texa s nu r s e s .o rg
TEXASNURSING M A G A Z I N E
NURSES IN NUMBERS
Researching Policy, Influencing Change, Making Their Voices Heard
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 | FA L L 2 0 1 8
FALL 2018 Volume 92, Number 4 EDITOR IN CHIEF: Cindy Zolnierek, PhD, RN, CAE MANAGING EDITOR: Kanaka Sathasivan, MPH 4807 Spicewood Springs Rd., Bldg 3, Suite 100, Austin, TX 78759-8444 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 Tamara “Tammy” Eades, DNP, MSN, RN, Vice President Kleanthe Caruso, RN, MSN, NEA-BC, Secretary Gayle Dasher, RN, PhD, ANP-BC, Treasurer DIRECTORS: Tina Cuellar, PhD, RN, PMHCNS-BC Melinda Hester, DNP, RN Donna Wallis, MBA, MSN, RN Patricia Freier, MSN, RN-BC, RCIS Shakyryn Napier, DHSc, MSN, RN, CPN
TNA DISTRICT AND PRESIDENT Dist.1:
VISION Nurses transforming health TEXAS NURSING (ISSN 0095-36X) is published quarterly— Winter, Spring, Summer, Fall—by the Texas Nurses Association, 4807 Spicewood Springs Rd., Bldg 3, Suite 100, Austin, TX 78759-8444 Periodical postage is paid in Austin, Texas. One-year subscriptions: $25 (nursing schools, libraries, hospitals, non-nurses, out-of-state nurses), foreign $30; single copy $2.50. Subscription is not available to non-member Texas nurses. Some back issues may be viewed online at texasnurses.org. PUBLISHING PARTNER Monarch Media & Consulting, Inc. P: 512.680.3989 or 512.293.9277; F: 866.328.7199 monarchmediainc.com | chellie@monarchmediainc.com Advertising inquiries: call Chellie Thompson at 512.293.9277. TEXAS NURSING is indexed in The Cumulative Index to Nursing and Allied Health Literature and in the International Nursing Index. 16mm, 35mm microfilm, 105mm microfiche, article copies available from University Microfilms International: 1.800.521.3044 Statements of fact and opinion are made on the responsibility of the authors alone and do not imply an opinion on the part of the officers or the membership of TNA. POSTMASTER Send address changes to TEXAS NURSING, 4807 Spicewood Springs Rd., Bldg 3, Suite 100, Austin, TX 78759-8444
Dist. 3: Margie Dorman-O'Donnell, margie.dormanodonnell@cookchildrens.org, District Staff: Jamie Gilbert, jamiegilbert@texashealth.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: David Burzynski, president.tnad5@gmail.com Dist. 7: Crissie Richardson, crissag98@gmail.com, District office: P.O. Box 1482, Belton, TX 76513, tnadistrict7@gmail.com Dist. 8: Linda Juenke, 830.739.7028, ljsoaringeagle3@gmail.com Dist. 9: Tina Cuellar, tinaatutmb@aol.com, District office: Melanie Truong, 7324 Southwest Freeway, Suite 2-1453, Houston, TX 77074; 713.523.3619; tna9@tnadistrict9.com; tnadistrict9.com Dist. 11: Linda Treitler, linda.treitler@mwsu.edu 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. 35: Chrystal Brown, 903.434.8302, cbrown@ntcc.edu At-large: Contact TNA, 800.862.2022, ext. 129, brichey@texasnurses.org
ARE YOU MOVING? Need to change your address? If so, provide it quickly and easily in the Members Only section of the TNA website, texasnurses.org. Or mail your new address—at least six weeks prior to your move—to Texas Nurses Association headquarters. We’ll make sure your TEXAS NURSING makes the move with you. FEEDBACK EMAIL OR LETTER GUIDELINES TEXAS NURSING will select emails/letters on the basis of readership interest and relevance to current nursing/health care events. TEXAS NURSING reserves the right to edit all letters. Guide: Limit to 200 words; focus on single issue; include writer’s name, mailing address, and daytime phone. Send to: editor@texasnurses.org. Copyright 2018 © Texas Nurses Association
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Clarissa Silva, clarissa2277@att.net, Terry Acosta, shadowmon@sbcglobal.net
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NURSES IN NUMBERS
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TNA at the Capitol
TAKE THE FIRST STEP
THE DNP HEALTH POLICY EXPERIENCE
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Get Involved in 2019 Nurse Day at the Capitol
CHALLENGES FACING THE NURSING WORKFORCE IN RURAL HOSPITALS
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Contents IN EVERY ISSUE
FEATURES
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YEAR OF ADVOCACY IN REVIEW
NEW TPAPN MODEL INDIVIDUALIZES PARTICIPATION GUIDELINES
BOARD OF NURSING RULE CHANGES
NURSES LEADING INNOVATION IN TEXAS
CARE FOR THE CAREGIVER
What You Need to Know
Mobile Nursing and New Technology
PRESIDENT’S NOTES Amplifying Nurse Voices
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TNA MEMBER NEWS
Advocacy in Practice
Improved Structure Launches in 2019
Johnson & Johnson Foundation Grant Helps TNA and TONE Address Nurse Traumatic Stress
Kudos
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President’s Notes Jeff Watson, DNP, RN-BC, NEA-BC, NE-BC, CRRN
AMPLIFYING NURSE VOICES Making Nursing Visible at the Capitol
AS I SIT TO WRITE TO YOU, the 2018 midterm election is just a few days away. The commercials are almost non-stop, and the excitement brought about by participation in the democratic process in and among my family, friends, and colleagues is palpable. Elections are both exhilarating and exhausting at the same time! Soon we will be immersed in the activity of the 86th Texas Legislature in Austin. Organizations and associations, representing citizens from across the state, will have finalized their legislative agendas. Lobbyists and activists will intensify their efforts to move those agendas forward or find ways to compromise for the greater good. At the same time, we will continue to care for people in hospitals, rehabilitation facilities, long-term care facilities, and in the community. We will continue to educate the next generation of nurses in our universities and community colleges. We will continue to advance the profession of nursing in every space we occupy across this state. As you all well know, the work of nursing is never done. On February 18 and 19, 2019, nurses from across Texas will assemble in Austin for the Texas Nurses Association (TNA) Nurse Day at the Capitol. At this event, you will learn about the legislative efforts being made by nurses on behalf of nurses, as well as get updates on partnerships and collaborations with other associations and agencies. You will also get a fundamental overview on effective communication and follow-up with your legislator and their legislative staff members. If you have never been to a Nurse Day at the Capitol, then consider this your
