Nurse Marquette
2013
Goin g Di g ita l
Creating apps to aid patients
Simulation center ripple effect | Student-faculty research collaboration
F ro m t h e De a n
Responding to the changing marketplace Community engagement, research innovation and responsive graduate
John Nienhuis
programs characterize a year of steps forward Last year at this time, I remember thinking that things could not get busier or more exciting than they were during the opening of our new Wheaton Franciscan Healthcare Center for Clinical Simulation (see page 12) and the beginning of a year-long journey to develop a new university-wide strategic plan. I was wrong. This year has brought even more exciting news for the College of Nursing, as well as meaningful steps forward for the university as a whole. Following a year of collaboration and input from across campus, the Board of Trustees approved a new strategic plan, Beyond Boundaries: Charting the Course for Marquette’s Future, in May. I’m happy to report that the College of Nursing is already contributing to several of the plan’s goals, most notably in the area of social responsibility and community engagement. During the past year, we’ve forged exciting new partnerships with community organizations and health systems that will help us grow as a community resource for improving health care access and delivery. On page 2, you can read more about the $5 million grant we received from the Department of Veteran Affairs to teach veterancentric care in partnership with the Clement J. Zablocki VA Medical Center. The College of Nursing also partnered with the No. 4 children’s hospital in the nation, Children’s Hospital of Wisconsin, to open two new clinics in neighborhoods with few primary care options (see page 3). Another Beyond Boundaries theme is research in action, which complements the work our nursing faculty do every day to advance health care delivery, improve patient care, and enhance communication and procedural best practices and techniques. One of the hallmarks of successful nursing research institutions is the ability to combine this scholarship with technological advances to move the field forward. You can read about four new digital applications developed by our faculty to improve patient care beginning on page 10. To learn about the research our students are undertaking with the help of faculty mentors, turn to page 9. As we work to advance nursing research and health care innovation, we remain committed to achieving the highest levels of academic excellence. That means we are preparing our students for the field of nursing today, while also responding to the ever-changing health care marketplace of the future through new graduate-level programs in the field of advanced practice nursing (see page 6). I hope you enjoy reading this third issue of Marquette Nurse and learning about the achievements of your fellow alumni and the growth of your College of Nursing. One of my favorite parts of my role at Marquette is getting to hear from and meet our alumni who are changing the world through their compassionate care. The next time you’re on campus, I encourage you to come tour our new Center for Clinical Simulation, sit in on a class or just say “hi.” I look forward to hearing from you. Marquette blessings! Margaret Faut Callahan, Ph.D., C.R.N.A., F.N.A.P., F.A.A.N. Dean and professor, Marquette University College of Nursing Interim provost, Marquette University
Kat Schleicher
Tab l e of C o nt e n t s 2 NEWS Partnerships on Milwaukee’s front lines • Educating the next generation to care for veterans • Bringing primary care to Milwaukee’s inner city neighborhoods Faculty retirees leave their mark
Contributing writers: Kurt Chandler, Chris Jenkins, Alexis Lozinak, Andrea Petrie, Alexa Porter, Lynn Sheka, Paula Wheeler and Carol Winkel Editorial team: Margaret Faut Callahan, Stephen Filmanowicz and Lynn Sheka
Student perspective: the reimagined curriculum Nursing alumna starts scholarship to increase diversity
6 RESEARCH AND INNOVATION
Graphic design: Joan Holcomb
New graduate programs respond to changing marketplace
Contact: Share comments or ideas for future issues with Lynn Sheka at lynn.sheka@marquette.edu.
Tipping the scales toward healthier body weight
College mission
Stronger together: faculty-student research collaboration
Through a transformational Catholic, Jesuit education, the mission of the Marquette University College of Nursing is to prepare nurse leaders to promote health, healing and social justice for all people through clinical practice and development of nursing knowledge. The faculty, students and staff of the college are committed to: • Providing high-quality, compassionate care focused on individuals, families and communities. • Advocating for social justice to eliminate health inequities. • Engaging community partners to promote health care for all. • Generating, evaluating and applying knowledge to improve health and education outcomes.
