texa s nu r s e s .o rg
TEXASNURSING M A G A Z I N E
From Practice to Policy to Practice — How Nurse Experiences
Drive Policy Change
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 | S U M M E R 2 0 1 9
SUMMER 2019 Volume 93, Number 3 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, NEA-BC, 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.
Dist. 3: Margie Dorman-O'Donnell, margie.dormanodonnell@cookchildrens.org, District Staff: Jamie Gilbert, jamiegilbert@texashealth.org Dist. 4: Natalie Garry, natalie.garry@utsouthwestern.edu, District office: Pat Pollock, P.O. Box 764468, Dallas, TX 75376; 972.435.2216; d4tna@flash.net; tnad4.org Dist. 5: Leah May, 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: Juliana Brixey, jbrixey@hotmail.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. 17: Mari Grace Cuellar, mgrace2329@yahoo.com Dist. 18: Darla Smith, darla.smith3@stjoe.org Dist. 19: Colleen Marzilli, cmarzilli@uttyler.edu Dist. 35: Chrystal Brown, 903.434.8302, cbrown@ntcc.edu At-large: Contact TNA, 800.862.2022, ext. 129, brichey@texasnurses.org
POSTMASTER Send address changes to TEXAS NURSING, 4807 Spicewood Springs Rd., Bldg 3, Suite 100, Austin, TX 78759-8444 ARE YOU MOVING? Need to change your address? If so, provide it quickly and easily in the Members Only section of the TNA website, texasnurses.org. Or mail your new address—at least six weeks prior to your move— to Texas Nurses Association headquarters. We’ll make sure your TEXAS NURSING makes the move with you. FEEDBACK EMAIL OR LETTER GUIDELINES TEXAS NURSING will select emails/letters on the basis of readership interest and relevance to current nursing/health care events. TEXAS NURSING reserves the right to edit all letters. Guide: Limit to 200 words; focus on single issue; include writer’s name, mailing address, and daytime phone. Send to: editor@texasnurses.org. Copyright 2019 © Texas Nurses Association
T E X A S N U R S I N G M AGA Z I N E | S U M M E R 2 019
Clarissa Silva, clarissa2277@att.net, Terry Acosta, shadowmon@sbcglobal.net
PAGE 2
8
WHAT NURSES NEED TO KNOW ABOUT
STATUTES OF LIMITATIONS
20
IT’S A WRAP! How Nurses Advocated for their Profession in the 86th Legislative Session
16
PASSING ORAL SAFE HARBOR
NURSES
ON TRIAL The Verdict in Winkler County
How One Nurse’s Experience Changed the Law
12 Contents IN EVERY ISSUE
FEATURES
5
10
11
14
22
PRESIDENT’S NOTES
2019 POLICY SUMMIT
2019 HOUSE OF DELEGATES
Problem Solving, Partnership, and Presence
Predicting the Future of Nursing
Shaping the Future of TNA
CHAMPIONING PUBLIC HEALTH AT THE CAPITOL
EMPOWERING NURSES WITH MOTIVATIONAL INTERVIEWING
Protecting the Community through Policy
Using Best Practices to Strengthen TPAPN Participant Commitment and Support Recovery
6
TNA MEMBER NEWS Kudos
PAGE 3
S U M M E R 2 019 | T E X A S N U R S I N G M AGA Z I N E
Alison Pittman,
PhD, RN, CPN, CNE, CHSE
UNDERGRADUATE:
RN to BSN Program, Traditional BSN, and Second Degree BSN
MASTER’S:
MSN-Nursing Education, MSN-Forensic Nursing, and MSN-Family Nurse Practitioner + 350+ clinical practice sites across Texas + Face-to-face instruction offered in BryanCollege Station and Round Rock + Flexible online course completion of RN to BSN and MSN degree programs + Ranked in Top 10 of nursing colleges in Texas by Nurse.org + 99% NCLEX® first-time pass rate, 100% AANP first-time pass rate The baccalaureate degree programs in nursing and master’s degree programs in nursing at Texas A&M University College of Nursing are accredited by the Commission on Collegiate Nursing Education (http://www.ccneaccreditation.org).
For more information, visit nursing.tamhsc.edu.
President’s Notes Jeff Watson, DNP, RN, NEA-BC
PROBLEM SOLVING, PARTNERSHIP, AND PRESENCE Are the Solutions We Seek Right in Front of Us?
Many years ago, my niece April was in first grade and learning to count money with coins. I was determined to help her. One evening, I assembled coins of every value to begin our exploration together. For a while, we worked on the basics, matching counts with the value of each piece of currency. Then we started working on manipulating coins to get to different amounts: 25 cents could be one quarter, two dimes and a nickel, five nickels, etc. At one point, April grew quiet. I looked down at her and noticed she was silently crying. She was struggling to find an answer to the problem I presented. I was devastated. Half-dollars, quarters, dimes, nickels, and pennies spread out before us—all the pieces of the puzzle she needed to solve the problem lay before her. She was trying, I could tell, but maybe it was all just too much. Perhaps the problem was so overwhelming that she could not make sense of what she was seeing. A few days later, April asked me to help her again. This time, I was better prepared, and I believe she was as well. I entered into that work thoughtfully, with a real attentiveness to her and her way of thinking. From April, I learned the simplicity of watching and listening— came a new way to be present when problem-solving is needed. And April was finally able to master counting with my support. This summer, I have to admit that I have felt a little like April must have felt during her first attempt. Between escalating tensions over the immigration health crisis on our border and nation-wide mass shootings—most recently in Cali-
I invite and encourage each of you to use your advocacy skill set and your nursing wisdom to be a part of constructive discussions that will generate functional and meaningful responses to the trials of our time. opportunity to speak for themselves.
