the Official Magazine of the Emergency Nurses Association
connection
February 2014 Volume 38, Issue 2
NEW AGE Care of Geriatric Patients Takes Huge Step Forward With Online GENE Course Pages 6 - 7
LEADERSHIP CONFERENCE
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March 5-9, 2014 Phoenix, AZ
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*Accreditation statement: The Emergency Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
Dates to Remember Feb. 26, 2014 Deadline to submit applications for 2014 Lantern Award. March 1, 2014 Deadline for resolution proposals for the 2014 ENA Annual Conference in Indianapolis. March 5-9, 2014 Leadership Conference 2014, Phoenix. May 6-7, 2014 2014 ENA Day on the Hill, Washington, D.C.
ENA Exclusives
FROM THE PRESIDENT | Deena Brecher, MSN, RN, APRN, ACNS-BC, CEN, CPEN
Revolutions and Resolutions
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ast month, I talked about New Year’s resolutions and how we needed to start a revolution against unsafe patient care practices in our emergency departments. This month, I want to share how one person can make a difference in the profession of emergency nursing and ignite that revolution. For those of you who have never attended the ENA Annual Conference, you have never witnessed the energy, enthusiasm and excitement the conference generates about our profession. The meeting right before the conference is the one that I believe gives every emergency nurse an opportunity to make a difference and change our profession for the better. The meeting is the ENA General Assembly, and the change agent is called a resolution.
PAGE 5 Update From the Executive Director PAGE 6 Given the GENE Light: ENA Releases New Online Course for Geriatric Emergency Nursing PAGE 8 State Watch: Progress on Felony Workplace Assault Laws PAGE 10 Zero Tolerance for Bullying in the ED PAGE 14 No-Limit Nursing: ED Veteran’s Taste for Volunteering Has All the Makings of a Movement PAGE 20 Driving Home the Danger: Illinois ENA State Council Teaching Teens With Simulator
Regular Features PAGE 4 Free CE of the Month Letters to the Editor PAGE 18 Academy of Emergency Nursing PAGE 22 Perspectives PAGE 24 ENA Foundation PAGE 26 Ready or Not? PAGE 28 Board Writes
A General Assembly resolution is a call for a change. Resolutions are submitted by ENA members and are debated and voted on by the General Assembly. Resolutions start as ideas — thoughts that you have about improving or changing our profession. They need to be able to be supported by evidence and are written as a series of whereas and resolved clauses. Resolutions can call for ENA to take a Delegates share their views on a proposed resolution during the specific position (ENA 2013 ENA Annual Conference in Nashville, Tenn. believes all emergency nurses should have annual Congratulations: You just identified a training on workplace violence issues) or set topic that would be perfect for a resolution! a direction (ENA should develop educational What about interdisciplinary team products related to patient safety). education in the ED? Or zero-tolerance Think about your own emergency policies for unprofessional behavior? Or department. Where do you see the biggest maybe how supporting the reporting of near opportunity to improve patient safety? misses can help identify systems that need to Should there be a ‘‘quiet zone’’ around the be improved before the error reaches the medication preparation area to reduce patient? I have no doubt each of you can distractions and interruptions? Do you think come up with several topics that would having this type of practice can reduce errors make excellent clinical resolutions. in EDs all over the country? Do you wish The key questions to answer in forming a there were an ENA position statement to resolution idea are: What do you want ENA support this practice that you could take to to do? Why do you want ENA to do it? What your manager or director to support the implementation of this change? Continued on Page 31
Official Magazine of the Emergency Nurses Association
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The eyes have it, and so will you when you take advantage of ENA’s latest free continuing education offering!
Available to you starting Feb. 1 . . . ‘‘Exploring Eye Emergencies,’’ presented by Denise Ramponi, DNP, NP-BC, CEN, FAEN. (Credit: 1.0 contact hour.) In this e-learning course recorded at the 2013 Annual Conference in Nashville, Tenn., Ramponi goes over the core components in evaluating eye conditions, identifies true eye emergencies and describes the conditions that require urgent ophthalmologic referral. To take these and other CE courses free as an ENA member: •G o to www.ena.org/freeCE, where you’ll log in as a member (or create an account). • Add desired courses to your cart and ‘‘check out.’’ • Proceed to your Personal Learning Page to start or complete any course for which you have registered or to print a final certificate. • To return to your Personal Learning Page later, go to www.ena.org and find ‘‘Go to Personal Learning Page’’ under the Education tab. Please be sure you are using the e-mail address associated with your membership when logging in. If you have questions about any free e-learning course or the checkout process, e-mail elearning@ena.org.
ENA Connection is published 11 times per year from January to December by: The Emergency Nurses Association 915 Lee Street Des Plaines, IL 60016-6569 and is distributed to members of the association as a direct benefit of membership. Copyright© 2014 by the Emergency Nurses Association. Printed in the U.S.A. Periodicals postage paid at the Des Plaines, IL, Post Office and additional mailing offices.
ENA Connection welcomes letters from members. Letters should address content previously published in the magazine. Letters may be edited for space and clarity. Submission does not guarantee publication. Please include your name, credentials and contact information for verification. Send letters to connection@ena.org.
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have worked in the emergency room for the last 14 years. As the years have progressed, I have seen an increase in the violence toward health care workers in an emergency room setting. This is a growing trend that needs to be addressed before someone gets seriously injured or killed. A nurse should not have to fear for his or her safety when coming to work to help those in need. Upon arriving at work, I fear for my safety as well as others that I work with due to the increasing violence toward myself and my co-workers. There are not nearly enough safety and security measures in place to make us feel safe when taking care of patients. We do not have secure entrances or exits, first and foremost. Secondly, our security team consists of retired police officers who are not armed and rarely question anyone walking through the door. We do not have metal detectors or anything else that
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Editor-in-Chief: Amy Carpenter Aquino Associate Editor: Josh Gaby Senior Writer: Kendra Y. Mims Editorial Assistant: Renée Herrmann BOARD OF DIRECTORS Officers: President: Deena Brecher, MSN, RN, APRN, ACNS-BC, CEN, CPEN President-elect: Matthew F. Powers, MS, BSN, RN, MICP, CEN
would detect a weapon. We have brought these pressing issues up to our administration on a regular basis. It seems that every time we bring it up that the reputation of the hospital is more important than keeping the hospital staff safe. They do not understand the conditions we are faced with. I also believe that mandatory laws should be looked into being put in place to help with security issues. They need to look at the statistics such as a study where 50 nurses reported 110 episodes of violence against health care workers in a five-month period. In conclusion, I am asking for your help in raising awareness of the alarmingly high increase in violence toward health care workers. We as health care workers leave our families every day to save the lives of people that we have never met. We deserve to be safe and feel secure. Jill Kaiser, RN, Detroit Secretary/Treasurer: Kathleen E. Carlson, MSN, RN, CEN, FAEN Immediate Past President: JoAnn Lazarus, MSN, RN, CEN Directors: Ellen (Ellie) H. Encapera, RN, CEN Mitch Jewett, AA, RN, CEN, CPEN Michael D. Moon, PhD, MSN, RN, CNS-CC, CEN, FAEN Sally K. Snow, BSN, RN, CPEN, FAEN Jeff Solheim, MSN, RN-BC, CEN, CFRN, FAEN Joan Somes, PhD, MSN, RN-BC, CEN, CPEN, FAEN, NREMT-P Karen K. Wiley, MSN, RN, CEN Executive Director: Susan M. Hohenhaus, LPD, RN, CEN, FAEN
UPDATE FROM THE EXECUTIVE DIRECTOR | Susan M. Hohenhaus, LPD, RN, CEN, FAEN
Greetings from ENA Headquarters! I
n 2013, ENA staff followed the roadmap of the ENA Strategic Plan to focus on an implementation year. I’d like to share with you the highlights of the key items from the third quarter of 2013. ENA’s strategic partnership engagement is strong. Several members, including members of the ENA Board of Directors, have been involved in meetings — both in person and virtual — with strategic partner organizations. These include the American College of Emergency Physicians, the American Academy of Pediatrics, The Joint Commission and the Nursing Organization Alliance. ENA’s Government Relations staff continues advocacy efforts at the federal and state levels. Support for federal legislation, such as the SANE Deployment Act, the Registered Nurse Safe Staffing Act and the Nurse and Health Care Worker Protection Act, to name a few, has kept ENA and its members visible to elected representatives. At the state level, ENA staff members have been working closely with many of you, especially with Michigan ENA, Illinois ENA and Colorado ENA, on issues related to workplace violence. In Illinois, Public Act 98-0369 expands aggravated battery to include battery of a nurse ‘‘while in the performance of his or her duties as a nurse’’ and went into effect Jan. 1. The Government Relations staff provides monthly activity updates to state leaders and has redesigned the ENA Government Relations webpages and EN411 program for easier navigation. Our social media presence also continues to grow. At the end of September we had more than 24,000 ‘‘likes’’ on Facebook, with 19 percent of followers being international; almost 8,000 members on LinkedIn; 2,775 visitors to the president’s blog (a 24 percent increase from the previous quarter); 4,505 views of our YouTube channel and more than 3,000 Twitter followers. ENA’s total website traffic was 149,344, with 50 percent of those being new visitors. ENA sent more than 1 million e-mails to members. While no one topic dominates the content of our listservs, we are noticing a trend in requests for resources for emergency nurse educators. This environmental scan will assist the ENA Board of Directors in allocating association resources to the greatest needs. ENA’s Institute for Emergency Nursing Education staff has been working diligently to implement the newly revised
