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uAlberta | nursing SPRING 2013


The new normal in aging

Message from the Dean SPRING 2013 Dear friends and colleagues,

uAlberta | nursing Published by Faculty of Nursing Level 3, Edmonton Clinic Health Academy 11405 87 Avenue University of Alberta Edmonton, Alberta T6G 1C9 Website: Editor: Yolanda Poffenroth Photographs courtesy of Linda & Jin Szeto of Resplendent Photography, University of Alberta, Jessica Twidale, Leigh Pinard, Kara Schick Makaroff, Wendy Duggleby and Yolanda Poffenroth For more information about donating to the Faculty of Nursing, contact Jessica Twidale at jessica. /780.492.5804 Find us on Facebook!

As I write this message on a snowy spring day, I am both looking forward to some warmer weather and an administrative leave. On July 1, 2013 I will start a one year leave, during which I will visit leading nursing programs in the United States and the United Kingdom. My goals are to examine strategies, processes, best practices and outcomes of several highly regarded research-intensive nursing faculties in relation to: research and publication, recruitment and retention of faculty, fundraising, human patient simulation and work/teaching assignments. These are all areas that we have been focused on in the Faculty of Nursing, and I would like to explore ways to further enhance the work that we do. Also, I want to identify additional indicators of excellence and possible benchmarks that are used by other nursing education programs to help us further reflect on areas where we are strong and where we can continue to develop. To date, I have made arrangements to visit the University of Pennsylvania, Emory University and Manchester University, and am in the process of finalizing arrangements at several other universities. I am also looking forward to having a bit more time to spend on writing and research. As many of you know, my area of interest is quality of life of people with chronic illnesses. In this issue of uAlberta | nursing, you can read a bit more about the work that I am doing with Dr. Kara Schick Makaroff and colleagues from the University of Victoria. While the last five years have been highly productive for the Faculty of Nursing and exciting in many ways, the budget reductions that we have endured every year have made operating this large nursing faculty increasingly challenging. As you may have heard in the news media, the University of Alberta is now faced with a further 7.2 per cent budget reduction and the strategic goals of the government in relation to the post-secondary education system are not clear. As we sort through the messages, in the short term, we will not be filling three administrative staff vacancies and the Associate Dean, Teaching and Learning position that is coming to an end. We very much appreciate the work of Dr. Florence Myrick (PhD ’98) who has served in this role for the last five years and will plan ways to continue to enhance the quality of education in the future. In the longer term, I anticipate that some curriculum changes to the Collaborative (4 year) undergraduate program will reduce the costs of our operations. The new streamlined program will align better with our other undergraduate programs (After Degree and Bilingual). I hope that the changes will be well underway before I begin my leave. The Faculty will be in good hands over the next year as Joanne Profetto-McGrath (PhD ’99) assumes the role of Acting Dean and Wendy Duggleby (MN ’90) moves into the role of Acting Vice Dean. I will keep in touch with you through uAlberta | nursing to keep you informed about what I am learning while I am away. With my very best wishes,

Anita Molzahn

uAlberta | nursing


Taking a plunge into nursing Words: Bryan Alary and Yolanda Poffenroth

From airplanes to the pool to remote parts of Afghanistan, alumna enjoys unique journey to nursing degree. Leigh Pinard might enjoy jumping from planes, but she didn’t exactly fall into nursing school at the University of Alberta. Not right away, at least. An officer cadet with the Canadian Forces and former member of their SkyHawks parachute team, Pinard (BScN ’12) took a less direct trajectory to a degree from the Faculty of Nursing’s after-degree program. That



journey included stops in Ottawa, Borden, Kingston, Trenton, the United States and Poland, and even a seven-month tour in Afghanistan, where she served as a medic. “Nursing was kind of a natural progression from being a medic. I loved being a medic but being a nurse is an officer position,” said Pinard, 30. “I wanted to be in more of a leadership position, and nursing provides a great opportunity to do that.” Pinard knew very little about the profession until her late teens, when she had her appendix removed in a

hospital in her hometown of Ottawa. It was the nursing staff who left a lasting impression, and it’s no surprise that she finds hands-on patient interaction a true reward. “With nursing, you’re the person who is looking after that patient, you’re always at the bedside and you’re the person to hold their hand,” she says. “There are so many things a nurse can do that make or break a patient’s stay in the hospital.” But becoming a nurse didn’t happen overnight. When other students at the University of Ottawa were checking out

local clubs on campus, Pinard joined the reserves as an infantry soldier with an eye on being a ceremonial guard on Parliament Hill. She enjoyed the experience and her peers so much, she stayed on and completed full training, eventually volunteering to serve in Afghanistan as a medic with a counter-improvised explosive device (IED) team. “I got to see all the different sides of Afghanistan,” says Pinard of her travels, which took her from Kandahar to Kabul and less violent northern areas of the country. “It’s a completely different country up there, a lot more peaceful.” Her military career has also allowed

her to pursue more leisurely pastimes like skydiving and competing in triathlons with the Canadian Forces national team. Pinard did her first tandem skydive before leaving for Afghanistan and that was it; she was hooked. After some gruelling training, she made the Skyhawks parachute team—one of only eight women to do so in its 40-year history. From May until mid-October that year, Pinard performed in air shows across Canada and the United States, jumping from planes with the team’s signature Canadian-flag parachutes. “It was the best summer of my life and definitely

the coolest thing that I’ve done in the military,” she says. Skydiving pushes you to the limit, says Pinard, who now has 275 dives under her belt—still a far cry from her husband Sergeant Sebastien Pinard’s 1,000-plus.