fornia, Ohio, and right here in El Paso, Texas—it is just too much. Often, I am overwhelmed by the sheer humanitarian need before us. I consider what my response should be as a nurse. I feel powerless and lost. At times, I find myself like April, awash in silent tears. I believe we all recognize that these problems will not magically resolve without intervention. Solutions will require a sharp focus on the issue at hand. Solutions will also demand an attentiveness to one another and an acknowledgment of the external influences that have shaped us, forming our different opinions and perspectives. Perhaps most importantly, solutions require advocacy, giving voice to those who by structure, station, or life lost, have no
PAGE 5
We must harness the power of the diversity that is the Texas Nurses Association to inform potential solutions. Through the Texas Nurses Association, we have the tools of nursing advocacy for use in our in local, regional, and state-wide markets. I invite and encourage each of you to use your advocacy skill set and your nursing wisdom to be a part of constructive discussions that will generate functional and meaningful responses to the trials of our time. I have to believe that the solutions we are searching for are right in front of us. Perhaps the problems are too much, and for now we can’t quite see the answer. My hope is that we will help each other, and in turn, fulfill our social contract with society. May we continue to learn with and from one another as we cooperate to tackle these challenges. Peace, Jeff i
S U M M E R 2 019 | T E X A S N U R S I N G M AGA Z I N E
TNA MEMBER NEWS SPOTLIGHT ON YOU KUDOS Congratulations to Jeff Watson, DNP, RN, NEABC, on being elected a director-at-large of the American Nurses Association. He is currently serving his second term as Texas Nurses Association (TNA) president. Watson completed a Doctor of Nursing Practice degree in 2016 and is an assistant professor in Graduate Nursing Leadership Studies at the Texas Tech University Health Sciences Center School of Nursing in Lubbock, Texas. Congratulations to Erin Perez, DNP, APRN, ANP-C, AGNP-C, ACHPN, who was selected to represent the state of Texas at the National Academy for State Health Policy Palliative Care State Policymaker Summit. Perez is a member of the TNA End-of-Life Task Force and vice-chair of the Texas Palliative Care Interdisciplinary Advisory Council. TNA has selected Rodney L. Duckett, BSN, RN, NREMT-P, as this year’s American Nurses Advocacy Institute (ANAI) participant. As a community facilitator and activist for more than 15 years, Duckett has worked with urban youth and disenfranchised people, helping to give them a voice. Duckett earned a Bachelor of Science in Nursing from the University of Mary-Hardin Baylor, in Belton. He is pursuing his Doctor of Nursing Practice at the University of Incarnate Word to be a family nurse practitioner. Learn more at texasnurses. org/news.
Congratulations to Juliana Brixey, PhD, MPH, RN, who has been selected to serve as a Commission on Accreditation for Health Informatics and Information Management peer reviewer. Brixey is an associate professor of biomedical informatics and nursing at UTHealth and has 30 years of professional experience as a nurse in nursing management and direct patient care. She earned her PhD in health informatics at The University of Texas Health Science Center at Houston. The American Academy of Nursing announced the selection of 231 nurse leaders for the 2019 class of Academy fellows. The fellows were selected based on their contributions to increase access, reduce cost, and improve quality through nursing theory, practice, and science. Congratulations to these TNA members, who will be honored at an October ceremony in Washington, D.C.:
Cathy L. Rozmus, PhD, RN — The University of Texas Health Science Center at Houston Diane Santa Maria, DrPH, MSN, RN, PHNA-BC, FSAHM — University of Texas Health Science Center at Houston Mari F. Tietze, PhD, MSN, RN, BC, FHIMSS — Texas Woman’s University Carole L. White, PhD, RN — The University of Texas Health Science Center at San Antonio Julie Zuñiga, PhD, RN — The University of Texas at Austin Congratulations to the following TNA members elected to leadership positions at the 2019 House of Delegates!
Kathryn M. Daniel, PhD, RN, ANP-BC, GNP-BC, GS-C, AGSF — University of Texas at Arlington Nancy R. Downing, PhD, RN, SANE-A — Texas A&M University Anecita P. Fadol, PhD, RN, FNP-BC, FAANP — The University of Texas MD Anderson Cancer Center Kathleen Geraghty Fraser, MSN, MHA, RN-BC, CCM, CRRN — Case Management Association of America Carol J. Howe, PhD, RN, CDE — Texas Christian University Karen E. Johnson, PhD, RN, FSAHM — The University of Texas at Austin Janna Lesser, PhD, RN — University of Texas Health Science Center at San Antonio
T E X A S N U R S I N G M AGA Z I N E | S U M M E R 2 019
PAGE 6
Amy McCarthy, MSN, RNC-MNN, NE-BC, Secretary (top left) Gayle Dasher, PHD, RN, ANP-BC, Treasurer (top right) Patrick Laird, DNP, RN, ACNP-BC, NEABC, Leadership Succession Committee (bottom left) Sarah Williams, PhD, DNP, RN-BC, ANEF, Leadership Succession Committee (bottom right) i
Change the world with us!
Enrich your career with a graduate degree from e Universi of Texas at Austin School of Nursing. With enhanced clinical and leadership skills, you’ll be on your way to transforming health care. Choose from:
Doctor of Philosophy in Nursing
Doctor of Nursing Practice
Master of Science in Nursing
Specialize in research with world-renowned researchers and prepare to assume advanced leadership roles in health care and nursing education.
Meet the demand for the highest level of professional nursing practice and leadership competencies. e DNP graduate is educated to implement evidence-based knowledge in increasingly complex practice and clinical roles.
Expand your practice to provide health care to individuals, families and groups in a varie of se ings.
• Represents the highest level of formal education for a career in research and the scholarship of discovery • Features a combination of conceptual approaches, challenging interactions in seminar discussions and work with active researchers, producing a stimulating environment for scholarly development • Apply by November 1, 2019
• Represents the highest level of formal education for a career in clinical practice • 45-hour curriculum offered in a hybrid format, with both online and once a month onsite coursework • Applications are currently being accepted
• Family, Pediatric or Psychiatric/Mental Health Nurse Practitioner • Adult-Gerontology Clinical Nurse Specialist • Leadership in Diverse Se ings • Apply by November 1, 2019
Find out more: nursing.utexas.edu/graduate • 512-471-7927
IT’S A WRAP! How Nurses Advocated for their Profession in the 86th Legislative Session By Cindy Zolnierek, PhD, RN, CAE NURSES FOUGHT AN UPHILL BATTLE at the Capitol this spring. The 86th Texas Legislature shifted its focus from bathroom bills to more substantial issues of property tax reform and school financing, yet health care continued to take a back seat. Nursing held its own in funding; celebrated some wins in workplace advocacy, school nursing, and advanced practice registered nursing (APRN); and appreciated a good legislative year for public health initiatives.
EDUCATION FUNDING A budget rider introduced by Rep. Howard to sustain the Nursing Shortage Reduction Program at $20 million passed. Greater flexibility was introduced into what is known as the “over 70” program, allowing individual schools to set unique targets for growth of prelicensure graduate numbers. The rider requires an interim study on the program’s future structure. Texas Nurses Association (TNA) will work closely with the Texas Higher Education Coordinating Board on implementing of this rider.
Fifty eight bills were vetoed by Gov. Greg Abbott. The only years in which the same or more bills were vetoed were: 2001 by Rick Perry (83) 1969 by Preston Smith (67) 1870 by Edmund Davis (72) Several education-related bills failed to pass: HB 2980 by Howard would have directed $14 million to a grant program promoting novel approaches to the clinical education of nurses in graduate
HB 2410 was in direct response to a nurse who called TNA about a situation (see pg 14) in which she was unable to invoke Safe Harbor due to immediate patient care needs. The passage of HB 2410 protects nurses by allowing for oral safe harbor.
T E X A S N U R S I N G M AGA Z I N E | S U M M E R 2 019
programs. SB 358 by Sen. Hinojosa would have expanded the nursing faculty loan repayment program to include parttime faculty and remove the designated maximum reward. SB 2300 by Sen. Powell and HB 3111 by Rep. Klick would have established a student loan repayment program for nurses working in LTC.
