Volume 14│Issue 2│Fall/Winter 2023
Hello, outstanding team members! We had taken a break in publications but are back with this,
our Winter edition of Within REACH. As we bring 2023 to a close, I wanted to reach out and say thank you for all you do for our patients, the community, and each other. Our organization is great because of the staff and employees who give their all every day to ensure quality care and patient safety. Nowhere has this been more evident than in our recent Magnet Survey! The Magnet Survey took place between December 4th through the 7th. Many of you took part in the meetings with surveyors as well as discussions during the breakfast and lunch sessions, and the unit tours. The surveyors were overjoyed with these discussions, our stories, and the general demonstration of kindness and knowledge that we provided them. I hope you feel the same organizational pride that I feel having participated in this process! The Office of Nursing Research has undergone a change in 2023. New to the Office of Nursing Research and to Within REACH is Kathy Cook, Administrative Coordinator. Kathy came to us in May of 2023 to take the reigns from Beth Assenat as Beth entered retirement. Kathy comes to us from CVI, where she worked as a Department Secretary. She spent many years in Payroll at Carilion in her previous work life. Kathy attended Virginia Western Community College and Hollins University. Kathy is married and has two daughters and one granddaughter. She and her husband enjoy hosting dinner parties with friends and family and traveling (ask her about her recent trip to Alaska). If you haven’t already, please consider stopping by the Nursing Administration Suite on 1E to say “hello” and give her a warm welcome to the team. We want to remind you that Within REACH submissions are accepted on a rolling basis and that we accept stories and articles related to article critiques, human interest stories, literature reviews, evidence analysis, research, quality improvement, and proposed state or national legislation. Basically, any story that aligns with our REACH professional model of practice is appropriate for peer review and publication. We would especially like to hear your impressions of the Magnet Survey! What did it mean for you to participate in the meetings or discussions with surveyors? Again, thank you for all you do and hope your New Year is off to a fantastic start!
Carilion Clinic Roanoke Campus
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ARTICLES/NOTIFICATIONS 1
Editorial — Chris Fish-Huson, PhD, RN, CNE—Editor-in-Chief
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Using a Combined Implementation of Stress First Aid and the 4-A Model to Improve Workplace Wellness: A Pilot Quality Improvement Study Katelin Walls, MSN, RN-3, CNL, CCRN and Suzanne Beels, MSN, RN, AGCNS-BC, CCRN
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Legislative Corner Katherine Le, BSN, RN
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Impact of Mindfulness-Based Stress Reduction (MBSR) Programs on Perceived Stress: An Integrative Review (Part II) Margaret Chambers, DNP, RN
RECOGNITION/EVENTS 3 CAP Advancements Fall 2023
26 See Where Our Nurses Have Traveled
4 2023 TEACH Award / Rising Star Award
to Present Their Work
5 Shine Awards
27 Virtual Journal Club
11 2023 Peaks Graduates
28 External Conference Information
12 WOW Wall—Curiosity, Compassion 13 WOW Wall—Collaboration, Commitment 16 Citations & Recognitions 17 Basic Research Classes 2024
Carilion Nursing Research Editorial Board: Chris Fish-Huson, PhD, RN, CNE - Editor-in-Chief Reviewers
Nancy Altice, DNP, RN, CCNS, ACNS-BC Desiree Beasley, MSN, RN, CCNS, CCRN-K Sarah Browning, DNP, RN-BC Charles Bullins, DNP, RN, AGACNP-BC Sarah Dooley, MPH, BSN, RN Troy Evans, MSN, RN, CCRN, NHDP-BC, NEA-BC
Cindy W. Hodges, MSN, RNBC, FCN James Ingrassia, MSN, RN Pam Lindsey, MSN, RN Lauren Miley, BSN, RN, PCCN Laura Reiter, DNP, RN, CCRN, CNRN Cindy Ward, DNP, RN-BC, CMSRN, ACNS-BC
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CAP Advancements Fall 2023 RN 2 Heather Brogan, BSN, RN Jordan Duffy, BSN, RN Chastity Fontaine, RN, CEN Martha Gibbs, RN, PCCN Susan Hornsby, BSN, RN Jamie Jamison, BSN, RN, CCRN Emory Jones, BSN, RN Katherine Le, BSN, RN Alicia Lee, RN, MEDSURG-BC Amanda (Nikki) Mitchell, BSN, RN Heather Moreno, BSN, RN, CCRN Kristen Price, BSN, RN Tracy Scruggs, RN Jessica Shrewsbury, BSN, RN Douglas Stanfill, BSN, RN, CCRN Kristy Waldron, BSN, RN Brittany Williams, RN RN 3 Justine Bragg, BSN, RN, CCRN Stephanie Defilippis, BSN, RN-3, OCN Sara Grimsley, BSN, RN, PCCN Ann Jiminez, BSN, RN, CCRN, CEN Christy Rodgers, BSN, RN, CMSRN Katelin Walls, MSN, RN, CCRN, CNL RN 4 Rebecca Dampeer, BSN, RN, CCRN, CFRN Sandra Hubbard, BSN, RN, TCRN Sara McCaffrey, BSN, RN, CCRN Aimee Wooldridge, BSN, RN, CCRN, CPN
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Congratulations to the 2023 TEACH Award Recipients
Rising Star Award Rachel Altizer, BSN, RN, CCRN Center for Simulation, Research, & Patient Safety
The Rising Star award recognizes emerging leaders in health professions education whose teaching experience demonstrates ongoing and promising growth in contribution to teaching and increased levels of teaching leadership and responsibility. Recipients of this award have at least one year of teaching experience and are in no more than their fifth year of continuous service as a faculty member. This award is intended to acknowledge faculty members who show extraordinary potential at the beginning of their academic careers.
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Congratulations to Our 2023 Shine Award Recipients
President’s Award:
Carl Cline, VP Community Hospital
Courage Award: Kim Briggs Commitment Award:
Christine Riddell Compassion Award: Bethany David and Shelly Henson Collaboration Award: Sickle Cell Collaborative Clinic Mandy Atkinson, MD, Christopher Blake, Brittany Belcher, Bill Fintel, MD, Vera Hollen, Sunil Jain, MD, Jeri Lantz, MD, Karen Marable, NP, Joshua Morales, MD, Shyam Sundhar Odeti, MD, Suresh Kuar Ponnada, MD, Lisa Simpson, NP, Angela Venuto-Ashton, MD.
