begin the arduous task of clean up. Side-by-side, volunteers joined to help wherever and however they could. The selfless acts of kindness and generosity of so many from across the country and beyond is inspiring. Intellectually, we know there are various stages and phases of recovery. It can be a challenge to envision recovery when there are mountains of debris with water-soaked sheetrock, appliances, and someone’s heirloom dresser changing the landscape. Recovery can seem out of reach amid feelings of grief, fear, sad-
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ness, despair, survivor’s guilt, and anger. When and how will the suffering end? Part of recovery is recounting personal stories. There are stories of trauma and terror; stories of compassion and selfless courage. These are not my stories, but they are stories that need to be told and retold. These stories need to be honored, treasured, and woven into the process of healing from Harvey’s wrath. For those of us who did not experience the impact of Harvey directly, we are in the perfect position to listen. We can offer support and genuine interest. Sharing experiences is an essential part of healing. I know healing, recovery, and rebuilding will take longer than we imagine, and we cannot foresee obstacles yet to come, nor predict how long this process will take. As a survivor of Rita and Ike, I know with complete certainty that healing from Harvey is beginning to happen. Healing and recovery is a collective effort, and we can all find ways to contribute. I know “Texas Strong” is more than a T-shirt slogan. My hope is, as we join together to heal and rebuild, we will retain the sense of community and caring. I hope most of all we continue the human connections and compassion that poured out in the wake of Harvey’s destruction. We can, with intention, create a “new normal.” A better normal! i
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TEX AS NURS ES AS SOCIATION
TNA MEMBER NEWS SPOTLIGHT ON YOU THANK YOU The Texas Nurses Foundation thanks everyone who donated to the relief fund for nurses impacted by Hurricane Harvey. Together, you raised more than $80,000 to directly help more than 300 nurses.
ON THE MOVE Inspired by the foresight of past President Margie Dorman-O’Donnell, the 2016 TNA Board authorized staff to begin looking for office space to potentially purchase. Staff proceeded with groundwork and exploration of several options, and they identified a building that meets TNA/TNF needs while making good business and financial sense to buy. The TNA Board evaluated the proposal and determined that it was in the best interest of TNA/TNF to move forward with the purchase of an office building.
Interested members will find position descriptions, election policies, and the biographical submission form on texasnurses.org under the Resource tab, on the Elections and Surveys page. Other members on the nominating committee: Colleen Marzilli, PhD, RN; Patricia Francis Johnson, DNP, RN; Orlando Chapa, DNP, RN, and Irene Rosales, MSN, RN.
APPOINTMENTS Congratulations to TNA members Faith Aguilar, RN, and Li-Chen Lin, PhD, RN, CNRN, on their appointments to ANA’s 2017 Committee on Honorary Awards Subcommittee.
TNA anticipates moving to its new location (just across MoPac – slightly west of its current home) early next year. Stay tuned for updates!
We would also like to congratulate members who were selected as alternates for ANA’s Committee on Nursing Practice Standards. Ruth Ifediora, MSNED, RN, will serve a one-year term as first alternate, and Jordan Wilson, BSN, RN, will serve a two-year term as second alternate.
ELECTIONS
IN MEMORIAM
Nominating Committee Chair Jennifer Cook, PhD, RN, has announced the committee is seeking candidates for open positions on the 2018 TNA ballot.
TNA was saddened to learn of the passing of Marilyn “Lyn” Hurt Oct. 3, 2017, in Dallas. Hurt was an active member of District 4, serving as co-chair of the Governmental Affairs Committee for many years. She had a 50-year career in nursing. She worked as a hospital staff nurse and at NASA. Hurt was also a nurse educator, teaching nursing at community colleges in Waco, College Station, and Dallas.
Offices open on the ballot are: president/ANA membership assembly representative (two years, 2018-2020)
vice president/ANA membership assembly representative (two years, 2018-2020)
board of directors at-large – three positions (three years, 2018-2021)
nominating committee chair (two years, 2018-2020)
nominating committee at-large – two positions (two years, 2018-2020)
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She was a tireless volunteer—one of those whom, if you called her for anything, would say “yes” and do a great job. She taught ESL classes, was active in
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pastoral care, and provided foster care for at least a dozen dogs. She was born in Herington, Kansas, to James and Orana Hughes on Nov. 29, 1933. She is survived by her daughter, Sonja Boese (Bob), daughter Kelly Hurt (Matt Tillinghast), son Bill Hurt (Linda) and son Clint Hurt (Ilona). She is also survived by grandsons Rob Boese and Brad Boese (Joyce), and granddaughters Erin Lack (Jordan) and Lily Hurt.