WORKPLACE ADVOCACY HB 2410 was in direct response to a nurse who called TNA about a situation (see pg 14) in which she was unable to invoke Safe Harbor due to immediate patient care needs. The passage of HB 2410
BY THE NUMBERS
1,429
bills passed
438
bills tracked by TNA
85 bills TNA 58
bills vetoed by Gov. Abbott
$28 million nursing education funding secured
PAGE 8
registered support or opposition on
7,324
total bills filed
protects nurses by allowing for oral safe harbor in certain circumstances. Workplace violence is one of the two top concerns of nurses according to separate TNA and ANA surveys. HB 2980 by Rep. Howard built upon successful efforts in previous sessions and was unopposed by stakeholders. However, it languished in the House Calendars Committee. TNA will continue to promote the safety of nurses in the workplace. Funding for organizations to implement initiatives to prevent workplace violence against nurses was sustained this session (HB 280, 85th Legislative Session).
SCHOOL NURSING The attention on schools this session may have contributed to the success of several initiatives of the Texas School Nurses Organization: HB 2243 by Rep. Oliverson authorizes nurses to maintain and administer medications for students with asthma, and HB 18 by Rep. Price includes a provision requiring schools to notify parents regarding the presence of a school nurse on campus.
Advance to the Next Level
APRNS HB 1792 and SB 2438 would have authorized full practice authority for APRNs, including nurse practitioners, clinical nurse specialists, certified nurse midwives, and certified registered nurse anesthetists. While this is the first time the bills received a hearing in both chambers, they did not advance further. HB 278 by Oliverson passed, allowing face-toface meetings between an APRN and the collaborating physician to be conducted virtually. HB 387 by Cortez also passed, allowing APRNs to complete and sign a work status report regarding an employee’s ability to return to work.
LOOKING FORWARD
Top-ranked nursing programs Advanced practice nursing specialties for all interests Entry options for nurses and non-nurses Distance learning options Community of scholars with broad faculty expertise
MSN
Seamless BSN entry to MSNDNP option New! Executive Leadership DNP Track New Opportunity! BSN-DNP in Adult Gerontology Acute Care Nurse Practitioner
DNP
PhD
The Legislature called for several studies to be conducted during the interim. TNA will be closely monitoring interim committee hearings, studies, and other activities to continue to ensure nurses’ voices are heard. i
nursing.vanderbilt.edu Vanderbilt is an equal opportunity affirmative action university.
PAGE 9
S U M M E R 2 019 | T E X A S N U R S I N G M AGA Z I N E
2019 POLICY SUMMIT THIS YEAR’S POLICY SUMMIT had a unique structure designed to help members guide Texas Nurses Association’s (TNA) strategy in the 87th Legislative Session. After updates from speakers on TNA’s accomplishments during the session, public health victories at the Capitol, and regulatory changes for nursing, members split into groups to brainstorm nursing’s needs in the coming years.
Using the FORESIGHT MODEL, members scan present reality and consider what might happen in the future.
1
The breakout sessions at the Policy Summit were designed to help people talk about the future of nursing based on the foresight model of strategic thinking. This model involves environmental scanning on the present reality and encourages participants to consider what might happen in the future. The breakouts focused on four topics: environments of practice; emerging practice and nursing roles; quality, safety, and value-based care; and person-centered care and collaborative decision-making.
2
For each of the topics, participants worked in groups to discuss questions and record their thoughts from four perspectives: technology, economy, society, and policy. A spokesperson from each table reported their ideas to the whole group. Information from the flip charts was summarized by topic and by perspective and will be reviewed by the TNA Policy Council and committees to guide policy efforts and next steps to prepare for the future of nursing. i
3
4
1. Nurses discuss ideas for the future, organizing them into one of four perspectives. 2. After discussing, each table presented to the full breakout group. 3. Sarah Williams, D8 (left), Tracey Ramsey Abbott, D5 (right). 4. Virginia Rojo, D5 (left) and Melinda Hester, D5 (right).
RESOLUTION ON APRN CLINICAL EDUCATION Whereas, the academic curriculum for APRN education prepares graduates from accredited programs to practice in the advanced practice role after achieving national certification and state licensure,
Whereas, quality of clinical learning experiences within the academic APRN curriculum is essential to preparing APRNs for certification and licensure,
T E X A S N U R S I N G M AGA Z I N E | S U M M E R 2 019
PAGE 10
Whereas, an increased demand for APRNs has resulted in a nationwide increase in APRN programs and with this has come an increased level of competition for clinical sites and qualified preceptors (AACN 2015),
2019 HOUSE OF DELEGATES THE 2019 TEXAS NURSES ASSOCIATION (TNA) House of Delegates is in the books! This was the 111th annual business meeting—1918 being the only year without a meeting because many of the members were engaged with World War I. This year, 176 delegates plus the nine members of the TNA Board of Directors gathered in Georgetown, TX, to hear reports, pass resolutions, and work on a plan to rejuvenate TNA’s governance structure. Delegates listened to platforms from eight potential candidates and then elected Amy McCarthy, MSN, RNC-MNN, NE-BC, as secretary, Gayle Dasher, PhD, RN, ANP-BC, as treasurer, and Patrick Laird, DNP, RN, ACNP-BC, NEA-BC, and Sarah J. Williams, PhD, DNP, RN-BC, ANEF, to the Leadership Succession Committee. In addition, the delegates also adopted a resolution on APRN Clinical Education. Delegates heard from Ernest Grant, PhD, RN, FAAN, president of the American Nurses Association (ANA). Grant relayed ANA’s efforts to increase:
The diversity of nursing Relevance of ANA to nurses Nurses’ engagement with consumers Consumers’ understanding of nurses ANA’s advocacy on behalf of nurses and consumers
Grant also updated attendees on ANA’s work related to healthy work environments, the importance of ensuring safe staffing, making the workplace a safe, fair, and respectful place for all, eliminating nurse fatigue, and improving safe patient handling. He also spoke about the Healthy Nurse Health Nation Grand Challenge, reiterating the three imperatives:
Thanks so much!
Thank you to Kleanthe Caruso, RN, MSN, NEA-BC, for serving as Secretary from 2017-2019. We appreciate your service and leadership.
Communicate that the health of RNs is critical Empower nurses and organizations with a platform to improve health Partner with others committed to nurses’ health
bers can be a part of the association’s success: Strategic Goal 1: Enhance local engagement opportunities for members Role for Members: Facilitate a Nurse Talks event, host a Nursing Salon, or volunteer to serve on a committee either at the District level or with TNA. Strategic Goal 2: Aggressively grow membership by acquiring, engaging and retaining members Role for Members: Invite a colleague to join! Talk about TNA’s work with your colleagues, or volunteer to present at your local school of nursing—help us reach 16,000 members in 2020!
He ended his presentation by sharing ANA’s vision of a culture of innovation and every nurse as an agent of change.