Here is the link for all the 2023 Carilion Shine Awards: https://issuu.com/carilionclinic/docs/shine-2023-book?fr=xKAE9_zU1NQ
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Using a Combined Implementation of Stress First Aid and the 4-A Model to Improve Workplace Wellness: A Pilot Quality Improvement Study by: Katelin Walls, MSN, RN-3, CNL, CCRN & Suzanne Beels, MSN, RN, AGCNS-BC, CCRN Project Aim The purpose of the CVI Retention Committee Quality Improvement (QI) project is to determine if using the Stress First Aid (SFA) model will decrease the impact of stress and burnout for employees within CVI. The CVI Retention committee aimed to improve overall well-being and sense of moral distress as measured by the modified MMD-HP and SFA ProQOL survey. Current State of Knowledge Review of Literature The CVI Retention Committee utilized the Carilion Schwartz Center (SC) as a resource to jumpstart this QI project. The SC started SFA education at Carilion. The CVI Retention Committee also used the Carilion Library and reviewed the American Association of Critical Care Nurses (AACN) professional organization to expand our literature review. The team included literature written within the last ten to fifteen years. Moral Distress/ Moral Residue Moral Distress is defined as "a phenomena that occurs when nurses cannot carry out what they believe to be the ethically appropriate action because of internal (personal) or external (institutional) constraints" (Epstein & Hamric, 2009). Initial distress occurs the moment a situation unfolds. Reactive distress, or moral residue, are the lingering feelings after the acute phase. Moral residue is more challenging to characterize because it does not have a time frame or pattern, but it does exist and is experienced through feelings of anxiety, depression, professional avoidance of patients, or leaving the profession entirely. Moral Residue Crescendo is the interaction between moral distress and moral residue (Epstein & Hamric, 2009). Once a healthcare professional experiences a morally distressing situation, they feel a high level of moral distress. After some time, the moral distress feeling de-crescendos, or decreases, until the healthcare professional experiences another morally distressing scenario (in which moral distress spikes again). However, the healthcare professional is never able to decrease back to their baseline moral distress level (Epstein & Hamric, 2009). Resilience Many interventions have been suggested to reduce or decrease moral distress such as educational interventions, enhancing the ICU environment with ethics committees, include debriefings after morally charged events, adding multidisciplinary rounding, and assisting individuals in building stronger coping skills in work environment (Abbasi, Ghafari, Shahriari & Shahgholian, 2019). These types of interventions promote resiliency through mindfulness-based stress reductions, self-reflections, cognitive flexibility, and improved communication.
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MMD-HP Measure of Moral Distress- Healthcare Professionals (MMD-HP) scale. This scale is an adaptation of the Moral Distress Scale- Revised (MDS-R). The MMD-HP scale includes 27 items and is usable by all healthcare professionals in any setting. SFA ProQOL Stress First Aid Professional Quality of Life scale. This scale is intended for any “helper” (medical professional, first responder, service workers, etc.). It is utilized as a screening tool for “helpers” to measure the impact of providing care on their personal wellbeing, positive or negative (Watson & Westphal, 2020). The
higher the reported score, the greater the level of stress/trauma the individual experiences (Watson & Westphal, 2020). Schwartz Center Rounds Stress First Aid The foundation for the SFA model is the 7 C’s- Check, Coordinate, Cover, Calm, Connect, Competence & Confidence. Stress First Aid, the 7 C's, is a framework that healthcare workers can utilize to improve recovery from stress reactions (Watson & Westphal, 2020). The model aims to help us identify stress reactions in self and amongst others in a continuum, and to help reduce the long-term effects/problems of untreated stress. The model focuses on “five evidence-informed factors that help people recover from stress and adversity” (The Schwartz Center, 2022). The factors include safety, calm, connection, self-efficacy, and hope. AACN 4- A Model: American Association of Critical Care Nursing 4-A Model. Ask, Affirm, Assess, & Act To improve healthcare workers professional life by decreasing and alleviating moral distress by utilizing the 4 A's (Savel & Monroe, 2015). 1. Ask-the goal is to be aware of moral distress' presence 2. Affirm - validate the feelings and perceptions of the individual or coworkers. 3. Assess- the goal of this stage is to prepare an action plan. 4. Act-create and implement an action plan to preserve the individual's integrity and authenticity. The acting stage will vary by individual. Description of Population & Benefit Employees of CVI Surgery, all experience, skill, education, and age levels will comprise the population for this project. Please refer to the project aims; increase “this facility helps me deal with stress and burnout” score, decreased moral distress & improved sense of well-being and resilience. IRB Determination The Carilion Clinic Institutional Review Board (IRB) has determined that the above reference project does not meet the definition of human subjects’ research as outline in 45 CFR 46.102(d), and therefore does not require IRB oversight or approval.
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This determination has been made because the intent of your study is not to contribute generalizable knowledge but rather is designed to providing coping and resilience skills to improve overall wellness of the nursing staff to decrease turnover and improve job satisfaction at Carilion. As such, the study qualifies as as a quality assurance/quality improvement activity and not as human subject’s research. Methods & Procedures April of 2022 pre-project surveys were distributed to participating departments (MMD-HP and SFA ProQOL). May 27th, 2022, Carilion Schwartz Center SFA education was launched on Cornerstone for all nursing staff and education was provided on the AACN 4-A Model. CVI Retention committee held their first (stationary) town hall June 3rd, 2022. CVI senior directors, Chaplains, Employee Assistant Program (EAP), Carilion Wellness, Principal (retirement education and information), Schwartz Center Rounds, Grief Counseling, Morningside Urban Farm, and the TRUST team participated in Town Hall and provided education about each organization/entity for staff to attend. The purpose of the Town Hall was to disseminate further education about the SFA model and the 4 A Model, educate nurses about Carilion resources, and to create an environment where nurses’ feelings were validated. CVI Retention Committee also began introducing monthly Newsletters (CV-I Care Newsletters) in July 2022 which incorporate education and highlighted events in the Roanoke Valley and Carilion resources that promote resiliency, wellness and decrease moral distress. Assessment & Data Collection Since the beginning of this project in April 2022, the CVI Retention Committee has since created monthly newsletters, re-administered MMD-HP & SFA ProQOL surveys every 6 months and have hosted quarterly mobile town halls where team members round to every CVI unit with therapy dogs, snacks, and SFA and moral distress education. Findings & Discussions In the initial Survey (Survey 1) had 104 nursing respondents, whereas Survey 2 had 80 respondents. “MMD-HP Frequency” mean score is 36.9 for Survey 1 and for Survey 2 is 29. The p-value for “MMDHP” Frequency is .016 which is statistically significant, suggesting that the educational support and Town Halls has lowered moral distress frequency amongst nursing staff. Survey 1 mean “level of distress” score is 55.5 while Survey 2 is 54.25. The p-value for “the level of distress” is 0.7945 which is not statistically significant. While there are limitations this group is aware of, the CVI retention committee still recognizes that the level of distress is lower in Survey 2 than Survey 1, indicating that there has been improvement in moral distress levels amongst nurses with education efforts and Town Hall events.