“When we’re stressed, we go skydiving,” she says. “The only thing you can think about at that minute is the skydive. Everything else seems to melt away.” Pinard also pushes herself on foot, in the water and on two wheels, as a member of the national triathlon team. She’s bumped elbows and rubbed tires

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with military personnel from around the world, including Switzerland for the most recent Conseil International du Sport Militaire. “Physically and mentally it’s one of the most challenging sports I’ve ever done,” she says. While in the nursing program Pinard trained round the clock, something that wasn’t easy with a hectic academic schedule. She’d start in the morning at the UAlberta pool before going to classes, followed by studying in the library and then working out in the gym. “It was busy,” she concedes, but adds that her schedule did take her mind off other worries—like her husband’s tour



in Afghanistan. “It was a good and bad thing, I guess. It made me sit down and focus on school.” Pinard received her BScN degree a few short months ago, but her schedule is still as hectic as ever. After completing the remainder of her basic training and being promoted to Lieutenant, she began training in Edmonton to be a military nurse. The additional training, which focuses on medical-surgical and emergency room skills, is necessary. “Nursing during deployment is quite different than nursing in the civilian world,” she says. “You’ll have someone with a traumatic amputation flying in on

a chopper and they’re taken straight to the operating room. Your role is really big because you’re acting as both the emergency and operating room nurse, helping with the anesthesia and rationing the blood bank. It’s just such an exciting environment!” What does the future hold for Pinard? “Once my military nurse training is done in the fall I’m off Ontario for three more months of courses. When those are finished I’ll have completed everything necessary to be promoted to Captain.” With her husband being posted at CFB Edmonton, she hopes to be posted there as well. “Maybe then I’ll be able to relax a bit,” she says with a laugh. nx

Students team up to Save Stan Training effective health-care teams

Teaching health sciences students to work and communicate in a team setting. Words: Bryan Alary In the span of minutes, future nurses, health-care aides, pharmacists, respiratory technicians, doctors, paramedics and other health sciences students go from nervous anticipation to full-out action, triaging, diagnosing and treating a steady stream of patients in a busy emergency room. A 78-year-old male with end-stage heart failure and a do-not-resuscitate order is bedridden across the room from a scared eight-year-old boy who can’t breathe. “Can I get some help over here,” his mom pleads over the din. Soon the room fills. A woman in the throes of labour is wheeled in by a paramedic, followed by a patient complaining of a broken arm after a fall, and a woman with a migraine so intense she vomits in the waiting area. When a man in his 40s with mussed hair, bruises on his face and torn clothing shuffles into the ER, all hell breaks loose. “They won’t leave me alone—they’re trying to kill me!” he screams, momentarily freezing the entire room.

The noise, energy and tension belie the fact the entire scene is a training simulation. In fact, half the patients are made of plastic and circuitry and the rest are playing the part. Though no lives are actually at stake, the lessons learned are as real as they come. “Health care and providing health is messy, it’s complex, it’s really dynamic, and that’s what we need to replicate for the students,” said Sharla King, director of the Health Sciences Council’s Health Sciences Education and Research Commons at UAlberta, the creator and one of the main organizers of Save Stan. The annual event brings together students from across the health sciences at the University of Alberta, MacEwan University, NAIT and NorQuest College. This year’s Save Stan saw 250 students from programs such as nursing, medicine, pharmacy and rehabilitation medicine participate in nearly two dozen training scenarios in the state-of-the-art HSERC simulation lab and the Faculty of Nursing Learning Resource Centre in the Edmonton Clinic Health Academy. The simulations ranged from working with high-risk inner city youth to palliative care to prenatal care to the ER

“mashup,” featuring the high-fidelity mannequin nicknamed “Stan.” And though students do receive some preparation ahead of time, learning to deal with the unexpected is a valuable training tool.

Communicating as a care team Nadine Moniz (BScN ’01, MN ’05), a faculty lecturer, was the lead facilitator for the labour simulation in the ER mashup. The simulation saw students overcome their unfamiliarity with each other and come together as a team to deliver a healthy baby … doll. “It was fascinating to see students interact with each other from different disciplines, different institutions,” said Moniz. “They worked through it, and verbally clarified each other’s roles and people eventually took leadership roles. You never know during clinical practicums if they’ll get this kind of exposure to multiple disciplines.” Learning to rely on other members of the care team is essential to patient care, as first-year medical student Tracy Zhang found out. During the mashup it was her job to diagnose an emotionally disturbed patient, although he refused, citing distrust of doctors. “I couldn’t talk to him, so it was nice to be able to rely on the other health professionals on the team,” Zhang said. “It was an excellent chance to see what everyone does and how they work in a team.” nx

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Defining the new normal in aging Words: Bryan Alary Diana McIntyre approaches her 80th birthday later this year with the same energy and zest for life of friends decades her junior. Aside from back surgery years ago, she’s never been sick and, through a busy volunteer schedule, never seems to slow down. McIntyre’s good health feels normal— at least to her—although she recognizes not all seniors are so fortunate. But when it comes to terms like “normal,” “healthy” or “successful” aging, she shakes her head. “I don’t know what would be considered normal aging,” said McIntyre, past president of the Seniors Association of Greater Edmonton. “What’s normal for a 45-year-old? What’s normal for an 80-year-old? Those are really irrelevant terms as far as I’m concerned. My own philosophy is I would like to do as much as I can, for as long as I can, as well as I can.” Hannah O’Rourke (BScN ’08), a PhD student and Vanier scholar in the Faculty of Nursing says terms such as normal or healthy aging are commonly used by health-care professionals to describe or influence how seniors should age. Often they emphasize personal lifestyle choices in staying healthy, such as eating well, staying active and not smoking.

O’Rourke’s research was funded by Knowledge Translation Canada, Alberta Innovates – Health Solutions and the Canadian Institutes of Health Research.



Chronic disease might be the norm, but doesn’t have to be the focus But those terms can fall short of the experiences of most older Canadians, and how they’re used affects how a society views older generations— especially seniors living with chronic diseases such as cancer, diabetes and heart disease, says O’Rourke. “Normal aging is not something we can easily define,” she says. “There are many older adults with chronic disease who report they still enjoy life. When aging is just defined as ‘healthy’ and ‘devoid of disease,’ it doesn’t leave a place for what to do with all of these older adults who are still aging with chronic illnesses. “Cures for chronic illnesses are not always around the corner, and healthcare teams have patients to care for now. We need to find ways to support older adults with chronic disease to live well according to their own definitions of health and normality.” O’Rourke points out that many Canadian seniors are well enough to live at home, yet 80 per cent have some form of chronic disease. With that large a majority, putting the onus on individual

choices to age successfully sends the wrong message. “The implication is that if you have a chronic illness as an older adult, you’ve somehow failed in this goal of aging without chronic disease, which is perhaps not that realistic a goal.”