Geriatric Emergency Nurse Education program and the 7th Edition of Trauma Nursing Core Course. ENA’s Continuing Nursing Education processes have been examined and refined after many changes from the American Nurses Credentialing Center. We also have put in new processes and hired additional staff to better meet the needs of those applying for CNE. The Institute for Emergency Nursing Research staff has had several studies submitted or accepted for publication and presentation. These include ‘‘Identifying the educational needs of emergency nurses in rural and critical access hospitals,’’ published in the Journal of Continuing Education in Nursing, and ‘‘Nothing changes, nobody cares: Understanding the experience of emergency nurses physically or verbally assaulted while providing care,’’ authored by Lisa A. Wolf, PhD, RN, CEN, FAEN, Altair M. Delao, MPH, and Cydne Perhats, MPH (in press at the Journal of Emergency Nursing). The staff research team continues to work with the American Hospital Association on reducing catheter-associated urinary tract infections and with our Susan G. Harwood federal funds on the development of ED violence assessment and mitigation tools. The Institute for Quality, Safety and Injury Prevention published two topic briefs in the third quarter of 2013 — Adult Immunizations and Care of the Bariatric/Obese Patient. Translation into Practice reference documents were developed for right-sided and posterior ECGs and Hemolysis. Publications included five position statements — Mobile Electronic Device Use in the ED, Palliative Care, RN Delegation, Intimate Partner Violence (a joint statement with the International Association of Forensic Nurses) and Screening, Brief Intervention and Referral to Treatment (a joint statement with the International Nurses Society on Addictions) — and a white paper on nurse fatigue. We take our role as the support team for our members and the profession of emergency nursing very seriously. We are committed to providing quality products and an excellent member-service experience. We welcome your feedback and look forward to seeing many of you this March at Leadership Conference 2014 in Phoenix. Be safe,
Official Magazine of the Emergency Nurses Association
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Given the GENE Light
ENA Releases Geriatric Emergency Nursing Education Online Course By Amy Carpenter Aquino, ENA Connection
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he new Geriatric Emergency Nursing Education online course addresses the needs of the growing geriatric patient population in our emergency departments, said Marie Boltz, PhD, RN, GNP-BC, who served as subject matter expert for the 2013 Geriatric Committee and the 2013 Geriatric Work Team. The new GENE course reflects the expertise of the 2013 Geriatric Committee, as well as the 2013 Geriatric Work Team, which was developed to collaborate with the committee on completing the GENE course revision. Briana Quinn, MPH, BSN, RN, senior associate for wellness and injury prevention for the ENA Institute for Quality, Safety and Injury Prevention, served as staff liaison to both the Geriatric Committee and the Geriatric Work Team. Quinn compared taking GENE with keeping current with Trauma Nursing Core Course and Emergency Nursing Pediatric Course. ‘‘To feel truly competent in providing the best nursing care for this population, you have to acknowledge
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that they have different needs, they have different physiology, they have different considerations when it comes to their medications, and they have different presentations,’’ she said. ‘‘We have TNCC and ENPC for a reason — they fill a need. This fills the need for the older adult; there are more of them coming into our emergency departments every day, and there is going to continue to be an influx of them.’’ Boltz said GENE benefits patients and family members as well as nurses. ‘‘I think they’re going to be more comfortable, and I think they’re going to be more proficient and expert in the care, and I think that’s important,’’ she said. ‘‘One of the goals of this kind of training program is, first of all, you’re going to improve patient care — there’s going to be better care delivery. The experience for patients and families is going to better and the outcomes are going to be better.’’ Boltz, who was not part of the development team for the original course, said GENE was a pioneer in providing education to nurses around emergency care of the older adult.
About Marie Boltz As NICHE (Nurses Improving Care of Healthsystem Elders; PI: E. Capezuti) associate director for research, Marie Boltz, PhD, RN, GNP-BC, served as principal investigator, co-PI and consultant on studies that have examined the geriatric care environment, models of care, function-focused care and measures of quality around care of older patients. As practice director, she has led the extensive resource and program development for the NICHE program. As a geriatric nurse practitioner with extensive clinical and administrative experience, she serves on several national and international advisory boards informing aging program development and evaluation. ‘‘They really were groundbreaking in that respect, and they provided solid, excellent basic information around care of the older adult,’’ she said.
February 2014
‘‘This course takes it to a whole new level. It considers various types of disease manifestations, trauma care and operation practices — such as transitional care — so it really takes it to a much higher level.’’ Quinn agreed, adding that the new version of GENE is far more in-depth, especially in educating nurses about patient and family engagement. ‘‘The original GENE gave a great introduction to the awareness that we need for the geriatric population; it highlighted the risks that people fall into with ageism and that we need to make sure that doesn’t happen with any of our patients,’’ Quinn said. ‘‘Safe care doesn’t just extend to the medical practice — it extends to the care and the presence that we have with our patients and family members.’’ While the original GENE course touched on the different body systems, the revision ‘‘went much more in-depth with physiology and more of the atypical presentations, transitions of care and the specific needs of the emergency department,’’ Quinn said. ‘‘But we would not have been able to do what we did without the basis of the original GENE.’’ The new online course is much more interactive. For example, a slide in Module 4, Infectious Diseases, titled ‘‘Immunosenescence and Factors Increasing the Risk for Infection in the Older Adult,’’ prompts learners to click buttons to learn more about related topics, such as thermoregulation. Some
Boltz said. ‘‘We take TNCC to better treat and be prepared to handle our trauma Go to www.ena.org/gene to patients, so why wouldn’t we be doing purchase this e-Learning program, the same thing for our older patients?’’ with 17 modules that offer up to Quinn said. ‘‘They’re a specialty 15.21 credit hours. population. We take ENPC for our pediatric patients — they’re a specialty slides require the learner to correctly population with different medication answer questions before proceeding. needs, different care needs, different Learning objectives are clearly listed considerations from triage through at the beginning of each module. disposition, and the same goes for Boltz said GENE’s delivery system older adults. holds major appeal to members. ‘‘This is 100 percent safe practice, ‘‘It’s interactive — it provides visual safe care. After reviewing all the representation of patients and families modules for GENE, I think it is and staff, so you feel like you’re almost imperative to provide the safest, optimal immersed in the emergency care for the geriatric patient that you department,’’ she said. ‘‘The graphic take this course.’’ representations of pathological Said Boltz: ‘‘I can’t think conditions are really very of a resource anywhere that interesting, so I think it is very provides the breadth of much suited to how adults learn information around the care in general, and then it provides of the older adult in the information that’s relevant and it emergency department. What builds upon knowledge that is really amazing about this Briana Quinn, people already have. Plus, the MPH, BSN, RN set of resources is the fact delivery system is just interesting. that there have been so It helps you move along at a many expert clinicians and managers good pace. It provides very, very good who are really proficient in the care of assessments of knowledge so you can the older person who have been track if you’re assimilating things. It is a involved. This team of writers and very innovating approach to training.’’ editors has represented the entire Considering the special needs of country — all different types of older adult patients and the fact that emergency departments and hospitals they are at higher risk for — and provided a wide and deep set complications and ED readmission, it of expertise and skill. I think that’s makes sense to focus on family and why this series is so robust and patient education for transitional care, which is built into the GENE modules, wonderful.’’
How to Take GENE
Official Magazine of the Emergency Nurses Association
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STATE WATCH |
Ken Steinhardt, Director of Government Relations
Progress on Felony Workplace Assault Laws I
n 2013, significant progress was made by numerous states in the efforts to raise the criminal penalty for attacking an emergency nurse. While much still needs to be accomplished, prosecutors in a majority of states can now charge those who assault an emergency nurse with a felony, punishable with at least one year of imprisonment. In Illinois and Texas, legislation was enacted that made it a felony to commit assault or battery against emergency nurses, while Ohio saw its felony assault law take effect March 22, 2013. In addition, Tennessee increased the maximum monetary penalty for assaults on health care workers to $5,000, the same fine as for attacking a police officer. Although it is still only a misdemeanor to attack a nurse in Tennessee, this new law recognizes for the first time that health care workers are deserving of special protection because of the nature of their work. With the enactment of the new workplace violence laws in Illinois, Texas and Ohio, the total number of states with a felony assault penalty now stands at 29. When you add states such as Tennessee, which have higher-penalty misdemeanors for assaulting health care personnel, 35 states now provide enhanced penalties for attacking emergency nurses. Illinois, Texas, Ohio and Tennessee were not the only states that made progress in 2013. In Michigan, state legislation is pending that will make it a felony to assault an emergency nurse. Fortunately, Michigan has a two-year legislative calendar, allowing this same bill to be considered in 2014. The bill
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was approved by the Michigan State Senate on June 12, 2013 by a vote of 36-1 and then sent to the state House of Representatives for its consideration. A hearing was held in October before the House Criminal Justice Committee, with several ENA members testifying in support of the legislation. Unfortunately, because of concerns raised by some members of the committee, the bill has yet to receive a vote by the Michigan House. However, we remain hopeful that ongoing negotiations will result in Michigan becoming the 30th state to make it a felony to assault an emergency nurse. Progress is also being made in New Hampshire, where legislation to impose an extended prison sentence for assaulting an emergency nurse has made it out of the House Criminal Justice and Public Safety Committee and is scheduled to be voted on before the full New Hampshire House of
Representatives later this month. In Wyoming, legislation that would have made it a felony to assault an emergency nurse was approved by the state Senate. However, the bill fell just short on a final vote in the state House. Great strides have been made in many states in raising the criminal penalty for assaulting an emergency nurse or other health care personnel. If you live in one of the states where legislation was introduced but has not been signed into law, don’t get discouraged. The majority of bills take many years before they are enacted. The legislative process is often a slow, multiyear process. Become a champion of emergency nurses in your state by encouraging your elected state officials to join your efforts and introduce this important legislation. ENA’s Government Relations team stands ready to help in all your legislative efforts.