KUDOS TNA would like to congratulate the 2018 American Academy of Nursing fellows: Bob Dent, DNP, MBA, RN, NEA-BC, CENP, FACHE - Midland Memorial Hospital Anita G. Hufft, PHD, RN - Texas Woman’s University Anne Christine Floyd Koci, PhD, RN, FNPBC, WHNP - Texas Woman’s University Nelda C. Martinez, PhD, RN - The University of Texas Rio Grande Valley Rebecca McCormick-Boyle, MHA, MS HR, BSN - Navy Medicine Education, Training & Logistics Command Stacey Mitchell, DNP, MBA, RN, SANE-A, SANE-P - Texas A&M University Elda Ramirez, PhD, RN, FNP-BC, ENP-C, FAANP, FAEN - University of Texas Health Science Center at Houston Jing Wang, PhD, MPH, MSN, RN - University of Texas Health Science Center at Houston.
If you are a Texas Nurses Association member and you’ve changed employers, been promoted, received an award, or been elected or appointed to a board or community organization, we’d like to hear from you. Send submissions to editor@texasnurses.org.
THE UNIVERSITY OF
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texas.wgu.edu © 2017 Western Governors University. All Rights Reserved.
IN THE EYE OF THE STORM
Preparation, Communication, and Visibility during Hurricane Harvey By Jim Allard, DNP, RN, NEA-BC Interim Chief Nursing Officer and Assistant Chief Nursing Officer, Vice President of Pediatric Services The Woman’s Hospital of Texas
WHEN THE CALL FROM HCA HEALTHCARE Gulf Coast Division came on Wednesday, Aug. 23 for The Woman’s Hospital of Texas (TWH) to prepare for the likelihood of as much as 51 inches of rain from Hurricane Harvey, we realized immediately that this was not an ordinary storm. Harvey was already battering our sister hospitals in Corpus Christi, and we knew that the rain headed our way would flood any city. For Houston, built on a series of interlocking bayous and wetlands, the whole city was likely to go under water.
PREPARATION Advance planning and using available resources was key to preparing for this type of disaster. We began by addressing what we believed to be the worst-case scenario: evacuation of the hospital. How and where would we send the 145 babies and their mothers if they had to leave? While I was scouring my contacts list for phone numbers of my peers in and out of the HCA Healthcare system who could take my NICU patients, three important command centers were being formed. One here at TWH, the second at the Division level here in Houston,
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Our buildings were safe, secure, and dry, but all roads around us were flooded. No vehicles could get in or out. and a third in Nashville at HCA Healthcare headquarters. TWH was just one of 16 HCA Healthcare hospitals in the path of Harvey. We worked hand-in-hand with our Division leadership to estimate the needs of our hospital for an extended period of time: power, fuel, water, food, medicine, and staffing. Enough of each for seven days was delivered to our hospital by Friday night (Aug. 25). As it began to rain non-stop on Friday, we assigned staff into A, B, and C teams to ensure adequate relief. We went on lockdown on Saturday at 7 a.m. We were on our own and operating like a small town working to fill the needs of 1,000 “residents” within our walls. Our command center began work on supporting the needs of our patients, visitors, physicians, and employees. For patients, it was quality care as usual. Everyone else needed bed assignments, with many on air mattresses. All were supplied with linens: a blanket, sheet, and towel. Standardized meals were prepared in
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the cafeteria and, while the choice was limited, everyone was fed and assured hot meals. By Saturday evening, TWH was an island. Our buildings were safe, secure, and dry, but all roads around us were flooded. No vehicles could get in or out. Team A knew they would be in for a minimum of 48 hours before Team B would relieve them. We were receiving constant weather updates from the Division command center, which had employed meteorologists to predict rainfall and topographers to predict flooding risks for each location. They assured us the hospital would not flood, but the waters would rise all around us. It was becoming clear that our small town would be together for several days.
COMMUNICATION With the knowledge that those within our walls were safe, we knew it was important to keep everyone in the hospital informed. The concern for friends, loved ones, property, and the entire greater Houston area was real and
heart-wrenching. Time came for relief, and it was clear that Team B could not get to the hospital. Even if they could have come, half of Team B’s homes and/or cars had flooded. Many on Team A were hearing from family that their houses were flooded, and their loved ones had evacuated their homes.