Strategic Goal 3: Advance the quality and safety of patient care through policy initiatives
The highlights of the presentation by TNA President Jeff Watson, DNP, RN, NEA-BC, were new firsts for TNA this year:
Role for Members: Sign-up to be an Expert Advisor, attend the 2020 Policy Summit, or meet with your local representatives to the Texas Senate and House of Representatives
First Nurse Talks Empowerment Series First virtual House of Delegates First election of a president-elect First virtual Board of Directors meeting First time TNA membership has reached 14,000 RNs
Watson discussed the ongoing work of the association including financial stability, member engagement, governance, legislation, and programmatic and collaborative opportunities. He encouraged members to share the ways they’d like to engage with TNA and reminded members that’s it’s not too late to start planning for the 87th Legislative Session. TNA’s Chief Executive Officer Cindy Zolnierek, PhD, RN, CAE, updated delegates on TNA's strategic plan and reminded them how they and all mem-
Whereas, there is variability in the manner of managing clinical learning experiences among Texas APRN programs,
around structuring and arranging clinical learning experiences,
Whereas, little data exists on the number of clinical preceptors and academic practices
Resolved, the Texas Nurses Association should collaborate with other stakeholders
Therefore be it
PAGE 11
Strategic Goal 4: Eliminate the budgeted deficit by 2020-2021 fiscal year end Role for Members: Encourage your employer or other vendors you work with to be an annual TNA Sponsor; advertise with TNA—digital and print options available; and list positions on TNA’s Career Center. i
SAVE THE DATE The 2020 House of Delegates will be on June 6, 2020, preceded by the 2020 Policy Summit and 2020 Leaders & Legends of Texas Nursing banquet on June 5, 2020.
to pursue the collection of data regarding clinical learning experiences for APRN students to inform strategies that augment preceptor availability.
S U M M E R 2 019 | T E X A S N U R S I N G M AGA Z I N E
PASSING ORAL SAFE HARBOR How One Nurse’s Experience Changed the Law
By Tonya R. Poore, RN, BSN, CCRN, LP
How One Nurse’s Experience Changed the Law AS NURSES, WE TAKE AN OATH TO DO NO HARM, and beyond that, we must be advocates for patient safety. Nursing is the most respected profession in the nation, and as professionals, we should not take the integrity and honor of being the most respected profession for granted.
Last year, at the 617-bed hospital where I perform sedation procedures in the radiology department, a patient with multiple comorbidities came in experiencing somnolence due to needing dialysis. The patient was severely acidotic before the procedure, and with the first round of sedation, the patient became increasingly drowsy and vitals started dropping. As CO2 rose and respiratory rate started to decrease, the doctor wanted me to give additional sedation. I refused, explaining my concerns. The doctor continued and completed the procedure. After the procedure, I talked the team, and they agreed that it was a communication breakdown. Together, we found a solution to ensure everyone in the room is informed on the vitals I see during the procedure. However, my direct nursing charge nurse and the direct manager felt I should be reprimanded and wrote me up for not following a doctor’s orders. At the suggestion of human resources, I talked with the chief nursing officer (CNO) to have the write up reversed because I was advocating for patient safety. While the CNO was very supportive, she also educated me on the importance of enacting safe harbor and said I should ask for a peer review, which I did.
The problem with current safe harbor processes is the nurse has to print a form and speak to multiple people. It is not always feasible to stop to fill out the form because the patient may be sedated, critical, and or severely incapacitated, necessitating the nurse’s attention.
T E X A S N U R S I N G M AGA Z I N E | S U M M E R 2 019
However, the problem with current safe harbor processes is the nurse has to print a form and speak to multiple people. It is not always feasible to stop to fill out the form because the patient may be sedated, critical, and or severely incapacitated, necessitating the nurse’s attention. In this situation, I would not have had the option to enact safe harbor due to the patient’s immediate needs. During the peer review process, I gave my two-week’s notice. Ultimately, the peer review committee found that my actions
PAGE 12
were not reportable to the Board. However, the CNO decided to report me— overruling the peer review— because I left my employment. Overwhelmed, I contacted the American Association of Critical Care Nurses, the American Nurses Association and the Texas Nurses Association (TNA) about my situation. The support I received was absolutely outpouring.
supervisor would fill out the paperwork, and the nurse would be able to continue taking care of their patients without delaying care. The bill was signed by Governor Abbott and will be effective September 1, 2019. This new law is critical to safe nursing practice because it will protect nurses from retaliation if they, in good faith, refuse a doctor’s order because they feel that the order may endanger the patient.
The bill was signed by Governor Abbott and will be effective September 1, 2019.
I wanted for this to never happen to another nurse, and I spoke to TNA several times, even as the Board of Nursing started their investigation. Recognizing the gap in protections for nurses, TNA started working to change the current practice for how nurses enact safe harbor. With the help of Rep. Stephanie Klick, HB 2410 was introduced to allow nurses to call safe harbor orally. The nurse
I hope no one will ever have to experience the emotional anguish I went through after doing the right thing for a patient. After seven months of distress, I learned that the Texas Board of Nursing found my situation was not a reportable circumstance. When a nurse takes an oath to adhere to the nursing code of ethics, that means we advocate for patient safety even if it might destroy us professionally. Nursing is a gratifying career, and we must support one another and come together to continue to advocate for our patients. i
Recognizing the gap in protections for nurses, TNA started working to change the current practice for how nurses enact safe harbor. With the help of Rep. Stephanie Klick, HB 2410 was introduced to allow nurses to call safe harbor orally.
Tonya R Poore, RN, BSN, CCRN, LP, is a family nurse practitioner student at University of Mary Hardin-Baylor. She earned her Bachelor of Science in Nursing from University of Mary Hardin-Baylor. Tonya has earned her paramedic licensure and critical care certification, and she has worked in multiple areas in nursing including critical care, emergency care, flight nursing, general medical and surgical care, procedures, and home health. She is passionate about quality patient care and patient safety.
Rep. Stephanie Klick
Rewarding Careers
TEXAS PEER ASSISTANCE
PROGRAM FOR NURSES
Join a team that is making a difference!
W
e offer predictable work schedules, set caseloads and an excellent benefits package, including: n New higher starting salaries for RNs n Health and retirement benefits n Paid vacation leave and up to 15 paid holidays a year n Shift differential pay
Find an exciting and challenging career in one of 23 health and specialty care locations across Texas.
CALLING TPAPN VOLUNTEERS
Ready To Volunteer?
Support Texas nurses who have substance-use disorders, mental-health conditions, or both. TPAPN seeks new peer support partners (formerly called advocates) to help participants through person-centered guidance and emotional support. Peer support partners meet or speak with their assigned participants on a regular basis and communicate regularly with their assigned participants’ case managers. TPAPN offers regular training workshops for peer support partners and provides additional resources online.