February 2014
ENA Call for …
Resolutions and Proposed Bylaws Amendments, 2014 General Assembly
R
esolutions may be submitted by any active ENA member. Others who may submit resolutions include the ENA Board of Directors, state councils, chapters, the Journal of Emergency Nursing editorial board and ENA committees. Bylaws amendments may be proposed by the ENA Board of Directors, state councils and chapters or five active members of the association. The Resolutions Committee is available to assist ENA members in developing resolutions and proposed bylaws amendments. E-mail componentrelations@ena.org to obtain assistance from the Resolutions Committee. All resolutions and proposed bylaws amendments must be submitted in the proper template form and must follow the format as outlined in the Resolutions and Bylaw
Guidelines. The guidelines may be found at www.ena.org in the General Assembly area (members only). Final resolution submissions must be sent by 11:59 p.m. Central time on Saturday, March 1, to componentrelations@ ena.org. Per ENA Bylaws, proposed bylaws amendments must be submitted at least 90 days before the General Assembly, no later than 11:59 p.m. Central time on Thursday, July 10, 2014. To allow the Resolutions Committee adequate time to thoroughly review amendment proposals and to work with the authors to finalize amendments for inclusion in the General Assembly Handbook, it is highly recommended that proposed bylaws amendments be submitted by March 1. Formal consideration of proposed bylaws amendments and resolutions will occur at the 2014 General Assembly, Oct. 8 - 9, in Indianapolis.
ENA Foundation State Fundraising Challenge Building a Strong Foundation February 1 – May 31
How will your state stack up?
þ þ þ
Largest percentage increase per capita Largest number of individual donations per state Can your state raise more than $5000?
Let’s get to work! 2014 State Fundraising Challenge visit www.enafoundation.org
ENA Foundation State Challenge_Connection_half_02 2014.indd 1
Official Magazine of the Emergency Nurses Association
1/8/14 11:48 AM
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LATERAL VIOLENCE
Zero Tolerance For Bullying in the ED By Mark Fanning, MSN, BA, RN, NE-BC, Director of Nursing, Emergency and Trauma Services, Lyndon B. Johnson Hospital, Houston and Lisa Hennessy, PhD, RN, Clinical Assistant Professor, University of Texas (El Paso) School of Nursing
H
ow much of a problem is workplace bullying? Lewis 1 reported, ‘‘Among nurses, the prevalence of bullying is reported to be widespread, with estimates suggesting 80 percent of nurses experience bullying at some point in their working lives.’’ Within the nursing context, the perpetrators are listed as patients, family members, colleagues, managers and other health care professionals, although bullying from colleagues is of utmost concern. Colleagues as perpetrators often feel a sense of entitlement, particularly when a novice nurse joins the team. They quickly target a victim they view as vulnerable.2
Review of Literature To further explore the dynamics and definition of workplace bullying, we are reminded that it is considered a psychological form of harassment. It is a vexatious behavior which manifests as repeated and hostile or unwanted conduct, actions or verbal comments or gestures that affect an employee’s dignity or psychological or physical integrity and that result in a harmful work environment.3 The precise strategy of a bully is to strip a victim of his or her dignity through any combination of behaviors that are offensive and unwanted. These behaviors are frequently manifested through vindictive, cruel, malicious or humiliating attempts to undermine an individual or group of employees.
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Martin and Martin 4 elaborate on bullying by offering: ‘‘It involves abuse or misuse of power intended to undermine, humiliate, denigrate or harm the recipient.’’ The operative word is power, which in many cases feeds the persecutor’s sense of entitlement. It negatively impacts the health of the victim, and it is a costly endeavor considering the resulting staff turnover and expense of training a new employee. To identify interventions that are supported by literature, Hutchinson et al.5 caution, ‘‘By confirming that bullying is influenced by organizational characteristics, which in turn influence work team norms, the model directs managers to features of their organization, rather than individual
personality differences and interpersonal conflict.’’ In other words, they recommend an in-depth exploration of the organizational culture and leadership style, which impacts work team dynamics. Pointing blame at individual personality differences or assuming that it is because of a personality conflict may result in the organization missing the bigger picture — it is the culture that could be the cause of the bullying, not the individual. Rocker 3 stresses the key role that nursing leaders play in communicating that bullying behavior will be ‘‘replaced with respect, while the perpetrators of bullying behavior receive help, thus creating a safe working environment for nurses.’’ The three strategies to eliminate workplace bullying, proposed by Rocker, include education, policy and celebration. In terms of education, Rocker recommends the development of an education program that contains the following content: definition of workplace bullying, legal obligations, anti-bullying prevention policies, bullying assessment, developing preventive measures and reporting/ investigating processes. Policy strategies include engaging nurses in the process of policy development and giving them the opportunity to take ownership and responsibility for the work environment. One strategy to decrease bullying is to enable nurses themselves to develop a specific policy addressing workplace bullying. Teharani 6 stipulates that such a policy should
February 2014
target positive behavior and work toward creating a working climate that instills a sense of fairness, dignity and mutual respect among nurses. Finally, Rocker3 recommends celebrating the newly developed awareness of bullying and the implementation of anti-bullying policies by scheduling specific bullying awareness activities. To increase awareness on the issue of bullying, and to empower victims to speak up, Service and Cohen 7 recommend the addition of Bullying Awareness Week. This is an opportunity for nurses to celebrate a positive work environment and teaches them how to become pioneers of anti-bullying initiatives. The goal is to celebrate a positive, bully-free work environment, which can decrease bullying behaviors. Increased awareness about how a positive organizational culture can impact our daily interactions also will reduce bullying. This celebration can easily be incorporated with the annual
Nurses’ Week celebrations or specialty nurse celebrations (i.e., Emergency Nurses Week). Ultimately, nursing leaders have the responsibility to create a culture of change. ‘‘The new culture will require an understanding of bullying and its implications and the establishment of guidelines for acceptable work behavior and peer interaction.’’ 8 The organizational culture can change from within if driven by the nurse leader. He or she has the duty, obligation and authority to promote positive changes in the work environment. The establishment of clear and succinctly written guidelines for what is considered acceptable work behavior must be derived from nursing leadership’s contributions.
Implementation of an Anti-Bullying Program As part of a graduate nursing management class, and in cooperation
with the course faculty and one of the hospital nursing administrators who acted as the agency liaison for this project, we conducted an analysis of the hospital’s ambulatory care services, to include the emergency department, and discovered that their existing anti-bullying strategies were insufficient to address the magnitude of the issue. As the literature has stated, victims of bullying should take advantage of a complaint system that offers confidentiality, if available. Consistent with most institutions, this agency had a mechanism of reporting through its internal compliance reporting system. The QI project, formatted as a Plan, Do, Study, Act cycle, included the development of a downloadable toolkit from each unit’s Internet communications/information platform. Included in the toolkit was a printable document titled ‘‘Zero Tolerance
Continued on next page
AGGRESSIVE BEHAVIOR...