Sound the alarm, a grey wave is here O’Rourke says much of the policy work, research and teaching about aging also relies on statistics to describe Canada’s greying population, such as estimates that, by 2026, one-fifth of the country will be over the age of 65. But those statistics frame aging as a problem to be fixed, she says, and that affects how we view seniors. McIntyre feels these implications, and not in a positive way. “When people think of seniors, they think of their limitations instead of their capabilities,” she says. “The huge majority of us are doing very well on our own, thank you.” O’Rourke points out that an aging society can also be viewed as a success story because it means the majority of us are living well into our older years. “Just because something requires resources doesn’t necessarily mean it’s a huge problem.” nx

The times they are a-changin’ Research gauges public opinion about assisted suicide; a contentious aspect of an ongoing legal, ethical and health policy discussion in Canada. Words: Bryan Alary & Yolanda Poffenroth

An overwhelming majority of Albertans believe dying adults should have the right to request to end their life, according to new research Donna Wilson (BScN ’81) led the team that studied the views of 1,203 Albertans on assisted suicide, currently illegal in Canada. Most—77.4 per cent—felt dying adults should have the right to end their life early. “Increasingly, there are countries or states where they are allowing assisted suicide or euthanasia. Like many of those countries, Canada will have to grapple with this question,” said Wilson, a professor in the Faculty of Nursing. “Until this point, nobody has asked the public, and that’s a very important perspective.” Wilson, an expert in aging and end-of-life care, used data gathered through a 2010 health-care survey by UAlberta’s Population Research

Laboratory. When asked, “Should dying adults be able to request and get help from others to end their life early?” a total of 36.8 per cent of respondents answered yes outright. Another 40.6 per cent of respondents indicated yes, but with the qualification that assisted suicide “should only be allowed in certain cases or situations.” The remaining 22.6 per cent answered no or declined to answer this question. The results showing support, Wilson said, are surprising in light of the province’s reputation as a society holding traditional, conservative views. “You have these preconceived images of Albertans, but Alberta is a very young province—the youngest in Canada—and we really value autonomy and independence,” she said. “A lot of people realize that, ‘If I were dying, I’d want to be able to say end it now. I might not want it in the end, but it would be nice to have that option.’” uAlberta | nursing


By the numbers… With population aging and population growth, the number of people who pass away each year is increasing. In Canada, 80 per cent of deaths happen

Personal experience factors into support The survey data show personal experience shaped opinions on assisted suicide. Individuals who had already been involved in a decision to stop or not start life-supporting treatment were 79.8 per cent in support. Even greater support—81 per cent—was found among those who have euthanized a pet. “It’s not just some abstract answer that ‘this isn’t right,’” Wilson said. “These are people with important experiences that made them much more open to assisted suicide.” Respondents who opposed assisted suicide were more likely to be less educated (39.8 per cent among those who had not completed high school) and to have strong religious beliefs. Some 40 per cent of Protestants answered no, as did 35 per cent of Catholics and 44.3 per cent of those in the “other religions” category—a group that includes Christians, Muslims, Hindus and Jews. Over 50 per cent in every group were in still favour of assisted suicide, however. Wilson’s research comes at a time when the federal government is appealing the B.C. Supreme Court ruling to allow Gloria Taylor, who had late-stage ALS and has since died, a constitutional exemption to proceed with physicianassisted suicide. A Quebec panel has also called on that provincial government to allow “medical assistance to die.” Wilson said she is not calling for legal changes, but cautions that if laws are changed to allow assisted suicide, it will be paramount to learn from the experiences of other countries to satisfy concerns about vulnerable persons, the impact on health professionals and fears of abuse of power. 9|


in old age and with close to 12.4 million Canadians over the age of 50, the government will need to review current health and social service policies and practices to ensure their future readiness. In 2010 the UAlberta Population Research Laboratory included a set of end-of-life research questions in their annual health-care survey. The questions, developed by Donna Wilson and colleagues with expertise in end-of-life care, aimed to uncover the experiences and preferences of Albertans regarding end-of-life. In addition to answering questions about assisted suicide, the 1,203 respondents were also asked about advanced directives and the preferred place of last days. • In Alberta, any adult can write down their preferences for health care should they ever be unconscious or unable to speak at a time when healthcare decisions need to be made. Of the respondents, 43.6 per cent reported having a completed directive and 42.1 per cent indicated plans to complete one. This survey data reveals for the first time the proportion of a Canadian population with a living will. This finding is much higher than the previously estimated 10 per cent. • More and more people are saying that they do not want to pass away in a hospital, which is not surprising as dying Canadians usually know that they are terminally ill and that they have had all available healthcare treatment to extend their life. When asked about the preferred place of last days, only 7 per cent said that they wanted to be in a hospital. Instead, 70.8 per cent stated that they preferred to be at home, 14.7 per cent preferred a hospice or palliative care unit and 1.7 per cent preferred a nursing home. This information is highly relevant for health policy and health service developments, such as expanding support for home-based end-of-life care.

“With 77 per cent of people saying it’s okay to do it, it’s not going to go away—Canada is going to keep talking about death hastening,” Wilson said, noting the number of deaths in Canada will double over the next two or three decades, which could further influence support. “The discussion is here, so now is really an important time to see what happens in other countries where they allow it. If we’re going to do it, let’s do it the best we can, and until then, don’t jump into this lightly.” nx

A lot of people realize that, ‘If I were dying, I’d want to be able to say end it now.

Ethnicity and Health Words: Yolanda Poffenroth

Growing up in England during the mid-1960s, Dr. Gina Higginbottom didn’t always have aspirations to be a nurse, but she did know that she wanted to have a role that made a real contribution to her community. It was during her time at a girl’s grammar school in the more affluent west end of the city Higginbottom, who hailed from a working class family in the east end, first understood, “that somehow affluence was a predictor of educational achievement in the education system that was prevalent in the 1960s.” It was this first insight into how inequalities are manifested into society that sparked her initial interest in inequalities. Years later during community placements as a student health visitor—a community health nurse in the UK—she was astounded to observe the level of material deprivation that many of the families she visited experienced every day. “The extent

and degrees of poverty that exist in society and the impact on health became acutely apparent to me,” says Higginbottom. With that, her spark of interest became a flame burning brightly. Higginbottom knew that she wanted to spend her career working to address health inequalities for minority communities and where better to conduct research than Canada, a country that has used immigration as a population expansion policy resulting in a highly diverse and multicultural society.