VISIBILITY Leadership realized that we were the conduit to keep things running smoothly and to lessen stress on the frontline. We also realized that we needed to be visible and helpful to all our employees, patients, and guests. We rounded the floors day and night. We worked the cafeteria line. We gathered linens and did the laundry. We came together as a team to do what was needed to make the best of a bad situation. Division leadership issued a daily Connect to Purpose newsletter that shared stories of heroism and acts of selflessness and teamwork across the region. We knew we were all in this together. Health care professionals are a different breed. Our physicians and staff dug in to step up their care giving. It became leadership’s job to force some relief from a routine of work, shower, and sleep. We involved ourselves in the shift huddles. We reported what we learned from our conversations with the Division and Corporate command centers. Our staff wanted to know what was going on at other facilities. We encouraged them to tell stories of their families’ situations. We cried together, we laughed together, we prayed together, we created a special bond together. We became very cognizant of our connections with each other. We involved our employees in planned activities. We held yoga classes, meditation sessions, had a game night and dance party. We encouraged all to connect with family.
TOP: The Woman’s Hospital of Texas AirCare Transport team lends a hand to the National Guard to unload supplies for a nearby hospital. MIDDLE: The Woman’s Hospital of Texas staff take time during a shift huddle to pray for those affected by Hurricane Harvey. BOTTOM: ACNO Jim Allard (far left) takes time out for breakfast with the hospital’s AirCare Transport Team during Hurricane Harvey. Photos courtesy of HCA Healthcare.
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On Tuesday afternoon, the fourth day of lockdown, it was clear the rain would begin to lessen and the flooding would have a chance to recede. More importantly, Division told us they were going to helicopter in more than 70 relief nurses to our facility. In addition to nurses, HCA Healthcare
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brought in social workers along with HCA Hope Fund personnel to support the mental, emotional, and financial trauma many of our colleagues were experiencing. This relief team guided these individuals to counseling, FEMA support, and when necessary, a contribution from the HCA Hope Fund that provided up to $7,500 to help them rebuild. As the storm began to move on, everyone—administrators, employees, physicians, patients, and visitors—was eager to leave. But we had to recognize that as the hospital became accessible, new patients began to arrive. The relief nurses were on-boarded, and Teams B and C needed to be organized. Once again, leadership had to prepare, communicate, and be visible.
LEADERSHIP LESSONS LEARNED While I would never wish this experience on anyone, I learned much from Hurricane Harvey. A few of my observation are:
We work in a great industry that supports each other. The next time training is offered, take it. Also, take time to build a network of peers in your own organization and throughout the industry. Don’t be afraid to ask others for help when you need it.
The Woman’s Hospital of Texas Leadership Team gathered in the Command Center multiple times a day for Hurricane Harvey briefings. Photo courtesy of HCA Healthcare.
Visibility of leadership is paramount. Not just making rounds to check on performance but total immersion and involvement. By organizing for laundry and serving meals, we touched every person in our hospital.
Preparation needs to extend beyond patient care to employee care and visitor care. Communication is critical. Listening is more important than talking. Sharing what you don’t know about a situation can be as important as what you do know. Hearing the voice of the front line in shift huddles
is informative and valuable.
Visibility of leadership is paramount. Not just making rounds to check on performance but total immersion and involvement. By organizing for laundry and serving meals, we touched every person in our hospital. Helping out in every job no matter how basic, so others may excel
REGULATORY RESPONSE TO HARVEY By Mark Majek, MA, PHR, SHRM-CP, Director, Operations, Texas Board of Nursing On Aug. 23, 2017, Governor Abbott is-
BON posted announcements on the BON
sued a State Disaster Declaration for 30
website and Facebook page explain-
Texas counties in anticipation of Tropi-
ing the temporary licensure process for
cal Depression Harvey making landfall
out-of-state nurses coming to help in
in the Gulf Coast Region. This declara-
the disaster areas. Applications were
tion allowed the Texas Board of Nurs-
received from hundreds of nurses seek-
ing (BON) to implement emergency
ing to provide assistance. Agency staff
emergency, provided the nurse holds
licensure procedures with notification
worked nights and weekends approving
a current license meeting the qualifica-
to the Office of the Governor. Following
applications for more than 600 nurses in
tions for nursing from their state. To this
approval from the governor, the BON
the first week following Harvey’s arrival
date, the BON has processed tempo-
waived certain licensure requirements
in Texas. In accordance with Section
rary licenses for 1,431 registered nurses,
for nurses from non-compact states to
418.171 of Texas Government Code, any
95 licensed vocational nurses, and 48
practice in Texas with a clear and cur-
out-of-state nurse may practice in Texas
advanced practice registered nurses to
rent license from their home state. The
for the purpose of rendering aid in an
work as volunteer nurses in Texas.
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at their job of patient care is critical.
Luckily, I work for an organization with extraordinary resources: before the storm with generators, fuel, medicine, and food; during the storm with communication, updates, transportation, security, and logistics; and after the storm with relief nurses, counselors, and financial support. HCA Healthcare spared no expense to make certain its employees had a safe place to work with all the resources necessary to treat patients as if nothing was different from any other day.