...towards staff at work is dramatically on the increase, especially in our Hospitals. Verbal abuse, threats with weapons, cuts, punches, even serious injuries are becoming everyday occurrences. The impact on the confidence and morale of staff is damaging and costly and has a serious impact on the caring and commitment that lies at the heart of the staff/patient relationship. Installing an INSTANTalarm 5000
Staff Personal Alarm System will make a dramatic difference INSTANTalarm does NOT • track you around the hospital • use radio-frequency • rely on unreliable wi-fi • have a computer controlling it
INSTANTalarm, however, DOES
• let you decide when you need help • pinpoint your location, to a room • work instantaneously • make you and your patients feel safer • reduce the frequency and impact of violent incidents Which is why, over 20 years, INSTANTalarm 5000 has been probably the most widely-installed, staff duress alarm system in the world. ®
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Official Magazine of the Emergency Nurses Association
® PROTECTING PEOPLE AT WORK
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Bullying in the ED Continued from previous page Reporting Document,’’ which could be completed and placed in a suggestion box located in the nurses’ lounge of each unit in the ambulatory care service line. A 10-question pre- and post-education survey was distributed to the ambulatory services nursing staff, and an educational program that addressed identifying bullying behaviors and introduced the toolkit was developed and implemented. The results of the pre-education survey revealed that the vast majority of the staff identified relational aggression (bullying) as a problem in their workplace. In addition, the results indicated a majority of the staff wished that management would address workplace bullying. Interestingly, a small percentage of the staff admitted they have stayed home from work due to bullying, experienced bullying on a daily basis or were seeking employment elsewhere as a result of the bullying behavior. The results confirmed the prevalence of bullying and identified staff perceptions about the emotional environment at work. The education campaign focused not only on the employees who were surveyed, but the entire leadership team of ambulatory care services. The education program consisted of a presentation that introduced key principles of bullying and focused on teaching staff to recognize bullying behaviors. The major topics included a review of the types of bullying, the impact of bullying on the individual and the organization and a presentation of the toolkit. The toolkit detailed three key principles: • How to report abuse/bullying • How you are protected if you report • What happens once you report It also included a review of the reporting document with a discussion on how to access and submit
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anonymously. The most important principle presented in the education session was the confidentiality and anonymity of the reporting toolkit, given that staff had admitted a fear of retaliation if the person they reported was their manager. The results of the post-education survey revealed the overwhelming majority of staff were familiar with how to report bullying after the training. The majority also confirmed the ability to recognize bullying behaviors once witnessing them. Once they learned the reporting structure was anonymous, the majority indicated they felt comfortable reporting the bullying behaviors. When asked if they were more likely to report bullying they either experience or witness, the majority gave a positive response. The post-education survey also indicated they felt a sense of trust that their management team would protect them from retaliation if they reported. Staff also were able to recognize the two internal reporting mechanisms. The results also showed a strong degree of support for a zero-tolerance policy toward bullying among all staff levels (licensed and unlicensed). As staff members learned of the toolkit, they expressed a desire to confront the issue as a unified front. After the education sessions, some staff reacted very emotionally. They expressed a feeling of gratitude and openly discussed how they were victims of bullying. The open discussion led the agency to develop a plan to expand the initiative to all service lines.
Conclusion All nurses, whether administrators of an emergency department or other nursing unit, senior nursing executives, nursing faculty or staff nurses, have a responsibility to speak up for the victims of bullying. We are their advocates. We must hear their cry for help and react swiftly. We must drive culture change. This experience has served to enlighten, raise awareness
and, we hope, save the careers of potential victims of bullying in the agency in which this project took place. We hope sharing our success will result in the implementation of similar initiatives in other health care agencies. As Rocker 3 put it, ‘‘Bullying must become unfashionable.’’ References 1. Lewis M. (2006) Nurse bullying: Organizational considerations in the maintenance and perpetration of health care bullying cultures. Journal of Nursing Management 14(1), 52–58. 2. Farrell G.A., Bobrowski C. & Bobrowski P. (2006) Scoping workplace aggression in nursing: Findings from an Australian study. Journal of Advanced Nursing 55(6), 778–787. 3. Rocker, C.F., (2008). Addressing nurse-to-nurse bullying to promote nurse retention. Online Journal of Issues in Nursing, 10913734, 13(3). 4. Hollins Martin, C.J., & Martin, C. (2010). Bully for you: Harassment and bullying in the workplace. British Journal of Midwifery. 18(1): 25-31. 5. Hutchinson, M., Wilkes, L., Jackson, D., & Vickers, M.H., (2010). Integrating individual, work group and organizational factors: Testing a multidimensional model of bullying in the nursing workplace. Journal of Nursing Management. 18(2): 173-81. 6. Tehrani, N. (2007). Bullying at work: Beyond policies to a culture of respect. Chartered Institute of Personnel and Development Bullying Guide. Available: www.cipd.co.uk/default.cipd 7. Service, J.C. & Cohen, K. (2006). Bullying awareness week: “Stand up!” to end bullying. Canadian Psychology Association. Available: www.cpa.ca/ cpasite/shownews.asp?id=499 8. Field, T. (2005). Working for a bully-free world. The Field Foundation. Available: www.thefieldfoundation.org/
February 2014
DEMAND EVIDENCE AND
THINK CRITICALLY Here’s what some are saying about the IENR Research Lounge: “Experienced researchers with great ideas for us first time researchers” “Was helped to bring ideas into realistic goals for dissertation” “It was an opportunity to discuss potential research projects with experts, and get their thoughts”
Experts will be ready to help you DEMAND EVIDENCE AND THINK CRITICALLY at the IENR Research Lounge 2014 Leadership Conference, Phoenix, AZ, March 5-9
For more information about IENR go to www.ena.org/ienr
NO-LIMIT NURSING
How an ED Veteran’s Taste for Volunteering Has All the Makings of a Movement B Y J O S H G A B Y ♦ E N A C O N N E C T I O N
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t the heart of this for Sue Averill are a room full of girls and women, a tube of red lipstick and a jarring wakeup moment. It was 2001, pre-9/11, and Averill, MBA, BSN, RN, CEN, was part of a surgical mission to Pakistan, working pre-op and recovery for children receiving surgery for cleft lips and palates. Whenever a child was taken off to the operating room, Averill would use the open time — an hour or two — to head to the wards to remove sutures, check on patients and spend time with them. ‘‘I wasn’t really all that welcome on the male ward, but I was completely engulfed in the female ward,’’ she remembers. ‘‘I had long hair at the time, and they all wanted to braid and
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touch and put all kinds of things in my hair and paint henna on my hands. It was just this physical demonstration of affection and female togetherness down in the ward, and it was the babies and the young girls, and it was their moms and it was their grandmothers.’’ What mattered to them wasn’t who Averill was in her pink scrubs, necessarily, but that she had cared to come and help. ‘‘And I always carried a tube of bright red lipstick and one of those little pocket mirrors,’’ she recalls, ‘‘so I would show them what their mouths looked like now that they didn’t have the cleft lip, and then have them put lipstick on. And the grandmas are also putting lipstick on, and the mothers.
Pretty soon everybody, probably 30 females in this ward, everybody’s wearing my bright red lipstick and laughing and just having this wonderful bonding time.’’ In this haven of warmth and strength, she asked one young patient to take a picture with her. The girl’s abrupt response threw her. And it occurred then to Sue Averill exactly why she does what she does, and why she must.
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hat Averill, 58, does is go out to where she’s needed, when
the word comes and when the mission fits. She used to be a ‘‘snowbird’’ — six months a year spent in Central
February 2014
Sue Averill, MBA, BSN, RN, CEN, on a trip to Darfur in 2005 to investigate a possible meningitis outbreak (left and top). The oil drum at right in the top photo was the hand-washing station.
America, Africa, Asia or any area affected by war, disaster or disease — but while her trips outside the United States aren’t nearly as long in recent years, there are more of them now, and they continue to form the hub of her schedule. Around them, she works as a per diem nurse for three emergency departments in the Swedish system in Seattle, her home area since she began her nursing career in 1979. Arching over everything, she runs One Nurse At A Time, the non-profit she and a couple of friends founded in 2007 to steer nurses into medical volunteering and to give them the resources to get started. The group’s website, www.onenurseatatime.org, has links to more than 500 other organizations, including Operation
Smile and Doctors Without Borders (Médecins Sans Frontières), with which Averill has volunteered repeatedly. One Nurse At A Time offers support with scholarships of up to $1,000 to nurses who hear the call. ‘‘We do anything we can to get nurses out volunteering,” Averill says. ‘‘We want to make a movement. We want all nurses to build volunteering into their careers.’’ Emergency nurses in particular tend to fit the bill, for more reasons than one. For starters, the work is no picnic. No matter what type of mission you’re on or in what part of the world, the norm is 12- to 16-hour days, Averill says. Conditions usually aren’t comfortable. You aren’t paid. You have to have the endurance to not eat
Official Magazine of the Emergency Nurses Association
well, to handle exhaustion. And you have to be a first-class thinker. ‘‘I think ER people are really uniquely positioned in this,’’ Averill says, ‘‘because even if you’re going to do recovery or something like that, you’re walking into a lower-resource environment [where] they are unable to provide the same care you’re coming across the world to do. There may be no wall suction, no oxygen. Patients have to bring their own food. They have to bring their own sheets. You may not have gloves or running water or soap. There are so many things that are missing that we take for granted, and now you have to figure
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The nurses’ stations are basic and the needs high in the emergency department Averill assessed last fall in Nuevo Laredo, Mexico.