Healthcare inequity in Canada According to Statistics Canada, between now and 2031, the foreign-born population of Canada could increase approximately four times faster than the rest of the population, reaching between 9.8 million and 12.5 million (25% and 28% of the population). Moreover, members of visible minority groups

Publication Mail Agreement Number 40065232 Return undeliverable Canadian addresses to: Level 3, Edmonton Clinic Health Academy, 11405 87 Avenue University of Alberta, Edmonton, Alberta, Canada T6G 1C9

could make up 32% of the population and nearly one Canadian-born person in two (47%) belonging to the second generation (the generation of children of immigrants) would belong to a visible minority groups, compared to 24% in 2006.”1 Although the Canadian Multiculturalism Act of 1985 requires not only that we respect and celebrate diversity but also that every citizen must receive equal treatment from the government, there are still some Canadians who suffer from health inequities. This is one of the issues that Higginbottom— who has research training and experience in nursing, health promotion and medical sociology—is working to improve. “If you think about the historical development of Canada, in the 1890s there were around 5 million people— now we have 35 million people,” says Higginbottom, who holds a Tier II Canada Research Chair in Ethnicity and Health. “We are seeing a lot of uAlberta | nursing

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“My interest in ethnicity and health is really both professional and personal. I have a multiple-ethnic origin myself, my dad is Ghanaian and mom is English, and I’ve always been very interested in different ethnocultural groups. When I was a clinician I could see that often people were being cared for in a sometimes culturally inappropriate way. It’s really driven my own personal philosophy, profound commitment to eradication of health inequalities. Access to adequate and appropriate healthcare is a human right and we should all have the capacity to acquire healthcare that is appropriate to meet our needs and our ethnocultural orientation.” —Gina Higginbottom

migration from Asia, India, Pakistan and from African nation-states and areas where there has been civil unrest and transgressions of human rights.” This migration leads to a very diverse population with people who have different ethnocultural orientation and associated with those differences is often the accompanying dissimilar health and belief systems. As Higginbottom notes, it’s a complex scenario and we need to remember that our immigrant populations are a heterogeneous group. On the whole, Canada only admits immigrants who meet the needs of the workforce and many immigrants arrive extremely healthy. The section of the population most likely to experience health inequities are refugee populations and those populations who may be in lower skilled jobs where they don’t need to have an excellent command of one of the official languages to undertake the roles. Higginbottom, whose clinical background in midwifery and public 11 |


health nursing has led many of her research projects to focus on maternal health and wellbeing, notes that it’s also important to keep in mind that when a family immigrates to Canada, it is often the husband who has the job and language skills and not the wife. As well, it can depend on the country the family has emigrated. “If they’ve come from an area where women’s rights and issues are marginalized, women may have a greater difficulty in navigating the healthcare system.” Similarly, some sectors of the immigrant populations may experience health inequities in relation to lack of language skills, lack of knowledge of the healthcare system, lack of ability to access and navigate the healthcare system and lack of a provision of culturally congruent and culturally safe care. In addition, there are also racist dynamics that exist in healthcare.

“We actually have evidence from research studies that visible minorities may experience more profound racism,” says Higginbottom, “especially if their appearance is very different. For example, if you wear a hijab, there is sometimes more stereotyping. “It’s a multi-faceted phenomenon in terms of the experience of equity that is related to the configuration of services, the delivery of services, policy and strategy, and sometimes the ability of the individual to navigate the system,” she says. Immigrants may be very unfamiliar with how health systems are configured and conversely, the practitioners may be very unfamiliar with the health and belief systems of the

people that they are caring for, “which has the potential to lead to cultural clash or cultural misunderstanding. In the delivery of our health care, we would aspire to an efficient and economical way of delivering the health care.”

What are the challenges? “We need to be using and delivering our health services in an effective and efficient manner,” says Higginbottom, “but there are numerous dimensions that need to be considered for this to occur, such as health economics, risk management, culturally competent care and ethics.” Communications between the patient and healthcare provider need to be effective at the first encounter. “If people don’t get the right treatment or communication the first time, they have to go back to their healthcare provider two or three times which isn’t a good use of health services,” she says. “It’s a very predominant discourse and the problem is that often the interpretation translation services are not available for the healthcare provider and the recipient to communicate appropriately and effectively.” Along a similar vein, Higginbottom notes that risk management is vitally important. If healthcare providers aren’t able to get the correct information from the patient about their health status or what has happened to them, a simple miscommunication may lead to a negative and adverse event. The provision of culturally congruent care also figures very prominently. In the Western world biomedicine is the predominant ideology, but sometimes the patients and their families do not subscribe to that form of medicine. “In

traditional Chinese medicine there is a theory on what is appropriate in terms of ‘hot’ and ‘cold’ and how an imbalance of these can cause disease or be more beneficial towards health,” says Higginbottom. “For example, sometimes women in labour are given ice water or after childbirth their wounds are treated with ice packs, which would be very inappropriate treatment in that situation.” Finally, Higginbottom believes that there’s also an ethical dimension that should be considered. “If you don’t have very good language skills, but you’re working in a country and contributing to the economic growth of the country through taxation, then you should be able to get services that meet your needs.”

How can we address these issues? Higginbottom thinks that we need to start addressing the issues at an undergraduate education level. Not just in nursing programs, but in all health professional programs to ensure that we provide education around the provision of culturally safe and culturally appropriate care. To that end, she’s worked with colleagues at the University of Alberta and Sheffield Hallam University in the UK to develop an online tool, Providing Culturally Safe and Competent Health Care, which will be offered to all undergraduate health science students at the University of Alberta. The self-directed workbook and digital resource is an interactive web-based learning resource that will help students enhance their understanding and application of cultural competence and cultural safety. But it’s not just about educating our new graduates; there is a whole workforce of health professionals who have been educated in previous decades who may benefit from learning more uAlberta | nursing

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about cultural competence and safety. “Alberta Health Services was interested in this online tool for their employees and I’m currently working with a member of their strategic planning group on cultural safety,” notes Higginbottom. As well, she suggests that at the governmental policy level, Canada needs to recognize that perhaps a national translation/interpretation strategy in health care is needed. “In other nation states, such as England, that exists, but in Canada it doesn’t and I think we need it.”

Canada and beyond… International migration isn’t specific to Canada; it’s a 21st century phenomenon. The movement and relocation of peoples, often from the south to the north and the east to the west is something that is not going to go away, it’s going to increase as we move further into the 21st century. There are diverse drivers of immigration such as transgressions of human rights, economics, education, family reunification, natural disasters, and so on. While Canada is unique in some respects by using immigration as a population expansion policy, large scale migration has also occurred to other highly developed nation states. “There are many parallels that we have with other top immigrant receiving countries, such as Australia and the United States, and there is lot that we can do to work together,” says Higginbottom, who has been involved in several international research programs with colleagues in England, Germany, Canada, Australia, Brazil and the United States.