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MMD-HP Frequency p-value
0.16
“Level of Distress” p-value
0.7945
In Survey 1, 32 out of 108 respondents reported “No-I have never considered leaving a clinical position due to moral distress” and in Survey 2 out of 80 respondents, 36 also reported not considering leaving. In Survey 1, 44 out of 108 respondents reported “Yes-I considered leaving but did not leave a clinical position due to moral distress” and Survey 2, 34 out of 80 reported considering leaving but had not left. Lastly, 22 out of 108 respondents in Survey 1 reported “Yes-I have left a clinical position due to moral distress”, and 11 out of 80 reported they had left a position due to moral distress. While the pvalue for this section in the survey results as 0.1798, the team recognizes that education and Town Hall events has decreased nursing staff from considering leaving their occupation and profession due to moral distress. Survey 1
Survey 2
(108) 32
(80)
“No-I have never considered leaving a clinical position due to moral distress.” “Yes-I considered leaving but did not leave a clinical position due to
44
34
moral distress.” “Yes-I have left a clinical position due to moral distress.”
22
11
p-value for considering leaving a profession due to moral distress
36
0.1798
Limitations of this project include not having the same sample size for Survey 1 and Survey 2. These surveys were anonymous, and the team was not able to ensure that the same nurses participated in both surveys. Employee attrition rates, travel nurses, new hires and patient unit acuity impacted survey completion. Another limitation of this survey that may have impacted results is unit acuity. Lastly, some surveys were not fully completed, which impacted data collection.
Conclusion This QI project lends credence to the benefits of educational and interactive (Town Hall) interventions. The team successfully provided education about moral distress to nursing staff in CVI, however, there is room for improvement through additional educational opportunities, town hall events, and surveying cycles. Morally distressing situations are hard to eliminate in totality. While the team did not achieve statistical significance in all surveying criteria, current literature proposes that prompt identification of nurses’ moral distress and appropriate resource engagement can both decrease moral distress levels and frequency.
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The team is currently re-surveying nursing staff to evaluate efficacy of interventions a year after project implementation. This QI project has improved how nurses view moral distress, how they alleviate their moral distress, and to become better self-stewards. The team continues to host quarterly Town Hall’s, produce monthly newsletters with education about moral distress and SFA, and continues to promote resiliency in nursing staff. Reference List Abbasi, S., Ghafari, S., Shahriari, M., & Shahgholian, N. (2019). Effect of moral empowerment program on moral distress in intensive care unit nurses. Nursing Ethics, 26(5). Retrieved from 10.1177/0969733018766576 Epstein, E. G., & Hamric, A. B. (2009). Moral distress, moral residue, and the crescendo effect. The Journal of Clinical Ethics, 20 (4). Epstein, E. G., Whitehead, P. B., Prompahakul, C., Thacker, L. R., & Hamric, A. B. (2019). Enhancing Understanding of Moral Distress: The Measure of Moral Distress for Health Care Professionals. AJOB empirical bioethics, 10(2), 113–124. https://doi.org/10.1080/23294515.2019.1586008 Kidd, M., Grove, K., Kaiser, M., Swoboda, B., & Taylor, A. (2014). A new patient-acuity tool promotes equitable nurse-patient assignments. American Nurse Today. 9(3). https://www.myamericannurse.com/wp-content/uploads/2014/03/ant3-Workforce-Management-Acuity304.pdf Molazem, Z., Tavakol, N., Sharif, F., Keshavarzi, S., & Ghadakpour, S. (2013). Effect of education based on the “4A Model” on the Iranian nurses’ moral distress in CCU wards. Journal of Medical Ethics and History of Medicine, 6(5). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3740193/ Samoya, A. (2019). Creating healthy work environments: An evidence-based toolkit for nurses. Retrieved from https://www.aacn.org/~/media/aacn-website/nursing-excellence/healthy-work-environment/ hwetoolkit.pdf?la=en Savel, R. H., & Munro, C. L., (2015). Moral distress, moral courage. American Association of CriticalCare Nurses, 24 (4). Retrieved from http://dx.dol.org/10.4037/ajcc2015 Stamm, B. H. (2022). Professional quality of life: Compassion satisfaction and fatigue (ProQOL). Retrieved from ProQOL.org The Schwartz Center. (2022). What is stress first aid? Retrieved from https://www.theschwartzcenter.org/ stress-first-aid-private/ Ulrich, B., Barden, C., Cassidy, L., & Var-Davis, N. (2019). Critical care nurse work environments 2018: Findings and implications. Critical Care Nurse, 39(2), 67-84. Downloaded on 6/25/2020 from http://aacnjournals.org’ccnonline/article-pdf/39/2/67/116850/67 Watson, P., & Westphal, R.J. (2020). Stress First Aid for Health Care Workers. National Center for PTSD.
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Curiosity! May is Stroke awareness month. The Stroke Program team made rounds to several CRMH units to interact with staff, review stroke education and discuss signs and symptoms of a stroke. Along with education, staff received coffee and fun giveaways to remind them how to spot a stroke and call for help. Many thanks to Ellen Harvey, D.N.P., C.N.S., Stroke Program Quality Improvement Facilitator Chrystal Wilson, and Stroke Specialist Pam Flinchum, R.N., for providing interactive education in a creative and fun way. Learn about the signs of stroke at CarilionClinic.org/BeFast.
Compassion! Heather Simpson RN was the room circulator for my OR day this week. When our third case of the day was about to be put on hold due to staffing shortages for the end of the day, Heather volunteered to stay so that the case did not have to be postponed or rescheduled. This patient is a special needs child who has been waiting for GA for dental care for almost two years, and was already rescheduled from earlier this week due to anesthesia shortages. Their family lives several hours away and relies on Medicaid transport, so many barriers to care would have to be addressed to reschedule them. Thank you again Heather for your commitment and compassion!