Health policy and public policy change because of prevailing voices and cultural shifts. Nurse Day at the Capitol is yet another opportunity to make certain that the nursing voice and perspective is one that is heard by the lawmakers who comprise the 86th Texas Legislature. invitation. If it has been a while since you last participated, we would appreciate seeing you again. Block the days on your calendar and come prepared to engage and extend your influence. This year marks the 10th biannual event, twenty years after TNA first gathered nurses together to amplify their voices at the Capitol. Not only does Nurse Day at the Capitol afford you an opportunity to meet with your representatives, but you will have a chance to meet nurses from diverse backgrounds who come from every region of our expansive state. You will meet nurses who work in large acute and sub-acute hospitals, small rural criti-
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cal access hospitals, public and community health entities, schools, community colleges and universities, and many other places. Perhaps the most important reason to come to Austin in February is to be seen and heard. Health policy and public policy change because of prevailing voices and cultural shifts. Nurse Day at the Capitol is yet another opportunity to make certain that the nursing voice and perspective is one that is heard by the lawmakers who comprise the 86th Texas Legislature. Peace, Jeff i
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TNA MEMBER NEWS SPOTLIGHT ON YOU KUDOS The University of Texas Medical Branch at Galveston School of Nursing Alumni Association annually recognizes graduates who have contributed to nursing through excellence in patient care, research, education, community service, or leadership. Ellarene Duis Sanders, PhD, RN, NEA-BC, was named the 2018 Distinguished Alumnus. Duis Sanders earned an associate degree from the University of Nebraska, a Bachelor of Science in Nursing from Northwestern State University, and both her masters and doctorate from the University of Texas Medical Branch at Galveston. She has been district president in several Texas Nurses Association (TNA) districts, served previously as interim executive director of TNA, and served on multiple ANA committees. In the past 37 years, she has worked in direct patient care, as a nurse manager, and as a director of nursing. Since 2014, she has been a member of the faculty for Texas Tech University Health Science Center RN-BSN Program, serving as assistant professor and lead faculty for the capstone course. Duis Sanders has also worked part-time as an evaluator for the Western Governors University MSN Leadership and Management Program since early 2017. Amy Anderson, DNP, RN, CNE, was selected to participate as an International Council of Nursing (ICN) Global Nurse Leadership Institute Policy Programme Scholar for 2018. After a highly competitive process, nurse leaders from around the world
were selected to build capacity to influence global policy and politics. The Scholars network and develop initiatives that advance nursing and health around the world. The 2018 cohort consists of 26 Scholars representing 23 countries. The five-month long program includes a residency week in Geneva, Switzerland, where Scholars develop connections with global health leaders at the World Health Organization and the ICN. Co-facilitators for the program are Jane Salvage and Dr. Diana Mason. The program receives generous funding from the Burdett Trust in Nursing. Congratulations to Molly McNamara, MHA, BSN, RN, NE-BC, CPHQ, recently promoted to Director of Utilization Review/Management for the Harris Health System in Houston, the third largest public health system in the United States. Having facilitated system operations for utilization management for over 10 years, McNamara will now direct utilization review services within the operation serving two acute care hospitals and 27 ambulatory care settings. With over 37 years of nursing and leadership experience, she brings with her a broad background in case management, grant administration, emergency care, and trauma care in large tertiary non-profit settings. McNamara holds a Bachelor of Science in Nursing from South Florida University, Master’s in Healthcare Administration, and is certified as a Professional in Healthcare Quality and as a Nurse Executive. The prior recipient of the Texas Nurses Association – Texas Outstanding Clinician Award, President of the Texas Trauma Coordinators, and a member
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of the Texas Organization of Healthcare Executives – Health Informatics Committee, McNamara enjoys and teaches on a variety of nursing and health care topics at local, state, and national levels. Cindy Strzelecki, RN, BSN, MBA, was elected to the Windcrest City Council in the November 6th elections. Cindy is a past president of TNA District 8 (San Antonio) and the immediate past chair of the TNA Governmental Affairs Committee (GAC). She is on District 8's GAC, which has been very active locally. She served on the Board of Directors of the American Association of Critical Care Nurses from 1990 to 1993. Cindy has been active in the City of Windcrest serving on the Windcrest Proud Committee, the Code of Conduct Ethics Advisory Committee to the City Council, and currently on the Special Events Committee. Cindy has over 20 years experience in hospital administration, serving as a chief nursing officer and for 13 years as a compliance officer. She is currently on faculty at the Baptist School of Health Professions, teaching in the Vocational Nursing Program. i
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. Please send submissions to editor@texasnurses.org.
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The 86th Session of the Texas Legislature
NURSES IN NUMBERS
TNA at the Capitol
By Andrew Cates, TNA General Council and Director of Government Affairs
THE 86TH SESSION of the Texas Legislature is right around the corner—beginning January 8, 2019. With the help of over 650 members, TNA has spent the last twelve months researching, collecting data, and honing our public policy positions to get ready.
We now have positions not only on advanced practice nursing and safe staffing issues, but also end-of-life care, mental health concerns, and statewide maternal morbidity and mortality issues.
Over the summer, the TNA Board of Directors approved a slate of public policy positions brought forward by the TNA Policy Council after nine months of rigorous development by the Policy Council’s seven committees. While lengthy and difficult, the process helped TNA prioritize inclusivity and accessibility so hundreds of members could influence the policy development process. And the results speak for themselves.