Projections of the Diversity of the Canadian Population, 2006-2031 Statistics Canada – Catalogue number 91-551X 1

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Higginbottom notes that although some aspects of her research are definitely transferable, actually making direct comparisons between countries is very challenging. “In a study I did with colleagues in England and Germany, one of the things we have to acknowledge is that yes, there is this commonality, but the healthcare systems, funding systems, as well as the policy directives are often configured in very different ways. Even the semantics of the language that we use to describe our population groups is different! In Canada, for example, the terms ‘visible minorities’ or ‘immigrant populations’ are used. In England the term ‘immigrant’ is considered quite derogatory and ‘ethnic minority’ is preferred.”

What’s next? With a research program committed to the ultimate goal of improving the health status of diverse ethnocultural groups, Higginbottom’s Canada Research Chair in Ethnicity and Health

was recently renewed for another five years (2013-2018), and she’s already preparing her future research. “I plan to further extend my program of research to greater international research collaboration and working to translate existing studies into action,” she says. Higginbottom has already started working on this by creating and convening the Collaborative Research in Ethnicity Social Care and Health (CRESH) network, a multi-provincial e-seminar and provincial email knowledge transfer network between local researchers, community members and health professionals, and a network of researchers working with her from all over the world. “I love my work and I’m grateful to have the Canada Research Chair and the resources and funds to be able to develop my research program in this way. As an immigrant myself, I feel extremely privileged and thankful for the opportunities that Canada has given me.” nx

How can Gina`s research help your nursing practice? 1 Do I understand what it means to be a culturally competent healthcare provider? 2) Do I understand the notion of culturally congruent care? 3 Do I understand the concept of cultural safety? 4) Do I understand the nature and structure of contemporary Canadian society and the population groups that exist? 5) Am I able to evaluate my own nursing care in respect of cultural competence and cultural safety? If you answered ‘no’ to any of these questions, or would like to learn more about providing culturally safe and competent health care, you can access the self-directed workbook and digital resource that Gina and Faculty of Nursing colleagues produced at: higginbottom. You can also read her article, ‘Identification of nursing assessment models/tools validated in clinical practice for use with diverse ethnocultural groups: An integrative review of the literature,’ which was published in 2011 in BMC Nursing, volume 10.

Faculty Accolades Olive Yonge The Alberta government has appointed Dr. Olive Yonge (BScN ’74) as the new Chair of the Campus Alberta Quality Council. Yonge, who holds a Vargo Teaching Chair, has served on the Council since 2011 and was the Vice Provost of Academic Programs at the University of Alberta from 2005 to 2010. “I am pleased Dr. Yonge has been appointed as Chair,” said the Minister of Enterprise and Advanced Education, Stephen Khan. “She has an array of experience as a nurse, an educator and as part of the Council. I am confident that the skills and leadership abilities she has developed in these roles has prepared her well to take on this opportunity as leader of this Council.”

In Memoriam Janet Basken (neé Paton), Dip ‘81 Carol Bell, BScN ’75, in May 2011 Karen Bradley, BScN ’78, in January

The Campus Alberta Quality Council, established in 2004, is an arms-length quality assurance agency that makes recommendations to the Minister of Enterprise and Advanced Education on applications from post-secondary institutions seeking to offer new degree programs in Alberta. After the degrees are implemented, it monitors the programs to ensure quality standards continue to be met. The ultimate goal is to decrease the monitoring role of the Council as institutions move to implementing evidence-based processes that will directly address quality in their own programming. Yonge is committed to ensuring students receiving degrees offered in Alberta have their credentials recognized nationally and internationally. nx

The Faculty of Nursing notes with sorrow the passing of the following graduates. (Passings occurred in 2013 unless otherwise noted.) Mary Fisher (neé Peterson), Dip ’56, BScN ’73, in November 2012

Diane Patterson, Dip ’58, BScN ’59, in November 2012

Deana Huff (neé Gibbons), Dip ’54, in April

Donna Seland (neé Wolstenholme), Dip ’62, in February

Nancy Brine, Dip ’60, in September 2012

Shirley Imeson (neé Ells), Dip ’46, in January

Susan Sutherland, Dip ’67, Dip ’68, BScN ’70, in January

Eugenia Kwasney, Dip ‘50, in April

Jean Clark, Dip ’60, in December 2012

Patricia Kyle (neé Klamsky), Dip ’53, in December 2012

Eva Trott (neé Sawka), Dip ’50, in February

Sandra Cobban, PhD ’12, in January

Debra May, BScN ‘92, in December 2012

Constance Cooper, Dip ’58, in January

Lois Murphy, Dip ’56, in November 2012

Helen Cotter, Dip ’62, BScN ’67, in February

Lorraine Pacholek (neé Hogge), Dip ’73, in January

Shirley Turner, Dip ’81, in October 2012 Muriel Wanless (neé Andrews), Dip ’39, in November 2012 Gayle Watt (neé Scott), Dip ’63, in April 2012

If you are interested in setting up a memorial fund, please contact Jessica Twidale, Director of Development and Public Relations, at 780.492.5804. uAlberta | nursing

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Wendy Duggleby The past six months have been incredibly busy for Dr. Wendy Duggleby (MN ’90). During that short amount of time, the honours for her program of research have been piling up. Diamond (Jubilee’s) are a girl’s best friend In January, Duggleby and five other nurses were honoured with Diamond Jubilee medals by his Honour Col. (Ret’d) the Honourable Donald S. Ethell, Alberta’s Lieutenant Governor at a ceremony in Edmonton. “The Diamond Jubilee Medal is a way to recognize those among us who have made lasting contributions to our communities,” said Lieutenant Governor Ethell. “The deserving health-care professionals chosen by the College and Association of Registered Nurses of Alberta [CARNA] to receive the medal have shared great care, compassion and skill with their fellow Albertans and they stand as excellent examples of the importance of serving the greater good.” Lieutenant Governor Ethell presented the medals with CARNA President Dianne Dyer and Canadian Nurses Association (CNA) CEO Rachel Bard. “These Albertans are leaders in their practice and within the profession, exemplifying pride, passion, caring and expert knowledge,” said Dyer. “Their innovation and hard work inspire us and

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make their colleagues, the more than 33,000 RNs in Alberta, proud to call ourselves registered nurses.”

nursing research and contributes demonstrably to dissemination of nursing knowledge through research.