Harvey forced us to become even better versions of ourselves as humans and as nurse professionals. Our job as leaders is to support this remarkable group of professionals and provide them with a supportive environment that allows them to shine… forced us to become even better versions of ourselves as humans and as nurse professionals. Our job as leaders is to support this remarkable group of
Finally, I know now that disasters, whether natural or manmade, can happen at any time. For us at The Woman’s Hospital, whether as a team member locked down in the hospital or as a team member waiting to come in as relief, we were all impacted by Hurricane Harvey. Everyone was touched, either personally by the loss of home or belongings or by the losses of our friends, family, or neighbors.
Jim Allard is the interim chief nursing officer and ACNO at the Woman’s Hospital of Texas. Jim has 19 years of nursing experience primarily in areas of pediatric critical care and has been a driven nurse leader since 2008 with experience and interest in civility, shared governance, evidence-based practice, MAGNET, and Just Culture principles. Jim’s current responsibilities include oversight of nursing services inclusive of pediatrics, pediatric intensive care, neonatal intensive care, mother-baby, labor, and delivery and antepartum.
Over and over again we heard, “I’m fine, my home only had a foot of water.” And, yet, they all came to work. Harvey
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NURSING PEER REVIEW A PATIENT SAFETY PERSPECTIVE By Ellen E. Martin, PhD, RN, CPHQ NURSE PEER REVIEW COMMITTEES (NPRC) play an important role in a culture of safety.
nurses in a climate of collegial problem solving focused on obtaining all relevant information about an event.”
Nurses have a duty to keep patients safe and are obligated to report practice violations in accordance with the mandatory reporting requirements of the Nurse Practice Act and the Standards of Nursing Practice outlined in Board of Nursing Rule 217.11 (1)(K).
This description aligns with the key features present in a culture of safety as emphasized by the Agency for Healthcare Research and Quality:
This obligation may be fulfilled by reporting to an NPRC. The committee evaluates the nurse’s practice and determines whether the nurse poses a continued risk of harm. The definition of peer review outlined in Board of Nursing Rule 217.19(a)(14) describes the process as “one of fact finding, analysis and study of events by
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Recognition of the high-risk nature of health care delivery
A just culture that encourages discussion and reporting of errors and near misses without fear of reprimand or retribution
Collaboration across disciplines to ensure that “safety is everyone’s job”
Organizational commitment of resources to address safety concerns
A just culture recognizes that health
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care involves human fallibility; even the most experienced and careful individual can make a mistake resulting in patient risk or harm. It is a culture that focuses on the behavioral choices of the individual, the degree of risk-taking behavior, and whether the individual deliberately disregarded a substantial risk. Rather than focusing solely on the fact that an error occurred or the patient experienced an adverse outcome resulting from an error, just culture holds accountable individuals who make unsafe or reckless choices that endanger clients or others.
LEARNING FROM ERRORS Patient safety depends on individuals learning from mistakes. Evaluation of and
reflection on practice errors can be an important source of learning for nurses. One study of nursing practice errors examined the causes, consequences, and potential change in the nursing practice based on what they learned from experience. One hundred and twenty-nine nurses answered a 22-item questionnaire relating to an error they had made. The study identified that the most common causes of errors were lack of knowledge or information, work overload, stressful atmosphere, and lack of support from senior staff. Positive changes in practice were driven by accepting responsibility and by planned problem-solving. Negative responses were defensiveness, distancing, and controlling strategies, including a tendency not to disclose the error. The study recommended a framework of support for constructive problem-solving that encourages nurses to accept responsibility for errors as well as identification of systems factors contributing to error. The North Carolina Board of Nursing has developed a tool that NPRCs may find helpful in distinguishing simple human error from risk-taking and reckless behavior. A just culture assessment instrument, the Complaint Evaluation Tool (CET), was designed to guide employers when reviewing practice errors.
It was carefully pilot tested and was valuable in clarifying the criteria for reporting nurses to the NCBON. (In North Carolina, nurses do not have the option of being reported to a peer review committee in lieu of reporting to the BON and do not enjoy safe harbor protections.) The CET and Instruction guide are available online at www.ncbon.com under the Employer Complaint section. This website also includes just culture resources, such as the Student Practice Event Evaluation Tool, which may be of interest to nursing educators. The CET also includes a place to document the evaluation of mitigating and aggravating factors, which can be used by the NPRC in the evaluation of external factors as required by Board of Nursing Rule 217.19. Addressing external factors or system causes of error improves safety for all patients.