However, developing policy is just the first step. Once TNA has policies in place, the TNA Government Affairs Committee (GAC) transitions from their political role of interviewing candidates and engaging in campaigns to developing the policy positions into action items for the legislative session.
The breadth of involvement and expertise from our members allowed us to take positions on more issues than ever this year.
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Not all of the positions are ripe for consideration at the Texas Capitol at any given time, so the members of the GAC must filter the positions by considering which ones TNA can impact through legislation.
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Some of the major pieces of 2019 legislation TNA plans to advocate for: Protecting nurses in the workplace Full practice authority for APRNs Increased flexibility and full funding for the nursing shortage reduction program Expanded access and funding of the nursing faculty loan repayment program
cus having a relatively larger share of the overall House GOP Caucus, members of the Texas House will have to work together this session if any bills are going to have a chance. For nursing, this means that we need to establish broad support across both aisles and across both chambers of the Texas capitol in order to move our agenda and make our voices heard! i
In addition to TNA’s priorities, we also support multiple coalitions that will advance bills TNA supports, including the Coalition for Healthy Minds (addressing behavioral health issues), Texas Public Health Coalition (population health issues like immunizations and tobacco usage), and the Coalition for Health Care Access, which TNA leads (consumer and business interests on the APRN full practice issue). TNA also heads the Nursing Legislative Agenda Coalition, which targets nursing issues broadly supported by dozens of Texas nursing groups.
LEARN MORE ABOUT OUR 2018-2019 POLICY POSITIONS Visit www.texasnurses.org/nursingpolicy.
However, as is the case with all things political, the success or failure of many of these priorities will depend in large part on the make-up of the elected body at the capitol. The midterm election in early November saw twice as many voters as the last two midterm elections dating back to 2010. In total, it had the second most votes cast in an election in Texas in the last decade, including in Presidential elections! The “Blue Wave” materialized only slightly in Texas, with the Democrats picking up two Congressional seats, two Texas Senate seats, and 12 Texas House seats. It sounds like a big win, but the 2010 Tea Party wave through Texas picked up 22 Texas House seats, meaning the Democrats still have a long way to go to catch up. Currently, the new House has 83 Republicans and 67 Democrats, and the Senate has 19 Republicans and 12 Democrats. Lieutenant Governor Dan Patrick will still retain a three-fifths GOP majority in the Senate to make it easy to push through GOP agenda items, but the House will be different this time. With a larger Democratic caucus and with the Freedom Cau-
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THE DNP
HEALTH POLICY EXPERIENCE
How TNA’s Policy Fellowship Benefited University of Texas School of Nursing Students
By Stephanie Morgan, PhD, RN, FNP-BC IN A TIME WHEN OUR POLITICAL environment is full of adversity and division, the involvement of nurses in health policy cannot be more critical. Collaboration between nursing organizations and Doctor of Nursing Practice (DNP) programs cultivates and leverages the expertise and learning of both groups. At the forefront of utilizing this powerful collaborative strategy is the Texas Nurses Association’s DNP Policy Fellowship, which connects DNP students with policy committees. This past spring semester, I incorporated the DNP Policy Fellowship into my health-
care policy class for the DNP program at The University of Texas at Austin School of Nursing. The program offered a valuable experience for students that satisfied their academic requirements while meaningfully contributing to TNA’s 20182019 policy position statements. Andrew Cates, TNA’s General Council and Director of Government Affairs, mentored students throughout the semester, providing guidance and support related to
This unique collaboration empowered my nursing students with the opportunity to experience the role nursing leaders can play in the development and support of health policy for Texas nurses.
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TNA’s focused policy areas. This unique collaboration empowered my nursing students with the opportunity to experience the role nursing leaders can play in the development and support of health policy for Texas nurses. The partnership also allowed TNA to capitalize on the unique insight and skill sets that DNP students can provide, including high-quality research and knowledge about the context of a health-related issue. Students ultimately identified and synthesized evidence to support recommendations for changes in health policy. In order to provide structure and recognition for the work completed by the students, TNA outlined the expecta-
tions, work load, and time commitment required for students in the Policy Fellowship. The final products the students provided to the TNA policy committee also fulfilled the final project requirements for my class. Additionally, the formality of the Fellowship allows students to engage with the various policy committee members and thus experience the process used to drive policy changes while being mentored for a timely deliverable. The real-world experience of participating and learning alongside members of an organization conducting health policy work is invaluable to DNP students. The knowledge and understanding that our work significantly contributes towards TNA’s policy position statements was extremely rewarding. Using fellows in this type of program helps student research and suggestions
Using fellows in this type of program helps student research and suggestions transcend the requirements of a mere academic exercise and helps mold them into experienced DNP leaders for the nursing profession. transcend the requirements of a mere academic exercise and helps mold them into experienced DNP leaders for the nursing profession. The unique blending of an academic learning environment coupled with real world implementation undoubtedly encourages students to remain engaged in health policy through TNA, as well as other organizations, thus reinforcing the leadership role DNP’s play now and into the future. These types of collaborative experi-
ences provide doctorally prepared nurses with the skills and confidence to engage in health policy debate and an understanding of how to navigate the uncharted waters of health care policy in the future. Additionally, this program provides TNA with valuable new insights beyond those already identified by the organization. Nurses have been and shall remain committed to lifelong learning. The goal for all of us should be to cultivate and encourage collaboration between academics and those responsible for implementation and execution so as to secure our professions' ability to meaningfully lead and address health policy changes. i
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TAKE THE FIRST STEP
Get Involved by Attending Nurse Day at the Capitol By Patricia Freier, MSN, RN-BC, RCIS, CPHQ THE LONGEST JOURNEY BEGINS WITH A SINGLE STEP. I was born in South Dakota and earned my Bachelor of Science in Nursing from Texas Tech University Health Sciences Center and Master of Science in Nursing from Lubbock Christian University, along with three certifications. But the credential that gives me the greatest pride and fulfillment is my elected position on the TNA Board of Directors.