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Collaboration! Recently, the inpatient units at CFMH began piloting post-discharge call backs to any patient discharged to home from the hospital. During one of these calls, Phyllis Dalton, RN received a question from a patient regarding one of her medications. The patient did not understand the instruction to check “SBP”. Phyllis explained to the patient that this was the top number of her blood pressure. Phyllis then went back to the providers and collaborated with them to change the wording in these instructions to be more easily understood by patients.
Commitment! We continue work to destigmatize substance use disorder among hospital staff. Congratulations to Catherine Lane, LCSW, and team members Laura Fondy, RN, Tammy Mitchell, RN, and Kimberly Hunt, Peer Recovery Specialist, as winners of the Week of the Nurse Art and Science Showcase poster. Exemplary work was recognized for the positive impact on patient care. Learn more about the power of words in this StigmaAddiction Language Guide.
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By: Katherine Le, BSN, RN The full name of legislation: H.R. 2407- Nancy Gardner Sewell Medicare Multi-Cancer Early Coverage Act. The bill sponsor is Rep. Arrington, Jodey C. This national bill was established on March 30, 2023. The purpose of this bill is to amend title XVIII of the Social Security Act to provide for Medicare coverage of multicancer early detection screening tests that have been approved by the Food and Drug Administration. The current screening tests include but not limited to: physical exam and history, Laboratory tests such as blood, urine, or other bodily fluids, imaging procedures, and genetic tests. Cancer is the leading cause of death in the United States. The goal of screening tests is to diagnose cancer at its earliest stage before symptoms even appear. The earlier we can detect cancer, the greater the likelihood that treatment can be more effective, which will lead to less invasive treatments. Detecting cancer early on leads to a better prognosis. According to the National Cancer Institute’s Surveillance, 71 percent of the 600,000 cancer deaths each year are related to cancer without a Medicare-covered early detection test (“Nancy Gardner Sewell Medicare Multi-Cancer Early Detection Screening Coverage Act”, 2023). There are modifiable and non-modifiable risk factors that can cause cancer. Modifiable risk factors include diet, exercise, alcohol use, and smoking. According to CDC (2022), having obesity is linked to a higher probability of getting at least 13 different kinds of cancer versus an individual with a healthy weight. Another modifiable risk factor is alcohol use. According to CDC (2022), when an individual consumes alcohol, the body breaks down a chemical called acetaldehyde. This chemical will damage the DNA in a human body and prevents the body to fully repair the damages. When DNA is damaged, a cell can begin to develop out of control, which leads to a cancer tumor. Nonmodifiable risk factors: age, gender, and genetics. Age is an example of leading non-modifiable risk factor of cancer. Approximately 1,000,000 Medicare beneficiaries will be diagnosed with cancer this year, and as the median age for cancer diagnosis is 66 years of age. It is essential that this age group has access to free multi-cancer screening because of the high-risk factor they could develop cancer and be asymptomatic. The incidence rates for cancer overall increases steadily as age increases. For
instance, age groups under age 20, there are fewer than 25 cases per 100,000 people. About 350 per 100,000 people among those aged 45-49. For example, the median age at diagnosis is 62 years for breast cancer, 67 years for colorectal cancer, 71 years for lung cancer, and 66 years for prostate cancer (National Cancer Institute,2021). Screening tests in the current law are limited to 5 cancers: breast, colorectal, prostate, cervical and lung cancer. Currently, patients who have Medicare often have out-of-pocket expenses for screening exams that may make them non-compliant to follow preventive treatments. Existing Medicare- coverage early detection tests, such as mammograms and colonoscopies, have led to a significant reduction in mortality (“Nancy Gardner Continued on next page
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Sewell Medicare Multi-Cancer Early Detection Screening Coverage Act”, 2023). However, researchers are developing clinical trials to develop multi-cancer early detection blood-based tests. The purpose of these tests is the ability to screen for many cancers at the same time, including rare cancers. With one blood sample, we are currently able to screen for more than 50 cancers. The blood sample is tested for certain pieces of DNA or proteins from cancer cells. Benefits of the multi-cancer early screening include patients will be able to be compliant to their scheduled appointment. Mammograms and pap smears are both screening tests that are used to detect breast cancer and cervical cancer. These screenings can be painful and therefore patients may not be able to tolerate the pain and refuse to do the screening exam. X-rays can expose the patient to radiation. Therefore,
multi-cancer screening may be able to detect those cancers rather than the patient have to do invasive screening tests (National Cancer Institute, 2021). Many screening tests have the risk of having false-positive results, which can be stressful and expensive for the patient. Studies have also shown that false-positive results are not common with multi-cancer screening tests. Overall, multi-cancer screening exams would have a positive impact on healthcare. By a simple blood draw, it can potentially diagnose not just one cancer but multiple cancers at once instead of the patient having to go through rounds of different invasive screening tests. This exam will be an advantage because it allows us to diagnose cancer promptly for patients who are asymptomatic (“Nancy Gardner Sewell Medicare Multi-Cancer Early Detection Screening Coverage Act”, 2023). Cancers that are detected while still localized can be treated more effectively and have a greater survival rate compared to cancer that has metastasized.