Contact:
Apply online: hhs.texas.gov/about-hhs/jobs-hhs
18D0738
Laura Hunter atof Aging Texas Department and Disability Services laura.hunter@hhsc.state.tx.us
PAGE 13
tpapn.org S U M M E R 2 019 | T E X A S N U R S I N G M AGA Z I N E
Championing Public Health at the State Capitol THE TEXAS PUBLIC HEALTH COALITION brings together 30 health professional organizations dedicated to improving health through legislation. During the 86th Legislative Session, the coalition worked on 13 public health bills, 11 of which made it to the governor’s desk. Immunizations were a large topic of discussion this session, especially after studies showed that antivaccine groups, bots, and trolls were deliberately and successfully spreading misinformation on social media, leading to outbreaks of preventable disease. The Coalition also worked diligently on Tobacco21, the movement to raise the purchase age to 21 for tobacco and ecigarette products statewide. According to the Food and Drug Administration, 95 percent of adult smokers picked up the habit before age 21. Here are some of those priority bills and how they fared:
IMMUNIZATIONS FOR FIRST RESPONDERS HB 1418 | Signed Creates system to inform first responders of their immunization history and potential disease risk on certification and recertification HB 1256 | Signed Creates process for first responders and their employers to access their immunization status in disaster response
During the 86th Legislative Session, the coalition worked on 13 public health bills, 11 of which made it to the governor’s desk. INFECTION CONTROL IN LONG-TERM CARE HB 1848 | Signed Enhances infection prevention and control programs in nursing homes to include protocols for rapid influenza testing and limiting spread of multidrugresistant organisms
SB 952 | Filed without signature Aligns Texas child care facility licensing standards for physical activity, nutrition, and screen time with national standards SB 1834 | Signed Authorizes a pilot incentive program for SNAP recipients to purchase fruit and vegetables
TOBACCO AND CIGARETTES
MATERNAL HEALTH
SB 21 | Signed Raises the minimum age of sale for tobacco and e-cigarette products from 18 to 21 statewide, except for those serving in the military
Expands the TexasAIM maternal safety bundles for women with opioid use disorders
HB 4013 | Did not pass House Imposes a sales and use tax on e-cigarette vapor products
WATER FLUORIDATION HB 3552 | Signed Requires minimum 60-day public written notice period for reduction or termination of community water fluoridation
PHYSICAL ACTIVITY AND NUTRITION HB 455 | Vetoed Requires school districts to adopt model recess policies with minimum minutes of recess per week and whether recess can be taken away for disciplinary reasons
T E X A S N U R S I N G M AGA Z I N E | S U M M E R 2 019
PAGE 14
SB 436 | Signed
HB 744 | Did not receive Senate hearing Extends Medicaid coverage for new mothers to 12 months postpartum In addition to these specific bills, the Coalition worked on budget riders, particularly for studying vaccine-preventable disease outbreaks and allowing the Texas Department of State Health Services to use paid media for tobacco prevention. While several priority bills did not pass, the Coalition continues to work on these issues to help improve the health of Texans and is already preparing for the 87th Legislative Session in 2021. i
NURSES
ON TRIAL
The Impact of the Verdict By Cindy Zolnierek, PhD, RN, CAE
THIS ARTICLE CONTINUES our Winkler Co. 10-year retrospective. Read the introductory article in the Winter 2019 issue of Texas Nursing and how the nurses were accused in the Spring 2019 issue.
I would say to every nurse: If you witness bad care, you have a duty to your patient to report it, no matter the personal ramifications. This whole ordeal was really about patient care.
Nurses Vickilyn Galle, RN, and Anne Mitchell, RN, stood accused of sending patient information to the Texas Medical Board, allegedly to harass popular Kermit physician Roland Arafiles, MD. The tight-knit community in Kermit was deeply divided, and animosity towards the nurses would make it difficult to have a fair trial. A change of venue was granted in October 2009, moving the trial from Kermit to Andrews County.
Moments before the trial began, Tidwell offered a plea agreement to Mitchell. Defense attorney Cook advised, “I support whatever you want to do. It’s your decision.” Arms crossed in front of her, Mitchell paced for a minute, looked him straight in the eye, and said without hesitation: “I’m fighting this. Let’s do it.”
The official charge by prosecutor Scott Tidwell was misuse of official information, a third-degree felony with potential penalties of up to 10 years imprisonment and a $10,000 fine. The week before the trial, Mitchell learned she would face prosecution alone, as charges against Galle had been dropped.
THE TRIAL The State of Texas vs. Anne Marie Mitchell began February 8, 2010, in the 109th Judicial District Court with Honorable Judge James Rex presiding and John H. Cook IV and Brian Carney representing Mitchell.
The courtroom brimmed with Mitchell supporters, including nurses from across the state. Texas Nurses Association (TNA) supplied apricot ribbons (the academic color of the nursing discipline) to wear. The deep respect nurses held for Mitchell’s and Galle’s advocacy was clear. To make its case, the state had to prove that Mitchell misused information with the intention of harming Arafiles and that the information was used for a nongovernmental purpose. Prosecution witnesses testified that there was friction between Arafiles and Mitchell, the basis for the “intent to harm” allegation. Arafiles took the stand and responded to questions about his medical decisions in specific situations, at one point
T E X A S N U R S I N G M AGA Z I N E | S U M M E R 2 019
PAGE 16
stating that patients with diabetes were at “no more risk of infection than anybody else.” Nurses and nursing students throughout the courtroom collectively gasped, and the judge admonished the spectators to be quiet or risk being banned from the courtroom. Once Tidwell rested the state’s case two days later, Cook immediately filed a motion for a directed verdict—a request that the judge to direct the jury to acquit Mitchell as the evidence presented was inadequate. The judge denied the motion, and Cook began his defense. TNA member Lolly Lockhart, PhD, RN, testified as a defense expert witness regarding the nurse’s professional and legal duty to the patient. A medical expert testified that the five cases cited in the nurses’ complaint demonstrated substandard care.
THE VERDICT In the end, the jury returned a verdict of not guilty in less than an hour, with a juror later stating that there was no ques-
tion the nurse was acting in the best interest of patients. “I was just doing my job,” relayed a jubilant Mitchell in a phone conversation with TNA immediately following the not guilty verdict, “but no one should have to go through this. I would say to every nurse: If you witness bad care, you have a duty to your patient to report it, no matter the personal ramifications. This whole ordeal was really about patient care.” “We didn’t have any support—emotional or financial—until TNA and [the American Nurses Association] stepped in,” said Galle, who attended the trial as a spectator. “We could never have gotten through this without nursing’s support.” The civil lawsuit filed by the nurses in August 2009—alleging retaliation, civil rights and due process violations—was settled a few months after the trial for $750,000, or $375,000 each. Much of the settlement went to pay for legal defense costs.