It was the influence of Texas Nurses Association (TNA) that helped me understand how to begin at a grassroots level and focus on what I know best (nursing and other health care issues)… Getting my first nursing resolution passed at the Lubbock County Republican Convention was tremendously empowering. I had tried to be active in my political party in the past. It was difficult to learn how to start. Although I am a member of American Nurses Association, I don’t always have the same views. I really never had success until I learned how to begin in my own hometown. It was the influence of Texas Nurses Association (TNA) that helped me understand how to begin at a grassroots level and focus on what I know best (nursing and other health care issues). Getting my first nursing resolution passed at the Lubbock County Republican Convention was tremendously empowering. After eight hours of work, and doing my due diligence as a Precinct Delegate, I finally got my chance to introduce my resolution for the third time. After negotiating a friendly amendment and fight-
ing off a not-so-friendly amendment, “The ayes have it!” turned out to be very powerful words indeed. I believe I have been able to influence others to join TNA and take that first step. This year Representative Dustin Burrows asked me to serve and represent nurses
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on a multi-disciplinary task force in preparation for the next legislative session. I have been invited to speak on advocacy to student groups as well as speak on health care panels for scope-ofpractice and access-to-care issues for Texas Conservative Coalition Research Institute (TCCRI).
Attending Nurse Day at the Capitol is the perfect first step to take on the road to becoming an advocate. Now, I know I can do what I have done before, and I can probably do more next time. Over the last 15 years or so, I have participated in Nurse Day at the Capitol, served on the TNA Government Affairs Committee (GAC), and met with legislators in Austin and Lubbock. These initial steps lead to my serving on the task force, which led to the TCCRI health care panel where I was able to secure TCCRI as a new partner in supporting the APRN Full Practice initiative. I helped District 18 write a resolution calling for increased nursing engagement in end-of-life legislative issues, a resolve that garnered five additional districts as co-sponsors and was passed unanimously at the TNA House of Delegates. I now chair a statewide task force in the development of a position statement to lay the groundwork for such action. I love the challenge of inspiring young nurses and nursing students to engage in their advocacy role, such as the five students from U.T. Tyler who were assigned to meet with Representative Coleman’s staff person at Nurse Day at the Capitol in 2017. GAC members served as mentors and guides that day during the event. When I first approached the students, they indicated a little nervousness and wanted me to take the lead. They were eager and excited, just inexperienced in this arena. We were somewhat early, so I took time to teach them about the process and prepare them for the discussion. I explained how it was also important to meet with staff, even if the Representative was not present.
At that time we were working on a number of issues including workplace violence, which involved a grant program to support innovative approaches to reducing or eliminating workplace violence. We all sat down and I began the discussion of our talking points, looking at the students and offering to hand off to any one of them. The students participated fully in the discussion. They took the handoffs with confidence. They had already been exposed to violence even though they were not registered nurses yet. I was very proud of them. It did not matter if they were nervous initially; they resolved any anxiety they may have felt and presented themselves in a professional manner. I knew that once they did this, they could do it again and maybe push themselves to do even more next time. These students represented their school with pride. I hope they continue in their advocacy role, and I hope to see many of you there at the 2019 Nurse Day at the Capitol alongside nursing students. Attending Nurse Day at the Capitol is the perfect first step to take on the road to becoming an advocate. This year marks twenty years since the first event, and once again hundreds of nurses across Texas will come together to represent the profession in front of their state legislators. Celebrate the 10th biannual Annual Nurse Day at the Capitol with us and start your journey to improving nursing and health care statewide. i
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contingent had a lot of fun getting to know each other and making our voices heard. We received a briefing, issue briefs, and an appointment schedule. Nurses advocated on five positions this year: health care reform, safe staffing, nursing workforce development, home health, and gun violence. These visits with our elected representatives are also a great way to learn. We asked if they were aware of the staffing bill, and, if they weren’t following it closely, we had the opportunity to offer more information. In some cases, we learn from the representative or the staffer why a bill may not be supported and report that information back to ANA. The information conversation is a two-way street.
YEAR OF ADVOCACY IN REVIEW
Some of these issues are politically charged with divisive rhetoric. Yet, even when nurses don’t agree on the “how” for some of these issues, there are many things we do agree on. Often areas of agreement are evident when you dig a little deeper than the “headline.” Take gun violence for example. The ANA position simply asks that barriers to research funding on this issue be lifted so it can be treated the same as any other public health issue. Nurses are all about evidence-based solutions, and to develop those solutions we need evidence or research.
By Ellen Martin, PhD, RN, CPHQ Director of Practice, Texas Nurses Association
Make every year a year of advocacy at any level, in any role and setting. AS 2018 WINDS DOWN, we reflect on the Year of Advocacy. Throughout the year, we have encouraged Texas nurses to share their advocacy stories on the American Nurses Association (ANA) website. Texas Nurses Association (TNA) members Molly Flowers and Patricia Phelps have their advocacy stories—of improving nursing care in long-term care facilities and engaging all staff in workplace violence prevention, respectfully —featured on the ANA website. Stories of nurses acting locally, nurses making global impact, and nurses influencing elected officials were featured in Texas Nursing this year.
By now, when you receive this issue in your mailbox, the midterm elections have been decided. Voting is an essential element of advocacy and is a way to leverage health care expertise and public trust. Nurses have supported candidates running for elected or appointed positions and some are even running for office themselves.
National Advocacy ANA Hill Day in June was a wonderful way to connect with nurses from all over Texas and the USA as we gathered to discuss key issues with our congressional representatives and senators. The Texas
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Check out the talking points for these issues on the ANA website.
Advocacy in Practice This past year, two members worked with TNA and the Board of Nursing (BON) to clarify a position statement on use of anesthetic agents to reflect practice changes involving low dose ketamine. Part of advocacy is the ability to advocate for changes that affect your nursing practice at the state level or the organizational level. The TNA Continuing Nursing Education committee advocated for a change in the BON Continuing Competency Rule. A task force conducted an extensive literature review to provide evidence that CNE focused on changes in attitude, self-therapy, and self-awareness has a positive influence on patient outcomes.