References Centers for Disease Control and Prevention. (2022, July 13). Obesity and cancer. Centers for Disease Control
and Prevention. https://www.cdc.gov/cancer/obesity/ H.R.2407 - 118th Congress (2023-2024): Nancy Gardner Sewell Medicare Multi-Cancer Early Coverage Act. (2023, March 30). National Cancer Institute. (2021, March 5). Risk factors: Age. Age and Cancer Risk. https://www.cancer.gov/ about-cancer/causes-prevention/risk/age
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July 2023 - December 2023 (& past presentations not noted prior to this edition) Whitehead, Phyllis, PHD,APRN, ACHPN, PMGT-BC, Hubbard, S., O’Connor, K., Brogan T., Lockhart, E., & Harvey, E. September 2023. Nurse FNAP, FCNS, FAAN Selected as one of the Top Palliawork-related anxiety in the intensive care unit tive Medicine Specialist in the Top Docs of 2023 and aromatherapy: A blinded randomized con- sponsored by The Roanoker magazine. trolled trial. Podium presentation. 2023 Virginia Beels, Suzanne, MSN, RN, AGCNS-BC, CCRN SelectNurses Association, Virginia Nurses Founda- ed as a Gold Well-Being Hero Individual Award wintion (VNS/VNF) Fall Conference, Forging a ner. The CVI Surgery Retention Committee was also Successful Future for Nursing. Westfields honored with a Department Award. Marriott, Chantilly, VA. Virginia’s 40 under 40 by the Virginia Nurses Association: (Winners) Bless, M., Jenkins, F., Raju, A., Downing, L. August 2023. Superficial femoral artery aneu- Danielle Bona, MSN, RN, CCM Charles Bullins, DNP, RN, AGACNP-BC rysm as a result of Peripheral Fibromuscular Dysplasia. Oral case study presentation. 2023 Macon Coleman, DNP, RN, NEA-BC Society for Vascular Ultrasound Annual Con- (Trailblazers) Wrenn Brendel, DNP, RN, NEA-BC ference, Hyatt Regency, New Orleans, LA. Lisa Dishner, MSN, MHA, PMH-BC, NEA-BC PRS *Won Case Study Presentation Award Victoria Samarasinghe, MSN, RN Katelin Walls, MSN, RN, CNL, CCRN
Bath, J., Downey, W., Harvey, E., and Locklear, T. October 2023. Impact of a trauma boot camp on nurse knowledge, skills and confidence, and frequency of unplanned intensive care admissions. [Oral presentation]. Teaching Excellence Academy for Collaborative Healthcare (TEACH) Education Day. Roanoke, VA. Slusser, C. & Collins, L. November 2023. INVIGORATE: Nursing leadership empowerment - A collaborative program to deepen the people skills of nurse leaders in our organization. [Oral Presentation] 11th edition-World Congress on Nursing Education & Practice. San Diego, CA. Slusser, C. & Collins, L. November 2023. INVIGORATE: Nursing leadership empowerment - A collaborative program to deepen the people skills of nurse leaders in our organization. [Oral Presentation] The National Center for Healthcare Leadership. All Member Conference. Westin River North. Chicago, IL.
Contact Chris FishHuson with your ideas so that we can find funders to support you!
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CLASSES & EVENTS Basic Research for the Healthcare Professional NR-CE333L
January 11 . . . . 4 - 8pm April 18 . . . . 8a - 12 noon June 20* . . . . 8a - 12 noon August 15* . . . . 12 - 4pm September 19 . . . . 4 - 8pm October 17 . . . . 12 - 4pm December 19 . . . . 8a - 12noon
Additional nursing research classes have been added for 2024
Go to our hub on Inside Carilion for additions to our Nursing Research Classes schedule for 2024. https://insidecarilion.org/hub/nursing-research-evidence-based-practice/ all-activity/nursing-research-classes
*Classes will be held in MED ED Classroom 2 (all other Basic Research classes will be held virtually)
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Impact of Mindfulness-Based Stress Reduction (MBSR) Programs on Perceived Stress: An Integrative Review (Part II) Margaret Chambers, DNP, RN Part One of this review outlined the significance of the practice problem, the search protocol, and inclusion/exclusion criteria. Part Two will discuss the synthesis of the findings and address implications for nursing practice, conclusions and contributions to the nursing profession, and recommendations for further studies. Results and Discussion Findings Synthesis
The literature selected for this review covered multiple facets of mental health and well-being. While some outcomes were easily measured, such as stress reduction or specific physical conditions, other effects were harder to quantify, namely the impact of increased mindfulness on overall mental health. The literature tends to support a combination of quantitative and qualitative study designs to fully appreciate the impact of MBSR programs. Nevertheless, five themes were identified from the fifteen articles selected for this review: (a) MBSR and impact on stress reduction, (b) MBSR and physical effects, (c) ease of MBSR via an electronic platform, (d) MBSR impact measured using the PSS instrument, and (e) MBSR programs and long-term effects. MBSR and Impact on Stress Reduction
High levels and prolonged stress can lead to physical and psychological problems. Unfortunately, stress is inherent within the field of nursing. Factors such as understaffing, high nurse-to-patient ratios, limited supplies, and caring for patients with ever-increasing complex morbidities combine to create stressful working environments for nurses. Traditionally, healthcare facilities have not focused on the mental health and well-being of their staff. However, multiple studies have shown that an MBSR program is a cost-effective and easily accessible way to enhance stresscoping mechanisms for individuals (Ghawadra et al., 2019; Ghawadra et al., 2020; Guillaumie et al., 2016; Hallman et al., 2016; Janssen et al., 2020; Juul et al., 2020; Lamothe et al., 2016; Lin et al., 2019; & Yang et al., 2018). In addition to MBSR programs being studied on registered nurses, undergraduate nursing students, and other healthcare providers, randomized control studies by Juul et al. (2020) and Shaygan et al. (2021) evaluated the effectiveness of MBSR programs in select patient populations and have been proven to reduce stress equally. MBSR programs are designed to be completed over eight weeks, with new concepts and techniques introduced weekly. There is a significant time commitment on the part of participants. to complete an eight-week MBSR program, and as such, attrition is commonplace in most studies evaluating MBSR effects. Janssen et al. (2020) conducted a standard 8-week MBSR program; however, they did not hold participants accountable to the suggested daily practice assignments. They evaluated stress using the Dutch 42-item Depression, Anxiety, Stress Scales (DASS)
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and found significant decreases in reported stress (Janssen et al., 2020). Notably, Janssen et al. (2020) also found a significant reduction in worrying, which has not been demonstrated in previous evaluations of MBSR programs and should be considered in future research topics (Janssen et al., 2020). Researchers have questioned and examined if a modified MBSR program would produce the same results. For example, Hallman et al. (2016) conducted one-group repeated measures designed study with healthcare workers, including registered nurses, with a 4-week MBSR program. Their results demonstrated increased self-care activities and decreased levels of stress (Hallman et al., 2016). A randomized-controlled trial conducted by Ghawadra et al. (2020) also found significant effects on stress after an abbreviated MBSR program lasting four weeks. Additionally, Shaygan et al. (2021) conducted a pilot cluster randomized parallel-controlled trial with patients hospitalized with COVID-19. They designed a two-week MBSR program that resulted in the intervention group reporting feelings of increased resilience and decreased perceived stress (Shaygan et al., 2021). Lin et al. (2019) conducted a randomized controlled trial with a modified MBSR program. While their study lasted for the standard eight weeks, they reduced the weekly group session time commitment and at-home practice requirements. They also eliminated the six-hour retreat typically scheduled between weeks six and seven (Lin et al., 2019). Their modified MBSR program produced statistically significant results immediately post-intervention and in a three-month follow-up evaluation (Lin et al., 2019). A systematic review of 39 studies conducted by Lamothe et al. (2016), of the 19 (19/39, 49%) studies included that assessed MBSR programs, 18 (18/19, 95%) of the studies concluded that MBSR programs decrease the perceived stress of health care providers. Additionally, in the meta-analysis of RTCs included in the systematic review conducted by Guillaumie et al. (2017), MBSR programs showed significant findings in reducing state anxiety and depression; decreases in stress were only found in uncontrolled studies with inconclusive results in RTCs they reviewed. Notably, the qualitative studies reviewed by Guillaumie et al. (2017) reported that mindfulness practices helped nurses communicate with colleagues and patients more effectively, which created better emotional balance at work with less frustration and anger. Hallman et al. (2018) condensed the MBSR program from 8 weeks to 8 days, which decreased participants' attrition and increased retention of MBSR techniques 2-months post-intervention. In addition, Yang et al. (2018) conducted an RTC on a group of psychiatric registered nurses working in three different hospitals and reported that the participant scores on the Nursing Stress Scale were significantly decreased compared to pre-intervention scores. In the nine studies included in the systematic review by Ghawadra et al. (2019), all the RTCs reviewed showed positive effects related to stress, anxiety, depression, burnout, and mindfulness. Additionally, outcomes improved compassion fatigue, job satisfaction, overall well-being, self-compassion, serenity, and quality of life immediately post-MBSR intervention (Ghawadra et al., 2019).