No-Limit Nursing Continued from previous page out how you’re going to provide quality care in this environment. How are we going to do a blood transfusion here? How are we going to resuscitate a patient here? When you don’t have the tools that you’re used to using, you become MacGyver.’’ Nurses who volunteer in developing areas return home as stronger problem solvers, with an eye toward upholding standards of care while conserving resources. And then there’s the real reward. ‘‘There’s just this floating feeling,’’ Averill says, her voice sweetening, ‘‘of peace and happiness of what you’re doing and the lives that you’re touching.’’ That feeling is the fuel in her tank — her ‘‘fix,’’ as she calls it. A childhood Army brat who as a young woman had lived in Mexico for three years, she got her first taste of it in 1985, when she organized a relief team to Mexico City after an 8.1-magnitude earthquake there killed thousands. It was her first volunteer trip, and she was amazed when other nurses from the Seattle/Tacoma area asked to come along. In 1999, she was invited to the northern mountains of Guatemala as part of a facial plastic surgery mission that required Spanish-speaking nurses. The feeling came again, stronger, and
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this time took hold. She began seeking out opportunities to do more. She arranged her career around the feeling. Honduras. Vietnam. Haiti. Romania. Last fall it was Nuevo Laredo — her eighth trip with Doctors Without Borders. Once a thriving city on the TexasMexico border, Nuevo Laredo has decayed into a dangerous nest of unemployment and urban violence, the result of drug cartels competing to control cargo traffic into the U.S. Those out of work — about half the city — rely on government medical care available only through a broken system of clinics and one Level 2 hospital serving 200,000 people. The emergency department constitutes only 2 to 3 percent of that 70-bed facility. There are quality nurses who wish to make a difference, family-practice doctors, willing administrators — but no ability to make improvements without outside help. Averill’s task was to run a diagnostic and create a project proposal, a two-year plan to make physical and systems changes, bring in the right medicines and equipment (including an ECG machine) and give the staff the proper training. Later, Doctors Without Borders will focus on fixing the clinic system and a ragtag emergency medical services network that relies on just two working ambulances at any given time.
Such is the work of the seasoned volunteers. Averill realizes that newcomers are hardly ready to jump into that level of service. That’s why One Nurse At A Time has focused on arranging missions for first-timers — nurses who never have volunteered outside the country and require a little more guidance. Averill accompanied four nurses from Seattle EDs to Guatemala over two back-to-back trips last February and March. One of those nurses has since gone back — ‘‘She’s just glowing over it,’’ Averill says — and plans to do so again in February. These are the transformations Averill sees as other emergency nurses reap the same satisfaction she has reaped. ‘‘I kind of float on that same cloud for a quite a little while,’’ she says of returning to home life. ‘‘I’m a nicer person. I’m a better nurse. I’m more compassionate. I’m a kinder person when I come back after a mission.’’
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he girl in Pakistan, wearing Averill’s red lipstick, surrounded by happy women, quickly pulled away at the request for a photo. ‘‘I can tell you tomorrow,’’ she told Averill timidly. ‘‘I have to ask my father.’’ It was a breach in the revelry. A reminder of the reality. And Averill never felt her call more strongly. ‘‘It struck me,’’ she says, ‘‘that here
February 2014
is this wonderful, open, loving half of society completely dominated by the other half of society and societal rules that didn’t allow them to move forward as people like we are expecting. And I thought, what happened to the spark that became me? My spark was in the United States [with] parents who believed in education, who were middle class, who loved me and encouraged me, and I didn’t have facial deformities. I didn’t have mental disabilities. I was born with all the privilege in the entire world … why was I not born a girl in Pakistan with a cleft lip and palate, and because I had a facial deformity I would never be married and therefore I was worthless? ‘‘What happened there? Why did that happen? And if I was born with all of that privilege, is it not incumbent on me to do more because of that and give back more because of that?’’ Medical volunteering can be international or domestic, for any length
Averill with some of the local and Doctors Without Borders staff in Uganda in 2006. of time — months or a week in Africa on an HIV project or a few hours taking blood pressures at a senior center or giving flu shots to the homeless. Never, Averill says, is an emergency nurse ‘‘just a nurse’’ limited by normal scope and responsibility. ‘‘If you have the knowledge and the
skills, you can do things — you can push beyond,’’ she says. ‘‘You can do whatever you need to do for that person who’s right there in front of you. You’re going outside those boundaries that feel really comfortable but really binding at the same time. It’s pretty remarkable.’’
Coming in Early 2014 SEVENTH EDITION Highlights Include: § Initial Assessment § New Chapters Teamwork and Trauma Care, Pain, The Bariatric Trauma Patient, Interpersonal Violence, and Post Resuscitation Care in the ED § Evidence-based Practice Balanced fluid resuscitation, blood component transfusion, and tourniquet use
The Emergency Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
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Meet the Accomplished 2013 AEN Fellows The 2013 class of fellows was inducted into the Academy of Emergency Nursing on Sept. 21 at the second annual Awards Gala at the ENA Annual Conference in Nashville, Tenn. AEN was created to honor emergency nurses for their contributions to the profession as demonstrated by • Enduring and substantial contributions to the advancement of the emergency nursing profession in education, practice, research, leadership or public policy; • Impact in advancing the emergency nursing profession in one or more of these areas; • Potential for sustained contributions to the advancement of emergency nursing and the Academy of Emergency Nursing.
Linda Arapian, MSN, RN, EMT-B, CEN, CPEN, FAEN, has been an active ENA member for more than 20 years at the chapter, state and national levels. With her background as a pediatric emergency nurse for more than 35 years in a Level 1 pediatric trauma center, she is most proud of her involvement in the development of the Certified Pediatric Emergency Nurse examination. She was selected to participate in the 2007 pediatric expert panel for the first role delineation study, was in the first CPEN item writer group and is completing her second term on the Examination Construction Review Committee. She is very honored and proud to have been involved in the evolution and development of the CPEN exam; more than 2,500 nurses credentialed as CPENs have been recognized for their knowledge and expertise in pediatric emergency nursing.
Susan Barnason, PhD, RN, APRN, CNS, CEN, FAEN, FAAN, FAHA, has been an active ENA member throughout her career. ENA has provided a strong basis for her clinical excellence in emergency nursing practice in both direct patient care and advanced practice responsibilities as a clinical nurse specialist, as well as when mentoring graduate nursing students. She is a Certified Emergency Nurse and has served in state offices for ENA as well as on national committees. Her passion for research and evidence-based practice is demonstrated by her publications and funded research, but also in her leadership to the Institute for Emergency Nursing Research, the Emergency Nursing Resources Development Committee and the Clinical Practice Committee. An integration of clinical practice, education and research has been the hallmark of her accomplishments and contributions to ENA.
Nancy Stephens Donatelli, MS, RN, CEN, NE-BC, FAEN, has served ENA at the local, state and national levels. She joined the ENA Board of Directors in 1983 and was the 1988 ENA president. She has authored numerous articles and book chapters along with teaching topics related to leadership, management and care of the older adult. She helped design and teach the original GENE course and is the editor and frequent author of the ‘‘Geriatric Update’’ column in JEN. Recently she has been volunteering with a group of emergency nurses in a small, rural community hospital near her home as a mentor to the clinical manager, a resource person for clinical issues and coordinator of a self-study CEN review program. Little did she know when joining the newly formed Emergency Department Nurses Association in 1970 that this organization would become the core of her professional career.
Joyce Foresman-Capuzzi, MSN, RN, CCNS, EMT-P, CEN, CPEN, CPN, CTRN, CCRN, FAEN, found her niche in nursing and has been afforded tremendous opportunities to write, review, edit for JEN, present, teach and collaborate with test development. As an item writer, Foresman-Capuzzi received the Gail P. Lenehan Advocacy award. She graduated with a Master of Science degree in nursing from Liberty University and expanded her nursing to advanced practice as a clinical nurse specialist. She receives unconditional support and encouragement from her husband and daughter, John and Lizzie. Foresman-Capuzzi has been blessed with the passion to nurse, serve, advocate, speak and care for patients. She is fulfilled, empowered and privileged to be an emergency nurse and feels there is no greater professional accomplishment.
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February 2014
Cathy Fox, RN, CEN, CPEN, FAEN, began her emergency nursing career in 1985. Her ENA journey began in the 1990s. She was re-elected to a second term on the ENA Nominations Committee in 2013. She has served in many roles at chapter and state levels, including twice serving as president of the Virginia ENA State Council. She currently sits on the Virginia Governors EMS Advisory Board. She has instructed CEN review courses at regional, national and international levels for more than 16 years. One of her most cherished ENA accomplishments is co-founding the Southeastern Seaboard Emergency Nursing Conference, which has been held successfully since 2000. She looks forward to mentoring ENA members as a new fellow.
Lynne Gagnon, MS, BSN, RN, CPHQ, NEA-BC, FAEN, has been a member of ENA for 34 years, serving at the local, state and national levels, including five years on the ENA Board of Directors and as the 1991 ENA president. She served on ENA’s Education Committee when the Trauma Nursing Core Course was developed and was faculty at the first national course offering and the first course taught in England. As ENA president, she established the Pediatric Committee that would go on to create the Emergency Nursing Pediatric Course. She received ENA’s Lifetime Achievement Award in 1998. In 1991, she served as the first chairwoman of the ENA Foundation. Beyond the ED, her commitment to nursing has provided opportunities to serve on the national board of Health Care Quality Certification and on the American Organization of Nurse Executives task forces and committees.