REMEDIATION An important determination of the NPRC is whether remediation is needed to ensure the nurse’s practice does not pose a risk of harm. The NPRC considers alternatives to reporting practice violations determined to be a minor incident in accordance with Board of Nursing rule 217.16(g)(4): (4) The nursing peer review committee need not report the nurse to the Board if the peer review committee deter-
mines that either: (A) the nurse’s continuing to practice does not pose a risk of harm to patients or other persons; or (B) remediation could reasonably be expected to adequately mitigate any such risk and the nurse successfully completes the remediation. The organization’s peer review policy should address how the remediation will be documented and who will monitor successful completion of the remediation. If the nurse leaves employment before the remediation plan has been completed, Board of Nursing Rule 217.16(g)(5) provides guidance that should also be addressed in policy: (5) If a nurse terminates employment while undergoing remediation activities as directed by a peer review committee under paragraph (3) of this subsection, the peer review committee may either: (A) report the nurse to the BON; (B) report to the peer review committee of the new employer, if known, with the nurses written consent; (C) re-evaluate the nurse’s current conduct to determine if the nurse did complete sufficient remediation and is deemed safe to practice. This is an important role for NPRCs because one study noted that changing employers during a probationary period
REMEDIATION AND BOARD OF NURSING DISCIPLINE Remediation is also an essential element of discipline by the Board of Nursing. Nurses who are disciplined for practice violations are often required to take remedial education courses, such as “Sharpening Critical Thinking Skills,” offered by the National Council of State Boards of Nursing (NCSBN), to ensure they can safely return to practice. The NCSBN website has many valuable educational resources including continuing education for nurses and free videos on topics such as professional boundaries. One innovative model for remediation is the KSTAR Program, adopted by the Texas Board of Nursing in 2014 as a two-year pilot program.
It was to serve as an alternative to discipline for violations of the Nursing Practice Act that result in Board Orders of a warning or below. The program was developed in consultation with Texas A&M Health Sciences Center College of Nursing and the Rural and Community Health Institute, and it is modeled after a successful physician program. On July 20, 2017, the program shifted from pilot to permanent status when the Texas Board of Nursing approved the KSTAR Nursing Program as a disciplinary option for nurses who meet eligibility criteria in accordance with Board Rule 213.35. The program is self-paced, using individualized competency assessments and targeted
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remediation plans. Each participant is assigned a coach. The first session consists of two days of assessment and training, and the second consists of one day of reassessment and evaluation. The participant must complete their individualized educational plan between the two visits using web-based training modules. The timeframe is expected to be three to four months. However, the nurse must enroll in the KSTAR program within 45 days of the date of the Board Order and must complete the program within one year after signing the order. The cost of the program is paid by the participant.
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increases the risk of recidivism in nurses disciplined for a practice violation by their board of nursing. The researchers cited two main factors that may contribute to this increased risk: lack of familiarity with policies and procedures at the new workplace and disruption in supervision and support from a known resource. A pattern of practice violations is an important consideration for NPRCs as this study also found that nurses with multiple violations were more likely to recidivate. Nursing peer review is key to patient safety efforts through the evaluation of nursing practice and quality of care in a collegial and just culture. The nursing peer review law and associated rules address the rights, obligations of, and protections for nurses who raise care concerns. Texas Nurses Association is committed to ensuring health care organizations implement effective policies and processes to ensure safety for all patients in the care of nurses. i REFERENCES Burhans, LD, Chastain, K, George, JL (2012). Just culture and nursing regulation: Learning to improve patient safety. Journal of Nursing Regulation 2 (4), 43-49. Disch, J. Barnsteiner, J, Connor, S, and Brogren, F (2017). Exploring how nursing schools handle student errors and near misses. American Journal of Nursing, 117(10), 24-31. Gorzeman, J (2008). Balancing just culture with regulatory standards. Nursing Administration Quarterly 32(4),. 3-8=311doi: 10.1097/01. NAQ.0000336728.72501.c6 Helmchen LA, Richards MR, McDonald TB. (2011). Successful remediation of patient safety incidents: a tale of two medication errors. Health Care Management Review 36(2), 114-123. doi: 10.1097/ HMR.0b013e318200f916. Meurier, CE, Vincent, CA, Parmar, DG. (1997). Learning from errors in nursing practice, Journal of Advanced Nursing, 26(10), 111-119.
PRACTITIONER REMEDIATION AND ENHANCEMENT PROGRAM One example of an innovative, statewide nurse remediation program for minor practice concerns is the North Carolina Board of Nursing Practitioner Remediation and Enhancement Program (PREP). This program supports the remediation of minor practice concerns in a positive, non-disciplinary manner by encouraging employers to contact NCBON staff to consult about issues. If necessary, the employer and staff work in collaboration to develop a plan for remediation. This program opens lines of communication and allows early interventions to promote safe practice before disciplinary action is required.