Unless nurses at every level get involved with advocacy locally, organizationally, and state-wide, we won’t be able to create better outcomes for nurses and patients. After the Nursing Practice Advisory Committee of the BON discussed the proposal on May 7, 2018, adding additional changes to expand allowable content that meets older adult and geriatric care requirements, the changes were adopted at the July 2018 board meeting. A complete report is available on the BON website: read item 7.4 on the July 2018 agenda. At the organizational level, nurses advocate for change every day through committee service. For example, if your
Voting is an essential element of advocacy and is a way to leverage health care expertise and public trust. Nurses have supported candidates running for elected or appointed positions and some are even running for office themselves.
Advocacy for the Future
hospital requires you to sign up for overtime shifts to address surges in the census, and you don’t want to do that, talk to your unit representative for the hospital staffing committee. The hospital safe staffing law specifies that 60% of the members of the committee must be direct care nurses selected by their peers. If you don’t know who is representing you, have a conversation with your nurse manager. If you serve on a staffing committee, you can suggest alternatives to mandatory shift coverage. Or you might learn what coverage issues are specific to your unit. For example, in a specialty area, it is hard to have enough trained float nurses. Through committee service, you may learn that for specialty areas, an on-call system is the best way to ensure trained staff are available to come in when there is a staffing crunch.
Unless nurses at every level get involved with advocacy locally, organizationally, and statewide, we won’t be able to create better outcomes for nurses and patients. Although the year of advocacy is coming to an end, the work can’t stop. The Texas Legislative session starts in January 2019. To learn about the TNA policy positions visit the TNA website, participate in Nurse Talks on January 9 where Andy Cates, Director of Government Affairs, will share TNA’s legislative agenda, and join us for Nurse Day at the Capitol on February 18 and 19. It’s an experience not to be missed, and I hope I will see you there! i
On-Demand, Online Education Any Time, Any Place Check out our new Learning Curve modules on Peer Review: »» What the Nurse Needs to Know »» What the CNO Needs to Know »» Incident-Based Peer Review »» Nursing Practice Safety Net.
We’ve also added three great courses on electronic health records: »» The Nurse Experience with EHR »» The Role of Nurses in Using and Improving EHR »» Managing EHR Interoperability
Find these courses and more at
www.texasnurses.org/OnDemand!
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CHALLENGES FACING THE NURSING WORKFORCE IN RURAL HOSPITALS Report on Research Conducted Through Texas Nurses Foundation Grant IN JULY 2017, TNA member Jessica Smith, PhD, RN, received the first Texas Nurses Foundation Nursing Policy Research Grant for her proposal: Effects of Nurse Education, Skill Mix, Staffing Ratios, and Work Environments on Rural Hospital Patient Outcomes. Mentored by nurse scientists Eileen Lake, PhD, RN, FAAN, and Linda Aiken, PhD, RN, FAAN, FRCN, during post-doctoral studies at the University of Pennsylvania, Smith conducted a secondary analysis of data collected from large random samples from the 2005-2008 Multi-State Nursing Care and Patient Safety Study funded by the National Institute of Nursing Research and National Institutes for Health.
RESULTS The final sample included 566 urban, 49 large rural, 18 small rural, and nine isolated remote hospitals. The study found significant differences in urban and rural settings (p<.01).
TNA member Jessica Smith, PhD, RN, received the first Texas Nurses Foundation Nursing Policy Research Grant for her proposal: Effects of Nurse Education, Skill Mix, Staffing Ratios, and Work Environments on Rural Hospital Patient Outcomes. hospitals. Nursing foundations for quality care were poorer in large, small, and isolated remote rural hospitals compared to urban hospitals. Staffing and resource adequacy was rated as more sufficient in small rural compared to large rural, isolated remote rural, and urban hospitals.
Hospital percentages of BSN nurses: 38% urban, 28% large rural, 31% small rural, 21% isolated remote rural hospitals
On average, 72% of nursing staff were RNs (range: 45% to 100%).
Patient-to-nurse ratios: 3.3 urban, 3.6 large rural, 3.7 small rural, 4.0 isolated remote rural hospitals
Adverse event frequency ranged substantially, from 0% to 67%, across the 76 hospitals.
A 10% increase in nursing skill mix and a one SD increase in the PES-NWI* score were associated with decreased odds that adverse events occurred frequently.
Nurse skill mix differed and was lowest in isolated remote rural
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DISCUSSION Results add to evidence that rural hospitals employ fewer educated nurses, even among different rural hospital subsets. The most remote areas have the most under-resourced hospitals. Policies and funding mechanisms to establish greater access for rural nurses to advance their education may be beneficial to provide safer, higher quality nursing care. More robust nurse education programs designed to produce baccalaureate prepared RNs could address both the lower skill mix and lower levels of education for rural hospital nurses. Large rural hospitals were rated lower for nursing foundations for quality of care (presence of continuing education opportunities, preceptor programs for new RNs, and quality assurance programs) compared to urban hospitals. To achieve adequate nursing foundations of care, rural hospital administrators should ensure nurses have a nursing philosophy of care and are educated to effectively implement quality improvements in the same manner as urban hospital nurses. Rural hospitals with better skill mix and work environments were associated with less frequent medication errors, pressure ulcers, falls with injury, and UTIs. These associations were statistically significant. This provides compelling evidence for the value of investing in nursing resources in rural settings as a mechanism to improve outcomes. Two manuscripts reporting this research are currently under peer review for publication in the rural health literature. i
NURSING POLICY RESEARCH GRANT TNF is now accepting applications for its next grant award in Spring 2018. For more information and to apply, visit: www.texasnurses.org/AboutTNF. TNA CEO Cindy Zolnierek established the Nursing Policy Research Grant program in 2016 with a pledge of $10,000 over five years. Zolnierek believes in the importance of research-level policy inquiry that can inform policy initiatives to improve nursing education and practice and contribute to safe, quality patient care. The first recipient of the TNF Nursing Policy Research Grant was Dr. Jessica G. Smith, a postdoctoral fellow at the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing. Dr. Smith is a graduate of Texas Christian University and has been a TNA member since 2012. Her grant report here showcases what is possible.