Louise Hummel, MSN, RN, CNS, CEN, FAEN, has more than 35 years of emergency nursing experience. She took the first CEN exam in 1980 and has proudly held the designation since. Hummel is a faculty member at California State University, San Marcos, inspiring the next generation of nurses to consider careers as emergency nurses. She has held local and state ENA positions within California, served on several national committees, including chairwoman of the Nominations Committee, and has been a General Assembly delegate since 1993. Hummel was section editor for the Certified Emergency Nurse Review Manual, 4th edition, and a contributing author to the Certified Pediatric Emergency Nursing Certification Review and the CPEN Review Manual. As a fellow, she plans to share her experience by mentoring others as they influence the future of emergency nursing.
Elizabeth Nolan, MA, BSN, RN, CEN, FAEN, an ENA member for more than 20 years, has been actively involved at the local, state and national levels. She has served on the ENA Membership Committee, the Awards Advisory Committee and the ENA Foundation Board of Trustees. A Massachusetts native, she began her nursing career as an officer in the Army Nurse Corps and retired as a colonel, U.S. Army Reserve, after 30 years. Nolan works for the University of Kentucky HealthCare as a staff development instructor, teaching TNCC, ENPC, Advanced Burn Life Support, Advanced Cardiovascular Life Support and Pediatric Advanced Life Support. In addition, she is an instructor for the Defense Medical Readiness Training Institute. She volunteers with Safe Kids Fayette County, the Medical Reserve Corps, the Lexington Medical Society Alliance and the Kentucky Horse Park.
Elda Ramirez, PhD, RN, FNP-BC, FAEN, FAANP, an ENA member since 1991, has been a faculty speaker for ENA national conferences for 12 years. She was the co-founder (1994) of the first master’s degree program for emergency nurse practitioners, which graduates more than 25 yearly. She was a member of the ENA Nurse Practitioner Validation Work Team, where her contribution supported the recognition of the emergency nurse practitioner role nationally. The work team’s deliverable was the nationally recognized Nurse Practitioner in Emergency Care Competencies; this product developed the groundwork for a national validation process that has been undertaken by the American Nurses Credentialing Center, of which she is a portfolio appraiser. Ramirez received a large grant from the Texas Education Board to educate graduate nurses in emergency/trauma care.
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INJURY PREVENTION Thelma Kuska, BSN, RN, CEN, FAEN, of the Illinois ENA State Council, gets down to business at Proviso West High School in Hillside, Ill., to educate students about driving dangers and give them a crack at a simulator that incorporates common distractions for teen drivers.
DRIVING HOME THE DANGER By Kendra Y. Mims, ENA Connection
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NA member Thelma Kuska, BSN, RN, CEN, FAEN, visited five high schools in the Chicago area during National Teen Driver Safety Week and showcased the Illinois ENA State Council’s newly acquired driving simulator to more than 2,000 high school students. Illinois ENA received the grantfunded simulator from State Farm and is the only ENA state council that owns a driving simulator, Kuska said. Although she has been traveling to high schools to talk about safe driving since 1989, this is the first time she was able to showcase a driving simulator to students and give them a hands-on learning experience on impaired and distracted driving. About 600 students attended the Oct. 23 NTDSW function at Proviso West High School in Hillside, Ill., where Kuska joined with Illinois State Police to demonstrate and talk about
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Illinois ENA State Council Uses Simulator to Teach Teens About Deadly Distractions
distracted driving. The police spoke to students about the dangers of texting while driving and pointed out that fatal car crashes are the No. 1 cause of death for teens in the United States. They showed footage of Illinois State Police trooper Starlena Wilson, who was struck by a car while conducting a traffic stop in 2010. The driver of the passing vehicle was not drunk or speeding — she had glanced down at her phone to read a text message and lost control of the car. Wilson’s body was crushed from the waist down. She underwent more than 20 surgeries and 13 months of rehabilitation. Because people tend to look at their phones when they ring or when they receive a text while driving, Kuska encouraged students to put their phones in a purse or another place where they aren’t visible to avoid the temptation of looking. After the lecture portion, students had an opportunity to use the driving simulator and experience the dangers
of distracted driving firsthand. The audio and visual features of the simulator are similar to a video game and showed students how they could easily get distracted. As they sat down and took the wheel, Kuska pretended to be a teen passenger — another major distraction for teen drivers. Students were prompted to dial phone numbers while they were driving, to respond to text messages, to pay attention to stop signs and directions and to heed Kuska’s requests to ‘‘go to the mall’’ or ‘‘get something to eat.’’ Many of the students crashed within the first minute or received a ticket for running through a stop sign. Many students showed surprise at how fast they crashed while trying to text and drive or answer an incoming call. Senior Justin Love stood in line to use the simulator twice. ‘‘I thought the presentation was a good learning experience, especially the simulator. It would be a good addition to a driver’s ed class,’’ he said.
February 2014
DID YOU KNOW? • The fatal crash rate for drivers ages 16 to 19, based on miles driven, is four times higher than for drivers ages 25 to 69. • In 2008, a total of 3,118 teens ages 15 to 19 died as a driver or as a passenger of a teen driver. • Nearly 70 percent of Americans ages 18 to 64 recently chatted on their phones while driving, and about 30 percent of this group sent text messages while behind the wheel. Source: teendriversource.org Students Against Destructive Decisions club member Limni Jimenez, a junior, also felt the simulator was a great hands-on experience. ‘‘I thought it was a really good idea for these teens to realize how hard it is to actually text and drive and how responsible you have to be on the road,’’ she said. ‘‘It’s a privilege to have a license, and they shouldn’t take it for granted and really be careful of
what they do and think of the consequences.’’ Kuska has received positive feedback from the schools and the students. Chicago’s Mother McAuley Liberal Arts High School, which Kuska visited during NTDSW week, requested that Kuska return this month with the simulator. She plans to continue visiting high schools with the Illinois State Police throughout the
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Official Magazine of the Emergency Nurses Association
school year, as well as attending the annual ‘‘March Madness’’ high school basketball event in Peoria, Ill. ‘‘We are going to go there with the simulator because there will be a lot of kids attending — it’s the one day where they are subjected to a variety of things before their events,’’ Kuska said. ‘‘The simulator is an added benefit. Anything we can do to promote injury prevention.’’
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PERSPECTIVES |
Kathy Szumanski, MSN, RN, NE-BC, Chief Nursing Officer
Watching Out For Risks With Mobile Medical Apps T
  he increasing uses of mobile technologies in health care are opening up a new world of access to health and wellness information for consumers. The increasing availability of applications provides individuals with instant access to details of health care information when they need it. Consumers also can find medical apps that give directions related to specific disease and management. It is estimated that by 2015, more than 500 million individuals will use a health care app on their smartphone. Health care professionals also use mobile medical apps in their daily practice. Some of these apps may provide key information related to care and management of particular diseases and conditions. In 2011, the issue of risk and safety related to mobile medical apps was explored by the U.S. Food and Drug Administration as part of its responsibility for public health. In fall 2013, the FDA released a guidance
document noting it had assumed an oversight role for monitoring the safety of mobile medical apps. Mobile medical apps are software programs that run on mobile communication devices and can be programmed to interact with other medical devices. The FDA focus will be on assuring that mobile medical apps work as intended and do not introduce greater risk to a patient. Some of these apps may be devices that transmit images and X-rays for doctors to review for diagnostic purposes. Other apps can be programed to transmit an electrocardiogram for interpretation and ultimate treatment. There are apps that can be accessed to adjust the infusion rate on pumps or to change the settings on various implantable devices. This part of the health care industry is expanding rapidly and can bring the diagnostic and treatment capacity of the health care professionals to a very different level. The FDA will not regulate general public use of various smartphones or tablets.
The use of mobile medical apps to transmit electronic medical records also will not be monitored for risk and safety by the FDA. The FDA has released a guidance document to inform the public, as well as health care professionals, on the current program established for the monitoring of mobile medical applications. It notes in the guidance document that the FDA oversight is based on the functionality of the apps and not the platform. Devices used strictly in research and not released for general public use are excluded from this monitoring; the devices used in a research study will be reviewed by an institutional review board to assure that the rights of research subjects are protected. The guidance document contains various levels of scrutiny that the FDA intends to apply as a part of its monitoring function. As with all medical devices, adverse events that occur relative to a particular mobile medical app must be reported. Clusters of similar adverse events may prompt the FDA to issue a recall for that device. The FDA has made available several online resources that will help individuals understand and comply with these newly published requirements related to mobile medical apps. The FDA Device Advice website can be accessed at www.fda.gov/Medical Devices/DeviceRegulation andGuidance. The FDA’s Center for Devices and Radiological Health webpage also provides training
February 2014
ENA Promotes Szumanski to Chief Nursing Officer
Attend the Candidate Election Forum at Leadership Conference
ENA has promoted Kathy Szumanski, MSN, RN, NE-BC, to chief nursing officer. Szumanski had served as ENA’s director of the Institute for Quality, Safety and Injury Prevention since 2010. Before joining ENA, Szumanski served in many key hospital leadership roles, including director of clinical excellence and nursing professional development for Advocate Lutheran General Hospital in Park Ridge, Ill. She has leadership experience in the areas of education, research, regulatory compliance, quality and risk analysis. She holds a Master of Science degree in nursing from Loyola University Chicago. Catherine Olson, MSN, RN, was promoted to director of IQSIP.