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Their systematic review is unique in that the authors only included studies that used an MBSR program or an adaptation based on the original program developed by Dr. Jon Kabat-Zinn (Ghawadra et al., 2019). MBSR and Physical Impacts Psychological disorders such as stress, anxiety, and depression can manifest as physical symptoms like sleep disorders, hypertension, and self-care neglect. While many studies seek to explain the link between MBSR and improved resilience and reduced perceived stress, studies have also been conducted to evaluate the effects of an MBSR program on sleep quality (Gallegos et al., 2018 & Janssen et al., 2020) and systolic and diastolic blood pressure (Kumar et al., 2017). In a randomized controlled study, Gallegos et al. (2018) used the Pittsburgh Sleep Quality Index (PSQI) to evaluate sleep quality on participants in an MBSR program. The study concluded that participants in the intervention group with moderate to severe sleep disorders experienced improved sleep quality immediately postintervention with sustained improvements at six months (Gallegos et al., 2018). Janssen et al., (2020) evaluated quality of sleep with the Dutch sleep quality subscale of the 14-item Vragenlijst Beleving en Beoordeling van de Arbeid (VBBA) and found significant improvements immediately post-intervention. Kumar et al. (2017) conducted a randomized controlled trial to evaluate the effects of an MBSR program on systolic and diastolic blood pressure. While systolic and diastolic pressure measurements were lower in the experimental group, the results were only statistically significant for systolic pressure (Kumar et al., 2017). Conversely, the randomized controlled trial by Juul et al. (2020) was not focused on an MBSR program's physical effects; however, they collected data regarding blood pressure in participants pre- and post-intervention. They did not observe a significant difference in systolic blood pressure post-intervention (Juul et al., 2020). Lamothe et al. (2016) reported that four (4/39, 11%) studies included in their systematic review addressed physical well-being, but only one (1/4, 25%) found MBSR effective in increasing physical well-being. MBSR via Electronic Platform MBSR programs conventionally take place in-person with a certified instructor guiding participants weekly through the assigned modules. However, with the increase of handheld devices connected to the internet, MBSR programs can now be conducted almost exclusively online. To evaluate a psychoeducational MBSR program's effectiveness, Shaygan et al. (2021) conducted a randomized parallel control trial with fifty patients quarantined in a hospital setting during the COVID-19 pandemic using online modules. Post-intervention, there was a significant improvement in resilience and reduced perceived stress in the intervention group than in the control group (Shaygan et al., 2021). Using a combined approach of initial in-person introduction and instruction with facilitators followed by subsequent practice modules accessed via personal devices has proven effective (Best et al., 2020; Ghawadra et al., 2020). In the quasi-experimental design study conducted by Best et al. (2020), a group of active-duty military nurse practitioners completed an abbreviated MBSR program on a personal device, communicating among the group and
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facilitators via email and Facebook group exchanges (Best et al., 2020). Participants were instructed to use any of the over 30,000 guided meditation activities via the free Insight Timer mobile application for 15 to 20 minutes per day over four weeks (Best et al., 2020). The authors concluded that mindfulness-based activities could be a tool to combat compassion fatigue and help to reduce stress (Best et al., 2020). In addition, the participants reflected that finding time and locations with free Wi-Fi, instead of using their data plans, was challenging but was more manageable than anticipated (Best et al., 2020). This study supports the idea of modifying a traditional in-person MBSR program to a more accessible electronic setting and still achieve desired results. Ghawadra et al. (2020) conducted a randomized controlled trial using the combined method of the initial twohour introductory workshop and subsequent modules completed via a website, with group interaction and facilitator reminders delivered via a private WhatsApp group. The authors concluded that the combined method of workshop and website is a practical, low-cost, and time-saving method to facilitate MBSR programs to healthcare personnel (Ghawadra et al., 2020). Additionally, in the systematic review conducted by Ghawadra et al. (2019), two of the included studies reported using electronic adaptations of an MBSR program via smartphones or the internet with favorable outcomes. Smartphones, tablets, and laptop computers are pervasive today making web and application based MBSR programs accessible to anyone at any time. MBSR outcomes measured using the PSS instrument There are numerous instruments in the public domain that are used to measure the effects of stress. Some studies use a combination of tools to explore nuanced aspects of psychological well-being. When the PSS instrument is used either independently or with other assessment tools, the results lend themselves in support of the PSS as a reliable measure of the outcomes of an MBSR program (Juul et al., 2020; Lin et al., 2019; & Rababah et al., 2020). In the randomized controlled trial conducted by Juul et al. (2020), the PSS-10 demonstrated a Cronbach's Alpha score of 0.84 in the study. The study concluded that the MBSR program outcomes measured with the PSS-10 were more effective at detecting decreases in perceived stress (Juul et al., 2020). Lin et al. (2019) used the original 14 question PSS (PSS-14) instrument in their randomized controlled trial. The PSS-14 was adapted to a Chinese version to evaluate better the study participants (Lin et al., 2019). The Cronbach's alpha for the study was .802, indicating adequate internal consistency (Lin et al., 2019). A randomized controlled trial by Rababah et al. (2020) used the 10 question PSS-10 to establish pre-and post-intervention scores. The Cronbach's alpha score for the PSS-10 in their study was 0.73, which supports the internal consistency of their trial, and is consistent with Cronbach alpha scores reported in other studies using the PSS-10 (Rababah et al., 2020). Hallman et al. (2018), in a one-way repeated ANOVA, compared the PSS-10 scores of participants at three distinct times, pre, post, and two months after the intervention, and found a significant effect over time, as reported by Wilks' lambda =.35,F(2,10)=9.246, p<.05.