Canadian Association for Nursing Research (CANR)

Nursing Graduate Student Association (NGSA)

CANR, a CNA interest group, is a national organization that was created to foster research-based nursing practice and practice-based nursing research. Duggleby was selected to receive the 2012 CANR Nurse Researcher Award, which is awarded biennially to an established nurse scientist who has contributed significantly to nursing research. The recipient of the award must demonstrate exemplary leadership in nursing research, which is something that Duggleby displays in spades. “To be singled out by a national group of nurses whose focus is on clinical research, is thrilling,” says Duggleby. “It’s just so wonderful to be recognized in this regard by my peers.”

The NGSA Annual Prize for Excellence is based solely on student nomination, and it’s this fact that causes Duggleby, who currently supervises/co-supervises eight graduate students, to be extremely proud of receiving first runner-up. “To have a graduate student say that I’ve made a difference in their life and their graduate experience is such an honour,” she says. “I think I learn so much more from the students than I do from anybody else.

College and Association of Registered Nurses of Alberta In May Duggleby was recognized by CARNA for her research contribution to the nursing profession in Alberta when she was received the Nursing Excellence in Research Award. “I’m elated because this is such a highly competitive field!” she says. The award is granted to a recipient who demonstrates excellence in conducting

Thankful “I’m really surprised and I feel so blessed,” she says. “I am honoured and thrilled for each award and I share them with my research teams, staff, collaborators, funders and donors of my research chair and the people who participated in the studies. You always hope that you can have an impact and with these awards it really is like someone saying, ‘Wendy, you might be.’” Has she had to add any wall supports in her office so that she can display all of the accolades? With a laugh she replies, “No!”

To learn more about Dr. Duggleby’s program of research, please www.nurs. nx

Navigating through the storm Words: Yolanda Poffenroth

A nurse will experience death in nearly every practice setting; there is no getting around this reality. Among healthcare professionals, nurses represent the largest group in terms of numbers, which means that they are also the point of contact for many families experiencing grief. “Families have said that nurses are often the most helpful in bereavement support because they knew the patient, knew what that end-of-life period looked like and have been through a lot with the family,” said Dr. Lorraine Thirsk (BScN ’00), whose research examines families experiencing grief.

“There’s a lot of obvious suffering when a loved one is dying, and it seemed that grief was one of the biggest areas of suffering,” said Thirsk, an assistant professor with the Faculty of Nursing. “Despite all of our technology and medical advancement, death has not been overcome; it’s a type of suffering that we can never prevent.” When Thirsk began to delve into grief literature during her graduate studies, she noticed that how healthcare providers viewed grief was very different than how it is seen in fields like psychology and theology. “There are still a lot of outdated beliefs about grief, like the Kübler-Ross model, that show up in nursing practice and interventions. This ‘disjoint’ between the in-depth knowledge we have about grief and the more superficial knowledge that appears in nursing resources affects how we approach treating grief.”

Much of the current nursing intervention literature on grief is anecdotal or based on grey literature— not empirical research. “The focus of a lot of nursing literature is ‘what is the experience of this family?’ or ‘what is the experience of the father who loses his son?’ Researchers examine the responses and offer suggestions for interventions, but don’t consistently study the actual interventions to determine their usefulness.”

Tick tock, tick tock... Humans rarely think about their life in terms of days, months or years; rather, most of our past is thought about in terms of ‘eras’ that are marked by significant events (like a death, a marriage, etc.). If we tend to remember the passage of time by eras, why do so many healthcare professionals gauge grief by a calendar? Thirsk was intrigued and began to probe timing in relation grief interventions.

uAlberta | nursing

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Sailing in calm seas “If the family is at the point where their ship is in the storm, so to speak, and they’re just trying to keep things under control and ensure that the basic necessities are covered, it might not be the best time for an in-depth therapeutic conversation about the meaning of life,” said Thirsk. “That’s when they may need instrumental support—like help filling out insurance forms or help with child care—which is exactly what you would do if you were in a storm.”

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Once the family finds ‘calm water’ and is able to reflect and think about charting their next course, they’ll need less instrumental support. Thirsk says that this is when they may need more help from professionals to discuss ‘What are we going to do next?’ or ‘How am I going to carry on?’ Why is this so important? “If we’re using outdated, incorrect theories about grief that aren’t research-based, it’s going to influence how nurses practice with

individuals and family members who are bereaved,” said Thirsk. “Grief is not something that is resolved in a certain amount of time; we need to recognize that grief can profoundly impact people for the rest of their lives and have a lifelong effect on their health.” nx

about grief?

What should you know

She encountered one family member who said she felt like a ‘ship in a storm’ trying to keep her family on an even keel after the sudden death of her husband. “I think that metaphor is more fitting to understanding the type and timing of the grief intervention, instead of just using a calendar,” said Thirsk. There are a range of interventions that nurses can provide, from education and instrumental support to in-depth therapeutic conversations about the meaning of life, spirituality, or suffering. However, what you do in terms of interventions really depends on where the family is at in their grief.

> It’s about the interpretation of the events rather than the events themselves. The nature of the loss might influence the grief (e.g. parent, child, spouse, friend, etc.), but the impact on the person depends on their beliefs or interpretations of the death. It is important to find out how they are making sense of the death. > Using the metaphor ‘a ship in a storm’ might be more helpful to assess where the family is at in their grief, instead of a calendar (e.g. ‘are they having trouble keeping afloat in rough waters’ vs. ‘has it been a year yet’). This determines what you do in terms of an intervention. > There is no right or wrong way to grieve; everyone experiences and copes with grief differently. > Grief is a lifelong and life-changing experience.

Symbols of living in-between Words: Yolanda Poffenroth

Many people with life-threatening illness—such as cancer, chronic kidney disease and HIV—live longer and healthier lives with the support of medical advances and technologies. However the outcomes of treatment are not certain and the possibility of the disease recurring or progressing is very real. What is it like to live with the Re-stor(y)ing Life Within Life-Threatening Illness’ exhibit at the British Columbia Ministry of Health

“There are different things that happen in their lives, but some of the stories that they go back to are almost repeated verbatim— sometimes even the same phrases were repeated years apart.”