NURSES FIGHT BACK In July 2009, TNA lodged a formal complaint with the Texas Department of State Health Services (DSHS) against Winkler County Hospital for establishing a policy prohibiting employees from reporting patient concerns to outside agencies without the hospital’s permission and for retaliation. Such a policy violates nurses’ rights under the Nurs-
The courtroom brimmed with Mitchell supporters, including nurses from across the state. TNA supplied apricot ribbons (the academic color of the nursing discipline) to wear. The deep respect nurses held for Mitchell’s and Galle’s advocacy was clear.
Tidwell was convicted on similar charges, removed from office, and his license to practice law was suspended and later relinquished to avoid disbarment.
ing Practice Act and Hospital Licensing Rules. DSHS substantiated the complaint and fined the hospital.
Arafiles was charged with two counts of misuse of official information and retaliation. Surrender of his medical license was a condition of his plea bargain.
After Mitchell’s trial and the civil case, the “good ol’ boys” faced their own day in court. The four men—hospital administrator, physician, district attorney and sheriff—were investigated and prosecuted by the Texas Attorney General’s office, resulting in sentences of jail time and fines for all of them. Hospital administrator Stan Wiley, who resigned in October 2009, was indicted on two felony counts of retaliation. Sherriff Robert Roberts was convicted on two counts each of misuse of official information and retaliation and official oppression.
In May 2012, TNA president Margie Dorman-O’Donnell recognized three Attorney General staff members with the Texas Nurses Association’s highest award, the President’s Award. David Glickler, Shane Attaway and Randy Muenzler (whose wife is a nurse) were honored to have played a role in addressing the violations, noting that suppression of nurses’ advocacy for patients directly conflicts with public interest in safety. i In the final 2019 issue of Texas Nursing, we will look at how the event continues to impact nursing practice ten years later.
EXECUTIVE HEALTH CARE ADMINISTRATION PROGRAM Now Accepting Applications Executive Masters in 16 months across 4 semesters 12 Healthcare centered courses taught by Healthcare Professionals Cohort model with hybrid classes, face-to-face and online environment Required 5-days on campus per semester followed by online delivery
No GMAT or GRE required
UTTyler.edu/ehca EHCA@uttyler.edu 903.566.7193
PAGE 17
S U M M E R 2 019 | T E X A S N U R S I N G M AGA Z I N E
Representing Nurses in Austin Since 1980 in Administrative Law Proceedings Before the: TEXAS BOARD OF NURSING AND
THE STATE OFFICE OF ADMINISTRATIVE HEARINGS Texas Super Lawyer - Thompson Reuters (2014-2019)
EL PASO OFFICE
717 E. San Antonio Avenue Toltec Building - Third Floor El Paso, Texas 79901
915.544.7860
AUSTIN OFFICE
1104 Nueces Street Austin, Texas 78701
512.478.7463
NURSES IN OFFICENURSES
Nurses in Local Positions
PAC DONATION Nurses in State Legislature
2020 5 2022 5 1 2024 5 2026 5 2 2028 5 2030 5 3 2032 5 SING for 60 years in a wide variety of roles, working with Texas NA), the Board of Nursing, and other health organizations. 2034 5 4 Nurses are highly qualified to 2036 5 Nurse as was engaged in local as getting tovariety vote of roles, working with Texas bepolitics, in positions making I HAVE BEEN INsuch NURSING for 60people years inpolicy aout wide Governor 2038 5 5 Office is the ng high school and later testifying for and against legislative Nurses Association (TNA), the Board of Nursing, and other health organizations. and regulation at all levels for 2040 5 1 expert for Anne Mitchell, the RN in Winkler County of Lollywitness Even at a youngwellbeing, age I was engagedand in localsafety. politics, such as getting people out to vote health, ges brought against her for reporting an incompetent 50 15 1 PhD, RN. for hospital bonds during high school and laterphysician testifying for and against legislative But 2010 getting nurses into office is oard. She was found forfor doing rightthe RN in Winkler County bills. In“not Iguilty,” was thevindicated expert witness Annethe Mitchell, ecounts a challenge. Are you ready to who criminal charges brought against for reporting an incompetent physician y,asconsistent thehad law and the Code of Ethics forher Nurses. inspired with tostep the Texas Medical Board. She was found “not guilty,” vindicated for doing the right up and run? is initiative. thing forPractice patient safety, with the law andinthe Code of Ethics for Nurses. ed amend the Nursing Act. Iconsistent was actively engaged
Road to esentation
IN OFFICE
DO THE MATH
Lloyd first state runIand win. In addition, while on the taff forDoggett’s several years the 1960s, helped amend the Nursing Practice Act. I was actively engaged in Ifin you’ve ever thought about ement on workplace ns for several candidates, violence. including Rep. Lloyd Doggett’s first state run and win. In addition, while on the
Which of those numbers fits your timing and goals? Remember that as perfect time to start your g Representatives Needed a member of the most research, and oncerned we do not have nursespaperwork, in at our current political landscape, I am concerned we do not have nurses in trusted profession you ositions of authority. When I saw positions Dr. Billyeof authority. When I saw Dr. Billye fundraising! ip roles such as elected and appointed a book by her student BrendaI read Cleary: Women or her 103rd birthday, she insisted a book by her student Brenda Cleary: Women are already ahead s. I could not put it down. Visit texasnurses.org/ of many other of howon Representative Donna board, Howard Istarted on find the local school board, I realized to helpful arted the localnursesinoffice school realized candidates!
running forstatement office,onnow is the k Force, I helped develop the current workplace violence.
the key. Get early and mid-career nurses to run for local offices. In a few years, they
tools In and on running for to run for local offices. a fewguides years, they e ready for the Legislature, and then for Governor or Congress. Getting more nurses Governor Congress. Getting more and nurses various local state run needs aorconcerted campaign. I started strategizing withoffices. Kevin Stewart, Texas ed strategizing Kevin Stewart, Texas urses Associationwith general counsel, and Ellen Martin, TNA director of practice. llen Martin, TNA director of practice.
ces to Run
w nurses underestimate what we can do, in spite of how e are respected. Our goal became to offer encouragement “As a registered nurse and a in spite of how port. Not many nurses are familiar with running for office member of the Texas House of TEXAS NU R SaIregistered N G M AGA Z I Nand E | 019 nursing rlack encouragement “As nurse a S U M M E R I2use time or resources. Representatives, the
unning for office
process member of the Texas House of daily to analyze complex nurses get started, TNA is providing resources for nurses public policy issues. The nursing Representatives, I use the nursing interested in running or finding a nurse to run for local process is a great framework urses will have many opportunities to share experiences process daily to analyze complex
rces for nurses
PAGE 18
Have you met the $20 challenge yet? TEXAS NURSE PAC is TNA’s officially-sponsored political action committee, which donates to candidates on both sides of the aisle. Our goal is $200,000. If every member donated just $20, we could exceed our objective and have a fighting chance at the Capitol! Help us support candidates who support nurses! Give at texasnurses.org/PAC.
TEXAS
If not now, when?