Zhong, EH, Kenward, K, Sheets, VR, Doherty, ME, Gross, L. (2009). Probation and recidivism: Remediation
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• Contains all relevant statutory and rule updates through July 2017.
• Breaks down complicated statutes and rules into issue sections for quick reference. • Visit texasnurses.org for your copy ($55 for TNA members, $79 for non-members).
T E X A S N U R S I N G M AGA Z I N E | FA L L 2 017
Wachter, RM, Pronovost, PJ (2009). Balancing “no blame” with accountability in patient safety. The New England Journal of Medicine 361.14 (Oct 1, 2009): 1401-6.
To learn more, Contact the Graduate Academic Advisor at 361-825-5893 or rachel.holman@tamucc.edu.
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SAN ANTONIO, TX
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Your career in nursing leadership begins at the University of the Incarnate Word (UIW). Here you’ll find one of the most successful nursing programs in the region offering excellent undergraduate and graduate programs including the Master of Science in Nursing Leadership degree. This flexible program of study allows the student to apply knowledge and expertise to improve healthcare for clients at the system level of care. Registered nurses seeking to advance their career will thrive in the RN to BSN pathway. Future Family Nurse Practitioners and Psychiatric Mental Health Nurse Practitioners have the opportunity to succeed in UIW’s BSN to DNP program. You have the potential to make a healthy difference. Discover how right here. uiw.edu/nursing DISCOVER THE POWER OF YOU
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TEX AS NURS ES AS SOCIATION
CHERYL KEE: 1959-2017 By Cindy Zolnierek, PhD, RN, Executive Director
In remembrance of her service and fellowship, a memorial fund has been established to create a welcoming area in her honor for those visiting TNA. visiting TNA. If you encountered Cheryl and were touched by her kind spirit, consider contributing to this fund. Visit
“TEXAS NURSES ASSOCIATION, how may I direct your call?” If you’ve had opportunity to call the TNA office any time during the past 29 years, chances are you heard the cheery voice of Cheryl Kee, our longtime receptionist who was always happy and eager to assist everyone who called. Cheryl treated everyone as if they were her best friend. She learned the voices of Board members and District leaders and greeted them by name either on the phone or when they came into the TNA office for meetings and gatherings. She was generous to a fault, always concerned for others and what she could do make their lives better. We were greatly saddened to learn of her sudden passing on Aug. 11, 2017. In remembrance of her service and fellowship with TNA staff and members alike, a memorial fund has been established. Cheryl would often sit in the common office area, or on a bench outside the TNA office, during her break time to soak in the sunshine or to center her mind before getting on with her day. We believe it fitting to establish a welcoming area in her honor for those
T E X A S N U R S I N G M AGA Z I N E | FA L L 2 017
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the Texas Nurses Foundation section on texasnurses.org to donate. i
HOW DO YOU WANT TO BE INVOLVED WITH TNA? As a TNA Member, You are Essential at Any Level of Involvement By Belinda Richey, Director of Membership Services TIMES HAVE CHANGED, communication has changed, and association involvement has changed, too. Every member of the Texas Nurses Association can choose their level of involvement and be satisfied that they are an essential part to a thriving, growing statewide association.
Keeps current with the weekly TNA Check-up e-newsletter so they won’t miss a Practice Tip of the Week
Knows what is going on in Texas and nationally by reading the weekly Texas Nursing News Flash
Checks out the opportunities in the weekly Career Center e-blast
UBER MEMBER This member is interested in networking and learning more about nursing policy (and how it applies to their everyday practice). They value a statewide network and seek to engage with nurses at every opportunity. How does this member engage?
Attends every TNA event — locally, statewide and online
Seeks appointed positions on committees, task forces, and work groups
Talks to anyone and everyone about TNA and invites them to join
Visits the website regularly to see what’s new — and knows when the call for nominations has been issued (View online in About TNA/TNF tab at texasnurses.org.)
Never misses the weekly TNA Check-up e-newsletter. Where else will they learn about statewide opportunities to serve?
IN–THE-KNOW MEMBER This member values the exclusive information they receive from TNA. How do they engage?
Reads their quarterly Texas Nursing for in-depth articles (View online in the Membership tab at texasnurses.org.)
SELF-STARTER MEMBER This member has limited time, but is interested in discussing issues and learning more about what TNA is doing. How do they engage?
Sign up as an online expert advisor for one of the committees supporting TNA’s policy council Talk with other local members or interest groups via TNA’s online SocialLink Downloads one of the Engagement Toolkits from the TNA website (in the Practice section), gives a brief presentation about TNA to their colleagues, or hosts a Nursing Salon
and are willing to let others take the lead. How do they engage?