Learn about the candidates running for the ENA Board of Directors during the Candidates Election Forum held at Leadership Conference 2014 in Phoenix on Saturday, March 8, from 11:30 a.m. to 1 p.m. Beginning in May, ENA members will have the opportunity to vote in the ENA national election and decide who will serve their organization. Before voting begins, learn who the candidates are, their qualifications for holding ENA office and their visions for the future of emergency nursing and for ENA. To learn more about the candidates in advance, go to www.ena.org. Profiles will run in the May issue of ENA Connection.
modules as a part of its educational activities for the mobile medical apps industry. These training programs can be found at www.fda.gov/Training/ CDRHLearn. If mobile medical apps are a new adventure for you, the U.S. National Library of Medicine has a guide to
mobile resources at www.nlm.nih. gov/mobile. It is anticipated this area of FDA monitoring will continue to evolve as the technology industry evolves. The full FDA guidance document of mobile medical applications is available on the FDA website.
You Can Make A Difference! Come to Washington D.C.
On May 6-7, 2014, please join emergency nursing leaders from across the country for ENA’s Day on the Hill event at the Crystal Gateway Marriott in Crystal City, VA, located just minutes from Washington D.C. and Capitol Hill. Meet with your members of the U.S. Congress and their Capitol Hill Staff. Learn more about advocacy and how you can make a difference in current emergency nursing legislative issues. Contact your ENA State President or Government Affairs Chair for details and reservations or email gov@ena.org with any questions. DayontheHill 2014_Connection_half_02 2014.indd 1
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ENA FOUNDATION
Keeping Co-Founder’s Fire Burning Permanent Kelleher Scholarship to Support Education of Nurse Practitioners By Kendra Y. Mims, ENA Connection
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NA co-founder Judith C. Kelleher, MSN, RN, CEN, FAEN, was a visionary and a leader who had a passion to change lives, improve the emergency nursing profession and contribute to emergency nursing education. She joined with Anita Dorr, RN, FAEN, and together they created the national Emergency Department Nurses Association in 1970. After Dorr’s passing in 1972, Kelleher carried on their shared vision and led the organization to national prominence, raising the standard of how emergency nurses practice today. Kelleher died Jan. 24, 2013, at the age of 89. Though ENA lost its co-founder and visionary, the ENA Foundation continues to carry on Kelleher’s vision to help emergency nurses advance their education through the Judith C. Kelleher Memorial Endowment — renamed immediately after Kelleher’s death. Through the generous donations of ENA members, state councils, chapters and friends of emergency nursing, the ENA Foundation will be able to offer the new $5,000 Judith C. Kelleher Educational Scholarship to a nurse practitioner each year in perpetuity. Kelleher’s granddaughter, Charlene Wilson, RN, expressed her excitement about the new scholarship. ‘‘My grandmother believed that the key to personal empowerment and professional advancement is education,’’ Wilson said. ‘‘It is fitting that a scholarship that continues to renew itself is named after a woman who never stopped learning. When I imagine how many nurse practitioners this scholarship will help to create, I am thrilled. I know my grandmother would be honored and proud.’’ ENA President Deena Brecher, MSN, RN, APRN, ACNS-BC, CEN, CPEN, said the scholarship will help serve an increasing need. ‘‘The role of the nurse practitioner in the ED is growing and evolving, and the demand for nurse practitioners is growing,’’ Brecher said. ‘‘Judy Kelleher was an incredibly
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ENA’s late co-founder, Judith C. Kelleher, and the recipient of the first $5,000 Judith C. Kelleher Educational Scholarship, Andi Foley, MSN, RN, CEN (inset). strong advocate for education, and providing scholarships for emergency nurses who want to go back to school to become nurse practitioners assures that her legacy lives on.’’ Andi Foley, MSN, RN, CEN, was the first recipient. She said the scholarship is helping her achieve her professional and educational goals. ‘‘I’ve always been passionate about nursing,’’ she said. ‘‘This scholarship has allowed me to focus more on my studies and become more aware of the meaning behind what I’m doing. Being selected, especially in the year that Judy died, is just unbelievably touching. It’s a reawakening and a call to really embody what she stood for in terms of her passion for emergency nursing, continuing education and lifelong learning. It’s about sharing that with as many
February 2014
people as I can.’’ Foley is a clinical nurse specialist and unit-based educator at St. Francis Hospital in Federal Way, Wash. She returned to school in 2012 and enrolled in the adultgerontology clinical nurse specialist program. She anticipates graduating from the University of South Alabama with her MSN in 2014 and receiving her doctorate of nursing practice in 2015 as a clinical nurse specialist. She believes pursuing further education and training can help to improve patient outcomes. ‘‘The really cool thing about the clinical nurse specialist training is that it’s really focused on patient outcomes for individual patients and groups of patients,’’ Foley said. ‘‘Because I don’t have a patient caseload like the front-line nurse, a lot of the work and training that I do requires me to look at patient care from a broader perspective by examining nursing competencies, processes, patient safety and best practices. I also have to review what is in the literature and figure out how we can bring it forward to help emergency nurses provide the best care to their patients at the bedside.’’ Foley is touched by the generosity and passion of those who have contributed to the Judith C. Kelleher Memorial
Endowment to make the scholarship opportunity possible for her and future emergency nurses. ‘‘Every time I’ve gone to school, I’ve learned something that has not only made me a better nurse but also a better person,’’ she said. ‘‘I’ve been very fortunate that the ENA Foundation has supported me to do this. I think the work that the foundation is doing is so important in terms of helping nurses continue their education and supporting nursing research. The opportunities provided are just amazing.’’ Becoming the first recipient of the Judith C. Kelleher scholarship was a humbling experience. ‘‘I feel extremely honored that the ENA Foundation saw the potential in me, and now I can use my education to continue advancing emergency nursing, following the path Judith Kelleher and Anita Dorr started so many years ago,’’ Foley said. ‘‘As the first recipient of this scholarship, I carry a great sense of appreciation and responsibility for the ENA Foundation and the fabulous emergency nurses I work with every day. I can’t say thank you enough.’’
Find out how you can carry on Kelleher’s legacy and passion for emergency nursing education and make a difference for your peers by visiting www.enafoundation.org.
Presents:
What it means to be a leader
Career Center
§ Integrity § Communication § Creativity
§ Passion § Confidence § Sense of Humor
Please join us for a panel discussion on the traits and qualities of successful nurse leaders. Followed by small group networking with the panelists.
Who: Emerging Leaders When: March 8, 2014, 6 pm Where: 2014 Leadership Conference, Phoenix, AZ
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READY OR NOT? |
Knox Andress, BA, RN, AD, FAEN
Radiation Emergencies: A Resource to Remember O
n Dec. 4, the International Atomic Energy Agency announced the theft and apparent hijacking of a truck transporting a radioactive and potentially lethal cobalt-60 teletherapy source. The truck was moving the gamma-ray source from a hospital in Tijuana, Mexico, to a waste storage facility near Mexico City. While in transport, the radioactive source is customarily sealed in a thick, protective casing that shields workers and personnel in the immediate area. Immediate and international concerns included public safety for potential radiation contamination (should the casing be opened) and for terrorism. Cobalt-60 is a desirable radioactive component in the construction of a ‘‘dirty bomb.’’ Such a bomb includes a conventional explosive and a radioactive element or source material. The detonated conventional explosive disperses the
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radioactive element within the shrapnel and flying debris, contaminating everything it touches. The truck and cobalt-60 were recovered two days after the theft; however, the protective casing for the cobalt-60 had been opened and six alleged thieves were being monitored for signs of radiation sickness. Intent of the theft was unknown at the time.
Missing Sources Recently, the Government Accounta bility Office published report 12-925, ‘‘Additional Actions Needed to Improve Security of Radiological Sources at U.S. Medical Facilities,’’ highlighting security challenges found during GAO visits to 26 hospitals. Radioactive sources are usually secure, but occasionally they are lost, misplaced or stolen, potentially posing a threat to humans and a radiation emergency challenge for the emergency department. In a 2003 GAO
report, ‘‘Federal and State Action Needed to Improve Security of Sealed Radioactive Sources,’’ more than 1,300 devices containing sealed radioactive sources were reported lost, stolen or abandoned since 1998. A radiologic incident could involve an accidental exposure, which most frequently occurs in an occupational or work setting and frequently involves the hands and feet. Terrorism-related exposures could result from contamination in food or water, placement of a source material in a public area, detonation of a dirty bomb, an attack on a nuclear power plant or waste storage facility or detonation of an improvised nuclear device. Where can the emergency nurse and physician quickly find radiation treatment guidelines and other needed resources?