The faculty team at Cizik School of Nursing are nurse educators, practitioners, scholars, and internationally recognized researchers committed to educating tomorrow's nurse leaders. Trained in many of the nation's leading hospitals, our students receive one of the finest nursing educations and experiences available in the world.
Academic Offerings
RN-BSN RN-MSN MSN Post-Master's
BSN-DNP DNP PhD
Learn more and apply online tody at nursing.uth.edu
WHAT NURSES NEED TO KNOW ABOUT
STATUTES OF LIMITATIONS By Jennifer Flynn, CPHRM, Risk Manager, Nurses Service Organization
DO YOU REMEMBER THE DETAILS of interactions with every patient you cared for two months ago? What about one year ago? The reality is nurses cannot rely on memory to recall details that could make the difference in successfully defending themselves against a lawsuit. After all, most of us can’t recall what we had for dinner two nights ago. The statute of limitations refers to the maximum amount of time between when an incident took place and when legal action can occur. Medical malpractice lawsuits can occur months or years after you last cared for the patient.
HOW STATUTES OF LIMITATIONS WORK Statutes of limitations specify the amount of time between when an injury occurs and when the injured party can file a valid cause of action in court. The intent of limiting this time frame is to promote fairness and often some pro-
Statutes of limitations vary by state and the nature of the offense, and they can be quite specific. For example, in Texas the statute of limitations for filing a medical malpractice lawsuit is generally two years from the date of the injury. tection for health care providers. Memories fade and witnesses can become incapacitated, making it difficult for the accused person to mount a reasonable defense.1 Statutes of limitations vary by state and the nature of the offense, and they can be quite specific. For example, in Texas the statute of limitations for filing a medical malpractice lawsuit is generally two years from the date of the injury, or if the injury occurred as part of an ongoing course of treatment, two years from when treatment concludes. 2,3 However, in California, it is three years or one year from the date the injured party should have known about the injury, whichever is earlier. 2,4
T E X A S N U R S I N G M AGA Z I N E | S U M M E R 2 019
PAGE 20
PROPER DOCUMENTATION Most nurses realize the importance of documenting treatment provided, but it is easy to forget or not document completely during a busy workday. Missing documentation makes it harder for attorneys to mount a defense in the event of legal action. Protect yourself by documenting patient interactions, whether they occur in person, on the phone, or electronically.
RECORD RETENTION Because of statutes of limitations, nurses can be named in lawsuits long after their last interaction with a patient. Retaining records based on state and federal laws and regulations ensures evidence is available in case of a lawsuit.
Medical malpractice lawsuits can occur months or years after you last cared for the patient. So, what can you do to protect yourself? Because of statutes of limitations, nurses can be named in lawsuits long after their last interaction with a patient. Retaining records based on state and federal laws and regulations ensures evidence is available in case of a lawsuit. While state laws generally govern how long medical records must be retained, some experts recommend keeping records for as long as 10 years. In the case of minors, keep records until the child reaches adulthood plus the maximum the length of time your state defines as the statute of limitations. Furthermore, though the Health Insurance Portability and Accountability Act does not include retention requirements, it requires administrative, technical, and physical safeguards to protect the privacy and security of protected health information for the amount of time such information is maintained.5
DOCUMENTATION TIPS Follow these tips to help ensure that complete documentation— not your memory—protects you in the event of legal action.7,8 99
Make sure your documentation reflects the nursing process and your professional capabilities.
99
Chart promptly. If you wait until the end of your shift, you could forget to include important information.
99
Chart in chronological order, specify exact times, and do not chart ahead of time.
You can find information about state and federal requirements related to retention of medical records at healthinfolaw.org/topics/60.6 i
99
Keep comments factual and objective to avoid any perception of bias.
99
Write clearly and concisely. Avoid using imprecise descriptions, such as “some”, “a little,” or “a large amount.”
RESOURCES
99
Document all communications: face-to-face, electronic, and by telephone.
99
Don’t chart a symptom without also charting what you did about it.
99
Do not blindly copy and paste standard entries or entries from the patient’s prior visits or between charts, and do not copy and paste another’s notes without proper attribution.
99
If you make an error when documenting, make the correction, noting the date and time of the correction.
99
Adhere to documentation requirements in your state, your organization’s policies, and professional standards. If there’s a conflict, use the most rigorous requirement.
1. Spero SJ, Cohen PL. (2008). Boundary violations and malpractice litigation. Psychiatric Times, 25(4). Retrieved from www.psychiatrictimes.com/ articles/boundary-violations-and-malpracticelitigation. 2. Larson, A. (2017). Statute of limitations by state for civil cases. ExpertLaw website. Retrieved from https://www.expertlaw.com/library/limitations_by_ state/index.html. 3. Texas Civil Practice and Remedies Code §74.251. 4. California Civil Procedure Code § 340.5. 5. Electronic Code of Federal Regulations 164.530(c) 6. Health Information & the Law Project. Medical Records Collection, Retention, and Access. The George Washington University Milken Institute School of Public Health & Robert Wood Johnson Foundation. Retrieved from http://www. healthinfolaw.org/topics/60. 7. Nurses Service Organization. Do’s and don’ts of documentation. Retrieved from https://www.nso. com/Learning/Artifacts/Articles/Do-s-and-don-tsof-documentation?refID=iiWLTNPi. 8. Nurses Service Organization. Defensive documentation: Learn how good charting can protect you from liability. Retrieved from https:// www.nso.com/Learning/Artifacts/Articles/ Defensive-documentation-learn-how-goodcharting-c?refID=iiWLTNPi.
This risk management information was provided by Nurses Service Organization (NSO), the nation’s largest provider of nurses’ professional liability insurance coverage for more than 550,000 nurses since 1976. Texas Nurses Association endorses the individual professional liability insurance policy administered through NSO and underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Reproduction without permission of the publisher is prohibited. For questions, send an email to service@nso.com, call 800-247-1500, or visit nso.com.
PAGE 21
S U M M E R 2 019 | T E X A S N U R S I N G M AGA Z I N E
Empowering Nurses with Motivational Interviewing Using Best Practices to Strengthen TPAPN Participant Commitment and Support Recovery THE THERAPEUTIC RELATIONSHIP The value of motivational interviewing lies in building a stronger therapeutic relationship between the case manager and participant. If a participant does not trust their case manager and feel safe in expressing their personal goals and motivations, progress can be hindered. A strong therapeutic relationship is the best predictor of lasting change. However, participants must often first overcome barriers or fears—perceived and real—especially of being judged or feeling threatened in their interactions with case managers.
The basis of motivational interviewing is using a collaborative style of communication with language focused on change.
FOR HUNDREDS OF NURSES, the Texas Peer Assistance Program for Nurses (TPAPN) facilitates positive life change. However, reaching a stable point in recovery is an ongoing process. Case managers work with nurse participants on this journey, supporting them for up to five years. Now TPAPN staff have a new addition to their toolbox that will make the process even more person-centered and goal-oriented: motivational interviewing.