They continue their membership
Talk about TNA with their peers
Join in on activities when they want
No matter how you choose to be involved, you are a valued member of Texas Nurses Association. i
SUPPORTIVE MEMBER This member values TNA and the work we do for nurses in the policy arena but has limited time, or has already given
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CONTRIBUTE TO TNA’S POLICY COMMITTEES BY BECOMING AN EXPERT ADVISOR By Andrew Cates, TNA Director of Government Affairs DELAYED BY HURRICANE HARVEY, the TNA Policy Council met following the Leadership Conference in September to discuss issues that will drive our policy conversations for the next year. The Policy Council designated the following committees: APRN, Regulation, Workplace Advocacy, Education, and Maternal Morbidity and Mortality. Members not appointed to committees can still play a vital role in TNA’s policy development process by serving as an expert advisor. Expert advisors participate in policy dialogue without the responsibility and commitment required of committee members. Each month, TNA Policy Committees will meet by video or phone conference to discuss important issues. Expert advisors will receive the agenda prior to each meeting and have the opportunity to email questions, suggestions, or comments for consideration. Participation of expert advisors expands the breadth of experience and expertise contributing to the discussions and helps to ensure a well-rounded conversation with multiple viewpoints and opinions considered as policy recommendations are developed. TNA thanks the 307 nurses who shared their expertise in developing positions leading up to the 2017 legislative session. This year our goal is to engage 500 expert advisors. Help us get there! Sign up to be an expert advisor using the form under the Policy section of texasnurses.org. i
Protect Your License!!
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713.759.6430 jslilly@me.com www.nurse-lawyer.com
If you cannot hire an attorney, please visit www.nursingcomplaint.com for suggestions, sample documents and information about the Investigation Process..
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HELP TNA COLLECT INFORMATION ON INNOVATIVE SOLUTIONS FOR NURSE STAFFING By Ellen Martin, Director of Practice IN SEPTEMBER 2015, the American Nurses Association (ANA) published “Optimal Nurse Staffing to Improve Quality of Care and Patient Outcomes,� the first in a series of papers that makes the case for nursing value. ANA collaborated with Avalere to review the literature and explore the clinical case for using optimal nurse staffing models to achieve improvements in patient outcomes. The report included six case studies of best practices from leading hospitals that address patient acuity systems, matching labor supply to demand across an integrated healthcare system, internal staffing agency solution, and real-time changes in staffing for changing conditions in intermediate care patients. The full text can be found on the ANA website, and the next white paper is due to be published by the end of the year. To disseminate the findings of these reports, Texas Nurses Association is collaborating with the Texas Organization of Nurse Executives (TONE) to host a preconference on staffing at their annual conference Feb. 22, 2018. Dr. Seun Ross, DNP, CRNP-F,
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NP-C, NEA-BC, is the director of Nursing Practice and Work Environment at the American Nurses Association. She will present on national trends and highlight ANA tools and resources for nurse staffing, such as a staffing cost calculator tool. In addition to the findings of these national industry reports, TNA is interested in identifying the innovative practices currently underway in Texas. At the TNA 2017 Leadership Conference, we learned of one hospital testing a change to nine-hour shifts. Another hospital is addressing on-call fatigue with a plan for back-up call schedules for the operating room staff. Throughout the fall, TNA will collect innovations and positive practices involving staffing, including covering nurse breaks, addressing surge staffing, new hire on-boarding, and on-call and alternative scheduling models. If you are willing to share what your organization is doing to address staffing issues or have a pain-point of which you would like TNA to be aware, please contact TNA Director of Practice Ellen Martin at emartin@texasnurses.org. i
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UTILIZING THE NPA WEBSITE TO THE FULLEST By Andrew Cates, TNA Director of Government Affairs TNA MAKES AN EFFORT TO PROVIDE the highest-quality resources to nurses so you can focus on your practice rather than searching for answers to your questions. That’s why we created an easy-to-use online companion to the “Annotated Guide to the Texas Nursing Practice Act.” The NPA Online Guide is a free, members-only section of TNA website that is written in plain English rather than in legal jargon. Find it under the Practice tab of texasnurses.org.
additional protections, and licensure requirements. The Annotated Guide still provides the most comprehensive information and resources for understanding and applying the NPA, so order your copy today! i
The NPA Online Guide contains specific and concise information about statutes, rules, and guidelines governing nursing practice in Texas. It is divided into seven sections: scope of practice, discipline, peer review, reporting, safe harbor,
T E X A S N U R S I N G M AGA Z I N E | FA L L 2 017
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TEX AS NURS ES AS SOCIATION
2017 LEADERSHIP CONFERENCE PARTICIPANTS SHARE THEIR TAKEAWAYS Thank you to all who attended the TNA 2017 Leadership Conference Sept. 28-29 in Georgetown. Here we share some excellent takeaways by participants on the events and conversations:
ON THE CONFERENCE OVERALL "I always enjoy the TNA Leadership Conference, as the networking opportunities and sharing of ideas and experiences inspire growth. My favorite part is the legislative update and related presentations since that is my passion. The 'relational competence' theme was very different and interesting, certainly in sync with ANA’s theme. Excellent presenters and a new twist on learner engagement strategies! Well done."