Radiation Emergency Guidance The U.S. Department of Health and Human Services, Office of the Assistant
February 2014
Secretary Preparedness and Response, offers a public health/radiation emergencies webpage at www.phe. gov/emergency/radiation. The easily navigable site is categorized into six linked areas: • ‘‘Medical Management’’ provides guidance in evaluating the exposure and/or contamination, external and/or internal contamination and considerations for cellular or systemic radio isotope incorporation. A beneficial and substantial feature in this section includes the algorithm for evaluating, decontaminating and treating the potentially exposed and/or contaminated patient. • The ‘‘Decontamination’’ section provides the considerations, process and evaluation for decontaminating the whole body, skin, eyes, open wounds, hair and body cavities and shrapnel management. Radiation survey resources include a printable graphic with instructions for performing and
Radioactive Source Examples in the Medical Community Application
Radioisotope
Irradiator (blood)
Co-60; Ce-137
Teletherapy
Co-60; Ce-137
Teletherapy (fixed gamma-ray knife) Brachytherapy
Co-60
Co-60, Ce-137
(high-medium dose) Brachytherapy
Ir-192
Ce-137; Ra-226;
St-90; Pa-103;
Io-125; Ir-192;
Au-192; Ca-252
Ru/Rh-106
documenting survey results developed by the Radiation Emergency Assistance Center/Training Site, Oak Ridge, Tenn. • ‘‘Patient Management’’ provides an overview of radiation and radioisotopes and the potential impact to the human
body. The pathophysiology and countermeasures for acute radiation syndrome are provided. Resources within this section include a video tutorial on radiation exposure time/dose relationships and federal ‘‘Radiation Emergency Contacts,’’ including the agencies and their phone numbers. • The ‘‘Overview and Background,’’ ‘‘For Public Health and Medical Professionals’’ and ‘‘For Media and Communications Professionals’’ sections link to the Centers for Disease Control website resources for radiation and nuclear incident management.
Other Resources There are several Internet resources for a radiologic or nuclear incident exposure, as well as state, community and hospital resources. State poison control centers are also available at 800-222-1222 as a resource in this and other potentially toxic exposure scenarios.
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BOARD WRITES |
Michael D. Moon, PhD, MSN, RN, CNS-CC, CEN, FAEN
The Wisdom We Can Learn From Children S
afe practice and safe care are central tenants to ENA’s mission. Every day in emergency departments across the country, emergency nurses have to care for a diverse group of patients in a variety of settings. Often, the pace of providing that care prevents RNs from taking care of ourselves, let alone engaging in activities that are central to our growth as professionals. It is imperative that we find ways to continuously grow professionally if we want to fully realize safe practice and safe care. This brings me to the discussion about what we as emergency nurses can learn from the children of the world. There are two pivotal points in childhood development that can provide a basis for our professional development. The first occurs when children are toddlers. This is a time when children seek clarity in their world, sometimes to the consternation of parents. ‘‘Why?’’ becomes the mantra. These toddlers are exploring their world and its complexities in a way that makes sense to them. It can get to the point where parents finally say, ‘‘Because that is just the way it is’’ or ‘‘Because I said so.’’ The second pivotal point occurs when children reach the preschool years. The ability of preschoolers to say what’s on their minds is one of the most endearing and sometimes stressful things about this stage. I’m sure we can all envision a child standing in a large group of people with an arm outstretched, pointing as she states the obvious: ‘‘Daddy, look at
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that man — he’s missing a leg.’’ There is no malicious intent – she is merely stating fact as she sees it. Think back to your last shift in the ED: Did you observe a practice that did not seem quite right at the time? Did you have the opportunity to discuss it or ask why care was being provided that way? How many times have you asked why something is done in your department? Perhaps it’s a particular procedure; perhaps it’s the way triage is performed. What was the response you received? Did you receive an explanation that seemed reasonable, or did you get the proverbial response, ‘‘We’ve always done it that way’’? Did this encourage you to take action or to accept things the way they are? Reflective practice is essential if we are to provide safe practice and safe care. It provides a means for emergency nurses to think about the care we provide. Tanner 1 highlights that ‘‘reflection on practice is often triggered by a breakdown in clinical judgment and is critical for the development of clinical knowledge and improvement in clinical reasoning.’’ Reflective practice does not have to wait until a sentinel event occurs. It should be an ongoing process throughout our careers. Reflective practice is not a new concept; Dewey first introduced it in the early part of the 20th century.2,3 However, it was not until the 1980s —
based on works by Schön 4 — that it gained more widespread acceptance as a critical component of learning. Schön 4 outlined two types of reflective practice: reflection-in-action and reflection-on-action. Reflection-in-action is defined as
Continued on Page 30
E m e r g e n c y N u r s e s A s s o c i a t i o n a n d G e n e n t e c h
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Q: As a conference attendee, why is it important that I stay at one of the ENA conference hotels? A: It is important for attendees to stay at one of the designated ENA conference hotels because of the contractual obligation ENA has with these hotels to ensure enough rooms are available to our attendees at a negotiated rate lower than the average tourist or traveler could obtain. Contracting with hotels for a specified number or ‘‘block’’ of rooms allows ENA to secure properties close to the convention center that offer the amenities and value consistent with the preferences of our membership. When attendees book ‘‘out of the block,’’ this can create room surpluses at one or more properties. If a surplus at
Wisdom of Children Continued from Page 28 the self-monitoring that occurs while an individual is engaged in an experience. Reflection-on-action is a review of an experience once that experience is completed. Emergency nurses are engaged in reflection-in-action on a daily basis. As conditions with our patients or the environment change, we adjust our practice to meet the demands of the situation. However, we rarely take time as individuals — much less as a group — to engage in reflection-on-action, which is just as essential to the safety of our practice. Reflection-on-action allows us the time to ask the ‘‘why” questions and really critique our practice in order to discover new understandings and improve our future practice. Tanner 1 notes several studies that demonstrate that engaging in reflection enhances experiential learning, improves clinical knowledge, improves
30
Use ‘‘Ask ENA’’ to ask about the organization and emergency nursing in general. Questions will be referred to the appropriate ENA staff or department. Submission does not guarantee publication. E-mail questions to connection@ena.org. a particular property reaches amounts beyond what is negotiated, ENA must pay attrition by paying the hotel for what it has lost by not being able to fill the room vacancies. A city is able to examine ENA’s past occupancy history, which is recorded much in the same way activity is recorded on your credit report. The better ENA’s performance is in fulfilling the agreed-upon hotel requirements, the better negotiating power we have as an association with the properties with which we do business. By booking your hotel room with the designated hotels and before the cutoff deadline, you have the best opportunity to maximize your conference dollar and ensure your association maintains its bargaining edge when booking subsequent cities.
judgment in complex situations and improves clinical reasoning. Kuiper and Pesut 5 and Ruth-Sahd 6 provide an excellent synopsis of the literature dealing with reflection. We as nurses are responsible for our own professional development and our own practice. If we are to find our experiences meaningful, we must first value those experiences,7 good or bad. Our experiences are a source of growth. As you move forward, remember the wisdom we can learn from children: clearly stating what we are experiencing and asking why. How you manage your practice can make the difference in patients’ lives. References 1. Tanner, C.A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204–211. 2. Dewey, J. (1910). How we think. Lexington, MA: D.C. Heath.
— Dale P. Gibbons, CAE, Director of Conferences
3. Dewey, J. (1933). How we think: A restatement of the relation of reflective thinking to the educative process. Lexington, MA: D.C. Heath 4. Schön, D. A. (1983). The reflective practitioner how professionals think in action. New York, NY: Basic Books. 5. Kuiper, R.A., & Pesut, D.J. (2004). Promoting cognitive and metacognitive reflective reasoning skills in nursing practice: Self-regulated learning theory. Journal of Advanced Nursing, 45(4), 381–391. 6. Ruth-Sahd, L.A. (2003). Reflective practice: A critical analysis of databased studies and implications for nursing education. Journal of Nursing Education, 42(11), 488–497. 7. Decker, S.I. (2007). Simulation as an educational strategy in the development of critical and reflective thinking: A qualitative exploration. (Doctoral dissertation). Retrieved from ProQuest Dissertations & Theses database. (UMI No. 3271413).
February 2014
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LOR E M
Letter From the President
Continued from Page 3
ADVERTISER INDEX
is the evidence to support doing it? Say you have an idea for a resolution but you don’t know what to do next. Head to www.ena.org and read the bylaws and resolutions guidelines. They can be found in the member’s-only section of the website under ‘‘General Assembly.’’ Contact the Resolutions Committee for help drafting or revising your resolution ideas by sending an e-mail to componentrelations@ena.org. The ENA members who serve on the committee will be happy to answer any question you might have about the process. Resolutions to be brought to the 2014 ENA General Assembly are due by 11:59 p.m. Central time on Saturday, March 1. Each year at General Assembly, ENA members like you bring forth ideas and suggestions for how ENA should proceed. It may seem like a long, overwhelming and intimidating process and something that is daunting to start yourself. I want you to know as an emergency nurse, anything is possible. Your ideas and your voice can be ENA Connection/Emergency Nurses Assoc. PUBLICATION heard154099 by writing a resolution, and you just might start a 625370
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NOTES
Official Magazine of the Emergency Nurses Association
31
28 41 55 68 %
Average improvement in throughput for admitted and discharged patients
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Average improvement in time from arrival to seeing a physician.
%
Typical improvement in patient satisfaction scores and likelihood to recommend
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Average improvement in LWBS rates, resulting in an additional $1.6 million in collected revenue
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