A PARADIGM SHIFT In June, TPAPN staff received extensive, multi-day training in motivational interviewing from Jacklyn Hecht, MSN, RN, an expert in motivational interviewing and faculty at the University of Texas. The focus of the training was to learn to communicate in a way that better facilitates recovery. “Through motivational interviewing, participants explore their own reasons for change within an atmosphere of acceptance and compassion,” said Dawn Webb, MSN, RN, TPAPN program director. The basis of motivational interviewing is using a collaborative style of communication with language focused on
“As we were wrapping up training, Hecht wanted to know our major takeaways,” Webb recalled. “One of our case managers stated that ‘before this training I did not realize I was in a position of power.’ It can be hard to recognize the dynamic you have with participants, but until we understand that relationship, we can’t build trust.”
change. Often, participants are ambivalent or reluctant to engage in the process. By working with participants—rather than telling them what to do—and listening empathetically, case managers can help strengthen personal motivations and commitment to a specific goal. The structure of motivational interviewing is summed up in the acronym OARS: Open questions: Ask for more information than a “yes” or “no” Affirmations: Highlight client’s strengths, determination, or values Reflective listening: Explore out loud what the person’s statements mean Summarizing: Connect and reinforce the points discussed “By attaching the participant’s goals to the larger goal of completing the TPAPN program,” Webb explains, “the participant’s journey through TPAPN will be more beneficial to the participant’s long-term recovery and nursing success.” For instance, while the end goal of the program may be returning to safe practice and ensuring public safety, the participant may have additional goals of personal sobriety or improved health and wellness.
T E X A S N U R S I N G M AGA Z I N E | S U M M E R 2 019
PAGE 22
At the simplest level, the goal of the case manager is to enable behavioral change. However, without a truthful and complete picture of where the
MEET DAWN WEBB Dawn Webb, MSN, RN joined TPAPN as program director in April. She most recently worked at Austin Travis County Integral Care as nursing supervisor where she provided oversight to multiple teams in outpatient clinics, community outreach, and homeless shelters. She also previously worked at Seton Shoal Creek Hospital and as a licensed chemical dependency counselor at Austin Drug and Alcohol Abuse Program. Webb received her Master of Science in Nursing Administration from The University of Texas at Arlington. In addition to her nursing education, she also graduated from the Institute of Chemical Dependency Studies.
participant is when they start the program, case managers won’t be able to appropriately meet the participant’s needs or accurately track progress. With a healthy therapeutic relationship, case managers can better assess how ready, willing, and able the participant is to change their behavior and then support them in that change.
LISTENING AND THE POWER OF WORDS Hecht framed the motivational interviewing process through the Four Stepping Stones: engaging, focusing, evoking, planning. This starts with agreeing on a target behavior or change goal. The case manager then acknowledges
the participant’s inner strengths and prompts the participant to provide ideas for change. Finally, they help participants identify why they want to make a change and then how they want to make the change.
“The power of our words came up a lot in the training,” Webb said. “One of my favorite books is The Four Agreements and my favorite agreement is ‘Be Impeccable with Your Word.’ I am teaching this and modeling it the best I can.”
Throughout the process, the case manager works on listening to the participant. They listen for words that indicate a desire to change (I want, I would like to), the ability to change (I can, I could), and a need to change (I have to, I need to). They also listen for words that indicate commitment (I decided to, I promise to) and examples of steps taken towards the identified goal.
Webb said she and the TPAPN case managers have already seen positive shifts in conversations with participants. When one case manager asked a new participant how they felt about being referred to the program, the participant responded, “Wow, no one has asked me how I feel about this except my therapist. Thank you so much for asking.” i
BE A TNA SOCIAL MEDIA AMBASSADOR
New to Twitter? Already follow us? Don’t even have an account? We want YOUR help in reaching nurses on social media in exciting new ways. TNA members Lisa Boss, PhD, RN, ACNS-BC, CNE, and Lisa Campbell, DNP, RN, PHNA-BC, are avid tweeters and great examples of TNA ambassadorship online. Campbell says nurses can serve as subject-matter experts on Twitter and offer an important perspective. To be most effective, she says “consider including a link to a recently released study, an
infographic or post—one great way to engage with others.”Designing your Twitter “handle” with a professional image is key for Boss. “Take time to observe the ‘culture’ of Twitter,” she says. “Once you are comfortable, chime in and let your voice be heard!” Read more about how Campbell and Boss (and other #nurseswhotweet) approach Twitter at texasnurses.org/news.
Ready to be a TNA social media ambassador? Get started by following and retweeting @texasnursesassn on Twitter, using the hashtag #NursesWhoTweet, and sharing our content via Facebook and LinkedIn. Your engagement grows our reach exponentially and ensures stakeholders hear about the great work we’re accomplishing.
DID YOU MISS POLICY SUMMIT?
If you have received:
Get your updates from the 2019 Policy Summit on the TNA Learning Curve:
Letter of Investigation from the Texas Board of Nursing
»» Tackling Workplace Violence Surveys and Grant Updates by Pam Lauer, MPH, Program Director, Texas Center for Nursing Workforce Studies
Notice of Peer Review
Joyce Stamp Lilly RN JD
»» Regulatory Update by Katherine Thomas, MN, RN, FAAN, Executive Director, Board of Nursing for the State of Texas
Registered Nurse and Attorney
713.759.6430 jslilly@me.com www.nurse-lawyer.com
»» Championing Public Health at the Texas Capitol by Troy Alexander, Texas Public Health Coalition
Get your CNE today! Visit
texasnurses.org/OnDemand!
PAGE 23
S U M M E R 2 019 | T E X A S N U R S I N G M AGA Z I N E
4807 Spicewood Springs Rd. Bldg 3, Suite 100 Austin, TX 78759
NOW FOR SALE! AN INTRODUCTION TO TEXAS NURSING PRACTICE This new book provides easy-to-understand guidance on everything Texas nurses need to know. From getting a license to renewal requirements to nursing laws, this book breaks down complicated regulations and includes practice notes with additional guidance. The simple flowcharts, diagrams, examples, and comparison charts included can help any nurse understand his or her responsibilities and rights in Texas.
Bulk purchasing available for universities and health systems. Contact tna@texasnurses.org for more information or visit texasnurses.org/store.
TAKE THE
YOUR NURSING CAREER.
OUR ONLINE GRADUATE PROGRAMS: Master of Science in Nursing Nursing Education / Nursing Administration & Leadership Clinical Nurse Leader / Clinical Nurse Specialist
Doctor of Nursing Practice Family Nurse Practitioner / Adult-Gerontology
Acute Care Nurse Practitioner / Clinical Nurse Specialist Post master’s DNP APRNs and Nurse Administrators
APPLY ONLINE harriscollege.tcu.edu/nursing graduatenursing@tcu.edu 817-257-6726