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MBSR Programs and Long-Term Effects Many of the studies included in this review did not examine the long-term effects of an MBSR program. Still, the studies demonstrated that even months post-intervention, MBSR techniques have a lasting impact on stress levels and mindfulness scores (Hallman et al., 2018). For example, in the one-group study conducted by Hallman et al. (2018), participants completed the PSS-10 instrument pre, post, and two months after the intervention. They observed a significant decrease in PSS immediately post-intervention and an even greater decrease 2-months later (Hallman et al., 2018). Additionally, they reported the absentee rate of the nursing unit two months before the intervention to be 288 hours or 36 shifts, and absenteeism decreased to 248 hours or 31 shifts in the two months post-MBSR intervention (Hallman et al., 2018). Since inadequate staffing plays a significant role in creating a stressful working environment, these results are exciting and warrant further investigation. In the study conducted by Gallegos et al. (2018), participants' PSQI scores were still lower than preintervention levels six months post-intervention. Two studies included in the systematic review by Ghawadra et al. (2019) conducted a follow-up with participants between six weeks and four months. Compared to immediate postintervention assessments, no additional improvements were seen, but scores did not return to baseline or preintervention levels (Ghawadra et al., 2019). Valley & Stallones (2018) conducted a six-month post-intervention followup following their qualitative study. They reported that 14 of the 16 study respondents (88%) continued to use and perceive benefits from the skills learned in the MBSR program (Valley & Stallones, 2018). Conclusions and Further Recommendations Implications for Nursing Practice Examining the fifteen studies and reviews selected for this integrative review provides multiple examples of the effectiveness of MBSR programs for nursing and other healthcare professionals. MBSR programs have been shown to increase resilience, decrease stress, and be cost-effective and easy to use (Shaygan et al., 2021). On a micro-level, MBSR programs help nurses resolve the effects of stressful situations, which allows for safer clinical decisions resulting in increased patient safety. In addition, when individuals are adept at processing their psychological and physical responses to stress, they can give more attention and be more present to circumstances regarding their patients and co-workers. On a meso-level, MBSR programs can mitigate presenteeism among staff, which improves the unit's productivity. Presenteeism occurs when staff members are physically present at work but are not thoroughly engaging mentally with their environment (Brandford & Reed, 2016). Implementing an MBSR program to nursing units demonstrates an organization’s commitment to evidence-based practice changes from a macro-level. Additionally, investing in an MBSR program for staff development shows the organization strives to create a patient safety culture (Hallman et al., 2017).
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The studies included in this review support the theory that registered nurses can benefit from MBSR programs. However, due to the extensive time commitment of a standard, eight-week MBSR program, nursing leaders who want to implement a program for staff need to be mindful of this barrier and search for ways to adapt the program to accommodate busy staffing schedules. Additionally, materials supporting the efficacy of mindfulness training among healthcare personnel should be provided to nursing staff before an MBSR program implementation (Valley & Stallones, 2018). Conclusions and Contributions to the Professions of Nursing The purpose of this integrative review was to select and analyze available literature addressing MBSR programs to mitigate stress, with an added emphasis to find studies that demonstrate the program's applicability to the stress prevalent within the nursing profession. MBSR programs can reduce stress among nurses, even when modifications are made to allow for the time constraints inherent within the field (Ghawadra et al., 2019; Ghawadra et al., 2020; Guillaumie et al., 2016; Hallman et al., 2016; Janssen et al., 2020; Juul et al., 2020; Lamothe et al., 2016; Lin et al., 2019; & Yang et al., 2018). In addition, MBSR programs can be accessed easily through electronic platforms and still achieve similar results compared to traditional in-person formats (Best et al., 2020; Ghawadra et al., 2020, & Shaygan et al., 2021). While there is not extensive evidence that either supports or discourages the long-term effectiveness of MBSR programs, studies that did incorporate long-term follow-up showed that benefits from MBSR programs have longevity among participants (Gallegos et al., 2018; Ghawadra et al., 2019; Hallman et al., 2018; Lin et al., 2019; Valley & Stallones, 2018). Recommendations Nursing leaders should consider a mindfulness training program to be modified and implemented to meet the unit's specific needs. Barriers to acceptance need to be addressed, such as time constraints, discomfort with assigned modules, whether physical or emotional. Evidence has shown that abbreviated MBSR programs tailored to a busy nursing schedule are effective. Classes could be limited to less than an hour, and electronic devices could access supplemental instructions. A combination of in-person discussion and website, smartphone app, or other electronic devices is a way to implement an MBSR program with a more manageable time commitment. The cost-benefit analysis of MBSR programs should be presented to nursing leaders to help in deciding on implementing an MBSR program. MBSR courses, such as the Palouse Mindfulness website, are free to use and easily accessible through a device with internet access (PalouseMindfulness.com). Additionally, after an MBSR program has been implemented on a unit, a conscious effort to keep meditation activities relevant could be weekly reminders and tips via email or open drop-in sessions for staff to participate. And finally, nursing faculty could implement MBSR principles and exercises in undergraduate nursing courses before students start clinical rotations to help improve resilience during a stressful transition.