*Practice Environment Scale of the Nursing Work Index
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FA LYLE 2A018 R S | T E X A S N U R S I N G M AGA Z I N E
NEW TPAPN MODEL INDIVIDUALIZES PARTICIPATION GUIDELINES The New Structure Should Lead to Better Outcomes and Increased Participation
SINCE 1987, THE TEXAS PEER ASSISTANCE PROGRAM for Nurses (TPAPN) has helped thousands of nurses with substance use and mental health conditions recover. However, sometimes the program felt rigid and not responsive to the specific needs of participants. Board of Nursing (BON) Sunset recommendations directed the BON and TPAPN to adjust the program to be more responsive to individual needs of participants. The new approach embraces a flexible framework in which comprehensive evaluations by qualified psychiatrists and psychologists provide information on the person’s diagnosis and severity, remission status, and individual needs. This information, together with license type and situational factors, enable TPAPN to match the person with the appropriate level of program requirements (e.g., monitoring, social support, practice restrictions, etc.). These approaches reflect the current evidence and best practices related to recovery of licensed professionals in safety-sensitive roles, such as nursing. TPAPN’s newly defined mission: Safeguard patients by providing early identification, support, monitoring, accountability, and earned advocacy for nurses (APRNs, RNs, and LVNs) in Texas who have an identified substance use or mental health condition or related incident, so that the individual may return to safe nursing practice. Participation in TPAPN is voluntary, and TPAPN hopes to see greater completion rates with the new, tailored approach. “The intent is to be fair, equitable, and consistent among participants while responding to their individual needs,” says Jona-
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The new approach embraces a flexible framework in which comprehensive evaluations by qualified psychiatrists and psychologists provide information on the person’s diagnosis and severity, remission status, and individual needs. than Wolfarth, MS, RN-BC, TPAPN program director. “Ideally, this individualization will enhance participant recovery as evidenced in program participation and completion rates.” Previously, nurses were required to enroll in TPAPN before undergoing a comprehensive evaluation. Under the new model, nurses receive an evaluation and proposed participation requirements before they sign on. This process enables nurses to fully understand what they are agreeing to before they enroll. Corinne Hernandez, MS, LCDC, TPAPN case manager, says the new model is a greater partnership between the participant and TPAPN. “They feel they’re having a voice in this rather than us being an authoritative figure,” she says. “We now play a more collaborative role.” TPAPN case managers like Corinne are being educated in motivational interviewing skills so they can meet participants where they are and support their success in the program. The new program also includes a revised role for volunteer nurse advocates. In line with evidence showing the pivotal role of
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Texas Peer Assistance Program for Nurses TPAPN safeguards patients by providing early identification, support, monitoring, accountability and advocacy to Texas nurses. Nurse experiences substance use or mental health event(s) or episode(s)
Nurse’s needs determined
Individulized participation requirements may include: Treatment Drug testing Refraining from practice
Drug test Substance use and mental health assessment
Nurse referred or ordered to TPAPN Nurse connects with TPAPN
Peer support from volunteer nurse advocate
Assessment includes: • Diagnosis • Treatment recommendations • Recovery support recommendations • Fitness to practice determination • Practice monitoring needs
Communication with TPAPN
peer support in recovery, volunteers now serve in a social peer support role rather than an oversight role. TPAPN partnered with SAMHSA and the Center for Social Innovation to offer evidence-based training to peer advocates as they transition to a support role. Wolfarth says case managers and advocates can sometimes be the only source of support for nurses with behavioral health conditions. “Studies suggest people do better in life and in recovery if they have social peer support,” he says. “Some nurses come to us with none of that.” TPAPN’s transformation is already underway, and the new
Recovery support Practice monitoring • Supervision • Restrictions Participation requirements are based on referral information, diagnosis, severity, remission, individual needs and license type.
Adherent
Nurse completes all TPAPN participation requirements
Non-adherent Nurse referred to Board of Nursing Board of Nursing investigates to determine next steps.
In line with evidence showing the pivotal role of peer support in recovery, volunteers now serve in a social peer support role rather than an oversight role. model defining participation requirements in TPAPN will be fully launched in January 2019. It will continue to be a work in progress as TPAPN works to improve the program with the goal of supporting the recovery and return to safe practice of every nurse referred to the program. i
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FA L L 2 018 | T E X A S N U R S I N G M AGA Z I N E
BOARD OF NURSING RULE CHANGES
THE BOARD OF NURSING continually updates rules that affect nursing practice, especially when implementing new laws after a legislative session. TNA monitors all rulemaking that affects nurses and makes comments to guide the process of rulemaking to reflect legislative intent.
after three years rather than five, based on studies on recidivism and deferment.
CHAPTER 213. PRACTICE AND PROCEDURE
22 TAC 214.3. Program Development – If a program has other nursing programs in other jurisdictions, the proposal must include evidence of an 80% NCLEX pass rate and approval from applicable state boards. Proposals must be ready for consideration within one year from submission of the initial proposal draft. Out-of-state programs providing clinical education in Texas must have 80% pass rates.
22 TAC 213.23. Decisions of the Board – Amended to reflect Sunset Commission amendments to the Nursing Practice Act. Board of Nursing (BON) cannot modify findings of fact or conclusions of law in a Proposal For Decision from the State Office of Administrative Hearings. 22 TAC 213.27. Good Professional Character – Amendments reflect modified disciplinary statute to ensure BON disciplinary actions are based on behaviors directly related to the practice of nursing (Sunset Commission, 85th Texas Legislative Session). 22 TAC 213.28. Licensure of Individuals with Criminal History – Replaced entirely after BON stakeholder meetings to ensure they only discipline nurses for crimes directly related to the practice of nursing. 22 TAC 213.34. Deferred Discipline – Modified to make an order confidential
CHAPTER 214. VOCATIONAL NURSING EDUCATION 22 TAC 214.2. Definitions – Clarifying, non-substantive changes.