WHEATLEY’S PRESENTATION "I learned much about 'creating islands of sanity' and 'sane leadership.' We were challenged to be 'warriors for the human spirit.' Very timely presentation amidst Hurricane Harvey, Irma, and more. We need to 'tend and befriend' and persevere."
1
WESORICK’S PRESENTATION "Excellent thought leader. She helped me think in terms of differentiating a problem vs. a polarity. When identified as a polarity, recognizing the polarizing issues each have value and create an energy that can be destructive if each value is not recognized and managed in the best interest of the institution."
2
3
4
5
SCREENING AND ACTIVITIES AROUND “12 ANGRY MEN” "Excellent approach using a mid-century movie that relates well to issues of today and provides good study of the human dynamic in a group setting. Descriptive of decision making that can occur in many healthcare arenas today. Very thought-provoking." i
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1 (from left) Jeff Watson, Norma Teran, Sue Ferguson, Laurel Pilkington, Molly Toon, Barbara Cherry, Serena Bumpus, Gail Acuña 2 Beverly Carrington, Dawn Pickens, Sheryl Gage 3 Kathy Thomas, Mary Beth Thomas, Kristin Benton 4 Bonnie Wesorick, Margaret J. Wheatley 5 Lauren Grotjan, Ami Pettersen, Victoria England
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TEXAS NURSES
Come to Work...
FOUNDATION NEWS
Where your work makes a difference!
FIRST NURSING RESEARCH POLICY GRANT AWARDED Jessica Smith, PhD, RN, received the first Nursing Policy Research Grant for her proposal Effects of Nurse Education, Skill Mix, Staffing Ratios and Work Environments on Rural Hospital Patient Outcomes. She is completing a post-doctoral fellowship at the University of Pennsylvania under the mentorship of Drs. Eileen Lake and Linda Aiken. Dr. Smith received her BSN from Texas Christian University and is a member of District 4 (Dallas). This program was founded by Executive Director Cindy Zolnierek with an initial pledge to the Foundation of $10,000 across five years. Additional donors are being solicited with the goal of minimum resources of $30,000, which will enable at least one grant award of $5,000 to $10,000 per year.
NURSES HELPING NURSES RECOVER FROM HARVEY In the aftermath of Hurricane Harvey, people from around the country and beyond donated to the Texas Nurses Foundation’s Nurses Helping Nurses fund. Recipients of these donations have written to share their heartfelt gratitude.
RNs and LVNs
W
e offer predictable work schedules, set case loads, and an excellent benefits package, including: n Competitive salaries n Health and retirement benefits n Paid vacation leave n Up to 15 paid holidays annually n Shift differential pay Contact: Laura Hunter atof Aging Texas Department and Disability Services laura.hunter@hhsc.state.tx.us
Exciting and challenging job opportunities await you at a state supported living center! Various nursing positions are available at 12 facilities around Texas.
Apply online: www.dads.state.tx.us/employment/sslcs/
"Thank you! I received my check, and it is coming at the best time. I am currently in the recovery phase with workers in and out of my house. Most companies want to be paid in full or at least half in advance. THANK YOU!" — Jackie
Words cannot express my gratitude. Thank you so very much for helping us through this. Each day we just keep putting another foot forward, and we will be OK. Please express my gratitude to all of those involved in helping make this happen. My nurse family is awesome! — Amy "A huge thank you to everyone who in some way or another helped Texas nurses in this time of need. Your kind gesture and monetary assistance is greatly appreciated! May each of you be greatly blessed for thinking of others affected by Hurricane Harvey." — Tracy "I received notification of my PayPal deposit today. I am speechless. I cannot even begin to relay to depth of my gratitude and appreciation for this gift to all who donated and to all who organized the effort. EVERY SINGLE PENNY I have is being counted and assigned since Harvey. And, yes, [while] it is true that this gift cannot make my home 'whole' again, it provides MANY meals and goes a long a long way to healing my spirit and making it 'whole.' To know that people care enough to reach out and donate in a time when so many people are struggling on their own in so many ways, related to or unrelated to the hurricane, reminds me that there is a hope and a light left in this world." — Julia i
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