Kara Schick Makaroff at the exhibit

uncertainty of life-threatening illness? The experience of living in-between a promise of prolonged life, and the possibility of illness reoccurring and progressing, is often misunderstood, says a team of nurse researchers from the University of Alberta and University of Victoria. People rarely talk about living and dying with these serious illnesses and the spiritual aspects of facing mortality are not a typical part of the care that nurses provide. Thirty-two people diagnosed with life-threatening illness participated in a study conducted by a team of researchers, including Drs. Anita Molzahn (BScN ’80, MN ‘86) and Kara Schick Makaroff, over a period of three years. During one of their four interviews, participants were asked to identify a symbol that represented their illness experience. They shared stories

to explain why they selected a particular symbol and described what the symbol meant for them as an individual living with a serious illness.

Communicating the ‘unsayable’ “Living with a life-threatening illness forced these people to confront the idea that their life is finite and in turn, their hopes and dreams and plans for the future shifted very quickly,” said Schick Makaroff, a postdoctoral fellow with the Faculty of Nursing. “Asking participants to identify a symbol that represented living with their illness opened up another avenue of communication; it allowed them to express something that was knowable to them, but not necessarily expressible through words.” When Molzahn and Schick Makaroff began interviewing people, the initial assumption was that stories around the symbols would shift over time as life and experiences unfolded; however, that rarely happened. “The stories were actually very stable over time, and people keep telling the same stories,” said Molzahn, dean of the Faculty of Nursing. uAlberta | nursing

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What healthcare professionals should know…

In addition to sharing their stories, a number of participants also had messages that they wanted to share with healthcare professionals. Give me a sense of the plan ahead: “Umbrella support from somebody… here’s how it is going to work, you know… nothing more terrifying than going into something like this not knowing.” Carey Relate to me as a human being not as an object or a disease: “I had to know everything that was happening…” for healthcare professionals to share what they were doing “…get down to the patient’s level instead of standing over the patient’s bed.” Kelly Choose your words thoughtfully as they have great impact and will stay with me: “I’ll never forget when he said…” Be aware of and sensitive to the metaphors you use, as not all of us believe our illness is a battle to be fought: “I don’t like the word ‘survivor’ ‘cause I don’t like that, but no, I have a chronic illness that is in remission.” Barbara

Kara Schick Makaroff (l) and Anita Molzahn (r)

“There are different things that happen in their lives, but some of the stories that they go back to are almost repeated verbatim—sometimes even the same phrases were repeated years apart.” Both Molzahn and Schick Makaroff were surprised that most of the symbols selected represented the participants lives as a whole—something that encompassed all of their life and who they were as a person. “What we saw were personal objects, family photos, clothing, and pieces of music with powerful stories behind them,” said Molzahn. “What we didn’t see was a dialysis bag or medications.” In fact, Schick Makaroff notes that one individual didn’t even identify a symbol, he talked about a hope that he had in his life. “He wanted to buy a Jeep and a trailer so that he could have vacations with his partner and his dog; the symbol was something in his mind and was something that he really wanted to do. Unfortunately he passed away before they were able to buy the Jeep.”

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Overall, it’s the human connection that matters, for example take time to sit with me, honour my vulnerabilities, and put kindness first. “You feel very vulnerable and you feel you’re only a number – I was 14-8-64 – that’s all you are at the Institute because it’s so busy.” And, “Dr. C. was the doctor that really worked with me through the process. And she spent hours, oh yeah, hours educating me. Like I have a PhD in the disease.” Louise

Feeling connected with others “People want to feel connection with others when they’re going through something as incredibly challenging as facing their own mortality and living with illness on a day by day basis,” said Molzahn. Participants from the study were very interested in learning what they shared in common with others that lived with those experiences, and what was unique to them. The research team developed a set of brochures based on the participants’ stories which are for both healthcare practitioners and other people living with life-threatening illnesses. In addition, an exhibit based on the project was created for the public and was displayed at the University of Victoria’s Maltwood Gallery and the British Columbia Ministry of Heath. Narratives from the participants and poems produced by the research team accompany the stories of these individuals living with a life-threatening illness. The symbols and narratives

highlight how living with a life-threatening illness is much more than a ‘medical story.’ Schick Makaroff found that the exhibit and the study itself struck a chord with her, and thinks that many other people will feel similarly. “A lot of people know someone well who has a serious illness—for me it’s my dad. In some ways I have lived my own experience and process of knowing someone intimately who is living with a life-threatening illness.”

Learn more (and access electronic versions of the brochures) at www. nx This research was completed with colleagues from the University of Victoria including Drs. Laurene Sheilds, Anne Bruce, Kelli Stajduhar and doctoral candidates Rosanne Beuthin and Sheryl Shermak. Dr. Schick Makaroff’s post-doctoral fellowship is funded by the KRESCENT program (joint CIHR, Kidney Foundation, and Canadian Society of Nephrology Kidney Research Training Program).

Heart disease is everyone’s business “Heart disease and heart health is relevant to everyone,” says Alex Clark, a professor and associate dean (research) in the Faculty of Nursing. The roots of the chronic heart problems that often cause heart attacks and heart-related chest pain and illnesses in later life have their roots in the behaviours that are established over a life time–even in our teenage years. “We tend to think we will never get old and that the effects of smoking, high cholesterol or a lack of physical activity on the heart will never catch up with us,” notes Clark. Unfortunately, although more and more Canadians are living longer, heart disease is still Canada’s largest cause of premature death and disability. This holds for both men and women, who are actually at the same risk over their lifetime of heart disease. One of the most interesting parts of Clark’s research is his work identifying particular healthy behaviours can delay or even prevent heart disease. “These benefits can happen whether we are older or younger, male or female and irrespective of race, income or where we live,” he explains, “and there can be noticeable improvements almost right away.” Research has shown that the effects of exercise and weight reduction on blood pressure happen in days and weeks—not months. In fact, the hearts of people well into their 90’s will benefit from physical activity after only about half a dozen periods of sustained exercise. Even after people have had heart attacks, if they stop smoking,

their heart disease risk can be similar to comparable non-smokers in two to three years. “In this way, the prevention of heart disease is everyone’s business too,” adds Clark, “and it is never too early or too late to start making heart healthy choices.” Of course, if only it were that simple. “The reality is, we often know what we should do to have healthier hearts, but we don’t make that healthier choice. When we’re tired, the television can be more attractive than the treadmill—the fries more pleasing than the fruit—and the talk literally trumps the walk.” So then, what can we do to have a healthier heart? A lot of what helps increase healthier choices is not New Year’s resolutions or expensive equipment, but rather small changes to numerous areas of our daily lives. “While it’s great that some people run marathons, do triathlons and go to boot camp, a lot of us don’t have the time or inclination to do this.” Clark notes that we can all find time to do something if we make it a priority and think about good ways to better integrate heart health into our routines. There are many simple and easy tricks you can do to move more every day explains Clark. “Choosing the stairs over the elevator is a great start. When

Tips for a HealthY Heart • Take a brisk walk outside or inside most days–shopping malls are perfect in winter. • Eat more raw fruit and vegetables • Eat less fatty and very sweet foods and substitute in healthier equivalents, like choosing chocolate mousse over chocolate. • Taste your food before adding salt • Substitute fresh or dry herbs for salt in your cooking the weather is good get off the bus one stop early, or park your car far away from the store entrance—where it is actually easier to park!”