22 TAC 214.4. Approval – Clarifying, nonsubstantive changes concerning withdrawal of approval status. 22 TAC 214.6. Administration and Organization – Director or coordinator of a program must hold a current license to practice nursing in Texas and must attend a BON workshop. 22 TAC 214.7. Faculty Organization – Personnel policies must include resources for incident-based and safe harbor Nursing Peer Review. 22 TAC 214.8. Students – Changes to a
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program’s Nursing Student Handbook, clarifying modifications to rules concerning criminal history, fitness to practice, and good professional character. 22 TAC 214.9. Programs of Study – Clarifying changes concerning standardized examinations and curriculum changes. 22 TAC 214.10. Clinical Learning Experiences – When a simulation laboratory is used, the faculty must be trained, the program may only use up to 50% simulation activities in clinical courses, and courses must be designed to meet clinical objectives. 22 TAC 214.11. Facilities, Resources, and Services – Simulations laboratories must be appropriately equipped, and scenarios must mimic real clinical situations. 22 TAC 214.13. Total Program Evaluation – Clarifying, non-substantive changes.
CHAPTER 215. PROFESSIONAL NURSING EDUCATION 22 TAC 215.2. Definitions – Same as 214.2. 22 TAC 215.3. Program Development, Expansion, and Closure – Same as 214.3. 22 TAC 215.4. Approval – Same as 214.4. 22 TAC 215.6. Administration and Organization – Same as 214.6. 22 TAC 215.7. Faculty – Same as 214.7. 22 TAC 215.8. Students – Same as 214.8.
22 TAC 215.9. Program of Study – Same as 214.9. Also adds: A curriculum must provide continuity and integration of learning; learning experiences must develop values, knowledge, judgment, and skills; learning in simulated or clinical settings must use contemporary technologies and develop communication and interpersonal skills. 22 TAC 215.10. Clinical Learning Experiences – Same as 214.10. 22 TAC 215.11. Facilities, Resources, and Services – Same as 214.11. 22 TAC 215.13. Total Program Evaluation – Same as 215.13. 22 TAC 215.8. Students – A program’s Nursing Student Handbook must include policies to ensure students fulfill requirements for obtaining criminal history record information. Reiterates that processes must be in place for policy development, implementation, and enforcement.
CHAPTER 216. CONTINUING COMPETENCY 22 TAC 216.3 – Updated guidelines for Older Adult or Geriatric Care CNE courses. 22 TAC 216.6 – Clarifies that courses focused on self-improvement, changes in attitude, self-therapy, and self-awareness could be acceptable CNE if they delineate the impact on nursing practice or improved patient outcomes.
CHAPTER 217. LICENSURE, PEER ASSISTANCE AND PRACTICE 22 TAC 217.1. Definitions – Changes a reference in definition of radiologic procedure to new Occupations Code section, pursuant to SB 202 (84th Texas Legislative Session). 22 TAC 217.2. Licensure by Examination for Graduates of Nursing Education Programs Within the United States, its Territories, or Possessions – BON must establish a pathway to licensure for out-of-state nursing education programs and define standards to ensure those programs are substantially equivalent to existing BON standards (Sunset Commission, 85th Texas Legislative Session). 22 TAC 217.9. Inactive and Retired Status – Clarifies that nurses with retired status may not engage in the practice of nursing, regardless of whether they are compensated or not.
22 TAC 217.12. Unprofessional Conduct – To take disciplinary action only on conduct that relates to the practice of nursing, BON removed subjective requirements, tenuous language, and a superfluous reference to criminal conduct (Sunset Commission, 85th Texas Legislative Session). 22 TAC 217.14. Registered Nurses Performing Radiologic Procedures – Reiterates that training programs for nurses performing radiologic procedures must prepare the nurse to provide safe care. Nurses who complete the training must maintain a record demonstrating completion, which must be available for submission to the Board upon audit. Nurses must notify the Board if there are any changes that would render the application incorrect. 22 TAC 217.16. Minor Incidents – Replaced entirely to provide clarity and avoid duplication after BON stakeholder survey revealed the old language was confusing or potentially misleading. 22 TAC 217.19. Incident-Based Nursing Peer Review and Whistleblower Protections – Amended to correct non-substantive errors and move portions of the minor incident rule to this one. 22 TAC 217.20. Safe Harbor Nursing Peer Review and Whistleblower Protections – Amended to reflect bill requiring facilities to maintain a nursing peer review committee if they employ at least eight nurses, with peer review specifically for registered nurses if they employ four registered nurses (85th Texas Legislative Session). The amendments also made non-substantive revisions. 22 TAC 217.23. Balance Billing – New rule from 85th Texas Legislative Session, which sets forth specific responsibilities of licensees related to billing mediation, including when an insurance enrollee may request mediation for out-of-network claims focusing on the provider’s charge and the insurer’s coverage.
HAVE YOU BEEN GETTING YOUR CHECK UP? The Check Up e-newsletter provides members with a weekly update on TNA activities, events, conferences, learning opportunities, grant and scholarship opportunities, and much more. If you don’t see the Check Up in your mailbox each Tuesday, make sure to check your spam folder, especially if you’re registered with TNA using your work email address. If you still don’t see it, please contact tna@texasnurses.org and let us know!
CHAPTER 133. HOSPITAL LICENSING RULES 25 TAC 133.41. Hospital Functions and Services – Sets standards for hospital Do Not Resuscitate (DNR) orders (85th Texas Legislative Session). The facility must include procedures and patient rights in bylaws, ensure DNR orders are placed into patient medical records, and require nursing plans of care to indicate whether a physician has issued a DNR order. i
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‘IF ONLY THEY WOULD ASK A NURSE’ Nurses Tackle Complicated Projects In Innovative Ways IN MANY WAYS, NURSES ARE THE BEST INNOVATORS in health care. Because of the hands-on nature of their work, they’re often the first to notice cracks in the system, understand how to improve patient experiences, and gauge the difference between what works and what doesn’t.