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References Best, N.I., Durham, C.F., Woods-Giscombe, C., & Waldrop, J. (2020). Combating compassion fatigue with mindfulness practice in military nurse practitioners. The Journal for Nurse Practitioners, 16(2020), e57-e60. https://doi.org/10.1016/j.nurpra.2020.02.023. Brandford, A.A., & Reed, D.B. (2016). Depression in registered nurses: A state of the science. Workplace Health & Safety, 64(10), 488-511. https://doi.org/10.1177/2165079916653415. Gallegos, A.M., Moynihan, J., & Pigeon, WR (2018). A secondary analysis of sleep quality
changes in older adults from a randomized trial on an MBSR program. Journal of Applied Gerontology, 37(11), 1327-1343. https://doi.org/10.1177/0733464816663553. Ghawadra, S.F., Abdullah, K.L., Choo, W.Y., Danaee, M., & Phang, C.K. (2020). The effect of mindfulness-based training on stress, anxiety, depression and job satisfaction among ward nurses: A randomized control trial. Journal of Nurse Management, 2020(28), 10881097. https://doi.org/10.1111/jonm.13049. Ghawadra, S.F., Abdullah, K.L., Choo, W.Y., & Phang, C.K. (2019). Mindfulness-based stress re duction for psychological distress among nurses: A systematic review. Journal of Clinical Nursing, 28, 3747-3748. https://doi.org/10.1111/jocn.14987. Guillaumie, L., Boiral, O., & Champagne, J. (2017). A mixed-methods systematic review of the effects of mindfulness on nurses. Journal of Advanced Nursing, 73(5), 1017-1034.
https://
doi.org/10.1111/jan.13176. Hallman, I.S., O'Connor, N., Hasenau, S., & Brady, S. (2017). Improving the culture of safety on a high-acuity inpatient child/adolescent psychiatric unit by mindfulness-based stress reduction training of staff. Journal of Child and Adolescent Psychiatric Nursing, 30(4), 175-180. https:// doi.org/10.1111/jcap.12191. Janssen, M., Van der Heijden, B., Engels, J., Korzilius, H., Peters, P., & Heerkens, Y. (2020). Effects of mindfulness-based stress reduction training on healthcare professionals' mental health: Results from a pilot study testing its predictive validity in a specialized hospital setting. International Journal of Environmental Research and Public Health, 17(24), 1-14.
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doi.org/10.3390/ijerph17249420. Juul, L., Pallesen, K.J., Bjerggaard, M., Nielson, C., & Fjorback, L.O. (2020). A pilot randomized trial comparing a mindfulness-based stress reduction course, a locally-developed stress reduction Intervention and a waiting list control group in a real-life municipal health care setting. BMC Public Health, 20(409), 1-16. https://doi.org/10.1186/s12889-020-08470-6. Kumar, S., Lathif, F., & Raghavan, V. (2017). Effects of mindfulness-based stress reduction on blood pressure (MBSR) among patients with type-2 diabetes- A randomized pilot study. The Nursing Journal of India, CVIII(2), 61-63.
Lamothe, M., Rondeau, E., Malboeuf-Hurtubise, C., Duval, M., & Sultan, S. (2016). Outcomes of MBSR or MBSR-based interventions in health care providers: A systematic review with a focus on empathy and emotional competencies. Complementary Therapies in Medicine, 24, 19-28. https://doi.org/10.1016/j.ctim.2015.11.001. Lin, L., He, G., Yan, J., Gu, C., & Xie, J. (2019). The effects of a modified mindfulness-based stress reduction program for nurses. Workplace Health & Safety, 67(3), 111-122. https://oi.org.10. 1177/2165079918801633.
Palouse Mindfulness (2021). Mindfulness-Based Stress Reduction Program. https://louseMindfulness.com. Rababah, R.J., Al-Hammouri, M.M., & Drew, B.L. (2020). The association between mindfulness and health promotion in undergraduate nursing students: A serial multiple mediator analysis. Journal of Advanced Nursing, 76(12), 3463-3472. https://10.1111/jan.14556. Shaygan, M., Yazdani, Z., & Valibeygi, A. (2021). The effect of online multimedia psychoeducational interventions on the resilience and perceived stress of hospitalized patients with COVID-19: A pilot cluster randomized parallel-controlled trial. BMC Psychiatry, 21(93), 1-12. https://doi.org/ 10.1186/s12888-021-03085-6.
Valley, M., & Stallones, L. (2018). A thematic analysis of health care workers' adoption of mindfulness practices. Workplace Health & Safety, 66(11), 538-544.
https://doi.org/10.1177/21650
79918771991. Yang, J., Tang, S., & Zhou, W. (2018). Effect of mindfulness-based stress reduction therapy on work stress and mental health of psychiatric nurses. Psychiatria Danubina, 30(2), 189-196. https:// doi.org/10.24869/psyd.2018.189.
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“The World is a book, and those who do not travel read only a page.” – Saint Augustine United Kingdom
Nottingham
Natl. Harbor, MD
Aurora Williamsburg
Palm
Anaheim
Greenville
Lake Buena Vista
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Virtual Healthcare Hot Topics Journal Club! Cindy Ward, DNP, RN-BC, CMSRN, ACNS-BC Research Council Unit Outreach Subcommittee The Unit Outreach Subcommittee of the Research Council has a virtual journal club to provide an opportunity to read and discuss issues of concern in healthcare. The journal club is open to any employee. The most exciting thing about the Healthcare Hot Topics Journal Club is that it is virtual! Using the Teams platform will allow participants to post their comments and opinions when it is convenient for them. A new discussion will be started every one to two months. There will be a channel for each new topic with the article posted in the Files section. Discussion questions for the article will be located in the Wiki. A separate tab will give access to the evaluation form. Please complete the evaluation to let us know your opinion about the journal club and what future topics you’d like to discuss. Participation in a journal club can be used to fulfill the Research criteria for RN 2. Leading a journal club discussion can be used to fulfill the Research criteria for RN3. Join the club by going to Teams and searching for Healthcare Hot Topics Journal club and select Join Team
Questions? Contact: Cindy Ward - Clinical Nurse Specialist email: cwward@carilionclinic.org phone: 540-224-2508
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2024 NURSING CONFERENCE INFORMATION March 10, 2024 @ 8:00 am - March 13, 2024 @ 5:00 pm
Annual Conference 49th Annual Conference April 2-6, 2024 Chicago, IL Poster abstract submissions are now being accepted through November 15. NTI 2024 - AACN's National Teaching Institute & Critical Care Exposition - American Association of Critical-Care Nurses
Hilton Richmond Hotel & Spa/Short Pump 12042 W Broad St Richmond, VA 23233 Fall Conference 11/22/2024 to 11/23/2024
2024 VCNP Annual Conference– March 13—March 16, 2024 Williamsburg Lodge, Williamsburg, Virginia