While healthier choices benefit the health of the heart, they also assist with the well-being of the brain. “Many of us often feel down, busy or stressed,” says Clark, “but healthier choices also have significant benefits for our mental health and well-being.” Clark’s research, conducted with graduate student Todd McClure, has revealed that heart healthy behaviours reduce anxiety and improve psychological well-being. You might not think it, but anxiety and depression are also risk factors for heart disease, so reducing these factors not only makes us feel better mentally, it also improves heart health. “In this way,” Clark adds, “both the head and the heart tell us that these behaviours are good for us, so whatever the weather, however old or young we are, the time to start making heart healthier choices is today.” nx uAlberta | nursing

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The 2013 Annual Alumni Dinner was held on May 7 in Calgary. Nearly 70 alumni—who graduated between the years of 1944 and 2012—came out to mingle!

Class of January 1953

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Class of Septemb

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Generations (L to R) - Michelle Hartwick (granddaughter; BScN ‘02), Jayne Collett (granddaughter; BScN ‘12), Greta Thompson (Dip ‘44), Valerie Kangles (daughter; BScN’74)

Dean Molzahn with alumnae

Upcoming Alumni Events Reunion Weekend Open House and Learning Resource Centre Tour Date: Saturday, September 28 Time: 10 a.m. – 12 p.m. Light refreshments will be served. Faculty of Nursing alumni are invited to join a tour of the Learning Resource Centre—featuring the simulator labs—for class photos, light bunch and an opportunity to visit with classmates, alumni and faculty.

Class of September 1959

2nd Annual Nursing MN & PhD Alumni Reunion Date: Saturday, September 28 Time: 4 p.m. - 6 p.m. Event is reception style. Light food will be served. Faculty of Nursing invites its graduate program alumni to mix and mingle with fellow alumni, faculty and staff at the Annual Nursing MN & PhD Reunion.

ember 1960 Class of Sept

Location for both events: Level 3, North Atrium Edmonton Clinic Health Academy (ECHA) 11405-87 Avenue University of Alberta

Class of September 1966

Nursing graduates at an alumni event in Phoenix in February 2013

For more information, or to RSVP to either event, please contact Fiona Wilson at 780.492.9171 or email

How you made a difference – Christina’s story Christina recently completed her BScN, and it’s because of amazing donors like you that she was able to make her dream a reality… “I was accepted into the Faculty of Nursing After-Degree BScN Program at around the same time I found out I was pregnant with my second child. My husband and I were happy to be able to have our children close together, although the timing presented some challenges for my education. I began the program part-time while continuing to work full-time. Once my baby was born I resumed full-time studies with the Winter 2011 cohort. My husband had been struggling with mental health issues prior to me beginning the program. His illness became more acute as my education progressed, and by the second semester he was unable to work. Shortly after I had to find full-time daycare for my children, both under the age of two, as my husband was unable to care for them. Given the long-term nature of his illness, I felt that the future of my family was best served by continuing in my studies. I applied for more student loans and every scholarship and bursary I could find, to provide for my family and pay for my tuition. With seven months left in my program, my husband’s mental health had deteriorated to the point where it was unsafe for us to continue living as a family and I made the decision to leave with the children. It was only through the support of the Faculty of Nursing and its generous donors that I was successful in being able to complete the BScN program. I am delighted to say that I am currently working in a permanent full-time position in critical care—every day is both rewarding and challenging. Thank you—it’s because of your support that I’m able to walk across the Jubilee Auditorium stage on June 10, 2013 to receive my degree.” nx

What does the Dean’s Discretionary Fund support? It helps students in financial need by providing emergency funds to cover things like: • Living expenses, like rent and food

• Tuition • Books

As well, the fund also helps cover the cost of attending conferences.

Name _________________________________________ Phone (________ ) _______________________________ Email__________________________________________ Address _______________________________________ ______________________________________________ Province_______ PC_____________________________ I would like to make a donation to support a:

❑ Bursary ❑ Scholarship ❑ Dean’s Discretionary Fund ❑ Nursing Research Chair in Aging and Quality of Life ❑ Other. ❑ I would like information on how to leave a legacy gift to the U of A.

❑ I have made a provision for the U of A in my estate plan (will, trust, etc.).

❑ I am interested in learning more about making a gift of stock

❑ I would like to be contacted about making a donation. I want to show my support of the FoN now with a total gift/pledge of $_________________­­­­­­­­­­­­­­­­­­­­­­­­__ ­­­­­­­­­­­­­­­­­­­­. If you wish to send your donation by cheque, make your cheque payable to the University of Alberta.

❑ VISA ❑ MasterCard

Card No

_______/________/_______ Expiry ___/___ Date _____________ Signature__________________ Make your gift online supporting the Faculty of Nursing at You will receive your electronic charitable receipt the same day.


Return undeliverable Canadian addresses to: Faculty of Nursing Level 3, Edmonton Clinic Health Academy 11405 87 Avenue, University of Alberta Edmonton, Alberta, Canada T6G 1C9 Ph: 780.492.9171 Fax: 780.492.2551 E-mail: Website:

Making a difference...

Elly de Jongh, one of 315 contributors to the Faculty of Nursing’s Chair in Aging and Quality of Life, with Dr. Wendy Duggleby (MN ‘90), the first holder of the chair.

To help a student in need or create a gift that keeps on giving, please contact: Jessica Twidale | 780.492.5804 | uAlberta | nursing | SPRING 2013

uAlberta | nursing  

Spring 2013 issue of the University of Alberta Faculty of Nursing alumni magazine.

uAlberta | nursing  

Spring 2013 issue of the University of Alberta Faculty of Nursing alumni magazine.