Bustamante said the key voice in the creation of these advancements is nurses, who can sometimes, for example, be working with eight different software programs daily. “If only they would ask a nurse” she often says. While health systems get excited about the “shiny new toy,” Bustamante said those tools may not realistically be the solution.
Across Texas, nurses lead innovation efforts every day. Here are a just a few examples. Let us know what is going on in your community!
While nurses and software engineers are tasked with very different jobs, if nurses are involved in the software creation process from the beginning, she said, innovative care coordination systems and virtual monitoring end up being more effective.
Mobile Nursing Van Rolls Into Austin Concordia University Texas College of Nursing’s new Mobile Medical Missions Van brings innovative nursing to the streets, churches, and community centers of Austin.
“They know the pieces that don’t work well; they know the areas where communication is lacking or where continuity of care could be broken and fixed with technology,” she said.
While the university’s nursing program has always focused on community health, their new “pop-up clinic” van takes care to the next level, serving the basic health needs of the city’s homeless and underserved patient populations while senior nursing students build crucial out-of-hospital skills. “There just aren’t enough nurses on the front line in Austin,” said Greta Degen, PhD, RN, professor and director of the Master of Science in Nursing program. “While most nursing graduates first work in hospitals to hone their skills, they still need to understand the challenges patients face in everyday living situations.” Made possible by an Austin Community Foundation grant, the van allows enough space for patients to sit with students and for the students to store all needed medical supplies inside. “From complicated medications to health education to biometrical assessments to nutritional needs, everyone needs a nurse and is better off for it,” said Degen. “If this van helps nurses reach out to more people, we will have done our job well.”
In confronting innovation, Bustamante said nurses should embrace change and ask themselves, “How does this tool help me improve patient care?” “Nurses shouldn’t self-filter ideas or be afraid to ask questions,” she said. “Use your voice.”
Hacking for Health TOP: Concordia University Texas College of Nursing students and nurse facilitator with the school’s new mobile nursing van. From left: ABSN students Darrell Kalina, Amy Schneberger, Ann Marie Nguyen, and Haylee Rowlette with Caitlin Rowlette, BSN, MSN.
In October, The National Health Equity Hackathon, a meeting of tech- and health-minded problem solvers, took place in Austin. Health care innovators from different sectors collaborated to think of ways to overcome systemic barriers to building healthy communities for marginalized populations.
MIDDLE: Elizabeth Bustamante MSN, RN, (middle) works among other participants during an Upstream Thinking Event in Austin.
Bonnie Clipper, DNP, RN, MA, MBA, CENP, FACHE, Vice President of Innovation, American Nurses Association, was one of many nurses who attended the hackathon. She said nurses have a lot to contribute in health care innovation. “This is where nurses shine,” she said. “We have a different foundation— we think in a holistic manner and are good at collaboration.”
BOTTOM: Ellen Martin, PhD, RN, CPHQ, CPPS, TNA Director of Practice, works alongside other participants at Austin’s Health Equity Hackathon.
The Link Between Nurses and Software Technology has vastly improved health care, but it’s also complicated the many care models health systems rely on today. A 2016 study from the University of Pittsburgh Medical Center found nurses now spend an average of 33% of their shift interacting with technology.* Elizabeth Bustamante MSN, RN, is at the forefront of health innovation for a large Texas-based health system’s “solution center,” where she works to integrate technology—like centralized cardiac telemetry monitoring and virtual surveillance or “e-sitters”—into a seamless end-to-end patient experience.
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But it’s not always the case that nurses can give input when health care innovation is discussed. “When people gather to redesign health care, nurses are underrepresented,” she said, adding that it’s important for nurses to be more involved. “We need to be participating in design efforts to improve care because we know where the gaps are and what is needed to address them.” i *Higgins, L.W., Shovel, J.A., Bilderback, A.L., Lorenz, H.L., Martin, S.C., Rogers, D.J., Minnier, T.E. (2016). Hospital Nurses’ Work Activity in a Technology-Rich Environment. Journal of Nursing Care Quality, 32(3), pp. 208 - 217.
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CARE FOR THE CAREGIVER Johnson & Johnson Foundation Grant Allows TNA and TONE to Address Nurse Traumatic Stress NURSES ARE DISASTER RESPONDERS. They help operationalize and implement emergency preparedness plans, often working additional hours, volunteering to assist displaced medically fragile people, and coordinating medical supplies, blood donations, and other vital resources. During disaster situations, nurses often find themselves dealing with the challenges and potentially undesirable outcomes of providing care in compromised environments. To help nurses in disaster areas, The Johnson & Johnson Foundation awarded a grant to Texas Nurses Association
Subject matter experts have worked on researching, writing, and recording content to help nurses learn more about preparing for a disaster, working during a disaster, and dealing with potential trauma after a disaster.
(TNA) and Texas Organization of Nurse Executives (TONE) to address the traumatic stress nurses experience. TNA Executive Director Cindy Zolnierek, PhD, RN, and TONE President Paula Webb, DNP, RN, NEA-BC, serve as project directors of the grant, which is administered by the Texas Nurses Foundation. Over the past six months, subject matter experts have worked on researching, writing, and recording content to help nurses learn more about preparing for a disaster, working during a disaster, and dealing with potential trauma after a disaster. Danita Alfred, PhD, RN, Cameron Brown, DMin, MDiv, BSSW, Jane Le Vieux, PhD, RN-BC, LPC-S, NHDP-BC, and Paula Stangeland, PhD, RN, CRRN, NE-BC, collaborated with TNA staff to produce a series of informative webinars with more content to come. i
Representing nurses and healthcare professionals who have dedicated their life to helping people.
Photo credit: FEMA/GeorgeArmstrong
Visit www.texasnurses.org/c4c to watch videos, download resources, and learn more about emergency preparedness, resiliency, and self-care.
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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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