Global impact: patient safety culture in China
10 creating apps to aid patients Nursing faculty “go digital” to improve patient care
14 THE RIPPLE EFFECT The cutting-edge Wheaton Franciscan Healthcare Center for Clinical Simulation has become an interdisciplinary hub
18 ALUMNI Perspectives Blazing a trail: Dorothy Klofta, Nurs ’59
• Creating a dynamic, innovative learning community.
Marquette nursing legacy families
• Leading change to improve the health care environment.
Staying connected
On the cover: Dr. Norah Johnson, assistant professor of nursing, demonstrates her iPad app, which helps put children with autism at ease before unfamiliar medical procedures.
Then and now: Class of 1963
20 NOTABLE SCHOLARLY ACCOMPLISHMENTS
Photograph by Aaron J. Ledesma
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Partnerships on Milwaukee’s f Educating the next generation to care for veterans By Lynn Sheka America is home to more than 20 million veterans, according to the Department of Veterans Affairs. Many of these veterans have specific
“Veteran-centric educational
health care needs that must be met during the next decade. Meanwhile,
opportunities will be woven
Center in Milwaukee are eligible for retirement.
throughout the college’s
Recognizing that nurses will be critical to providing care for those who
pre-licensure curriculum for
nership of the College of Nursing and the Milwaukee VA as one of six
all undergraduates.”
Program. The $5 million grant will prepare Marquette nursing students
20 percent of direct care nurses at the Clement J. Zablocki VA Medical
served our country, the Department of Veterans Affairs chose the partin the nation to participate in a five-year Nursing Academic Partnership to promote health, healing and social justice for veterans and their families through culturally based and spiritually reflective clinical practice. The program will fund 10 additional, full-time College of Nursing faculty members during the next five years. These faculty members will enable the College of Nursing to increase its freshman class size by 20 students this year (from 110 last year to 130 admitted for fall 2013) plus another 20 students in subsequent years, for a maximum enrollment of 150 students beginning with the 2014–15 academic year. “Marquette’s College of Nursing is committed to embedding itself within the Milwaukee community by partnering with health care leaders like the Milwaukee VA,” says Dr. Margaret Faut Callahan, dean of the College of Nursing and interim provost at Marquette University. “As part of the partnership, veteran-centric educational opportunities will be woven throughout the college’s pre-licensure curriculum for all undergraduates.” Students interested in veteran-centric care can apply to a competitive cohort program, where they will follow the pre-licensure curriculum but complete their five required clinical placements at the Milwaukee VA. The program’s goal is to place graduates into nursing positions at the Milwaukee VA or another VA facility. The five other partner schools chosen by the Department of Veterans Affairs are: Arizona State University, Emory University, New Mexico University, Oregon Health and Science University, and the University of Minnesota. ✣
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s front lines
Bringing primary care to Milwaukee’s inner-city neighborhoods
Expanding our footprint The two new clinics in partnership with Children’s Hospital will complement the College of Nursing’s existing community
By Lynn Sheka
clinics, including the nurse-managed Marquette Neighborhood Health Center in
Children’s Hospital of Wisconsin and the
care clinical placement requirement. The
College of Nursing have partnered to bring
organizations hope to partner to offer flu
two new nurse-managed community clinics
shot clinics and free health care screenings
to patients in areas of Milwaukee that most
to underserved populations from the neigh-
need primary health care.
borhoods surrounding the two clinics.
Adult and family nurse practitioners from
“The opportunity to partner with the No.
The Marquette Clinic for Women and
the College of Nursing staff the new
4 children’s hospital in the nation to bring
Children, run by the College of Nursing,
Children’s Hospital Primary Care Clinics,
health care to neighborhoods with few
is a central-city clinic that cares for some
which are located within the COA Youth &
primary care options is one the College of
of the most vulnerable populations in the
Family Centers — Goldin Center on West
Nursing could not pass up,” says College of
city. It is one of only 20 free clinics in the
Burleigh Street and the Northside YMCA,
Nursing Dean and Interim Provost Margaret
Milwaukee metro area.
located on West North Avenue.
Faut Callahan. “By working together, each
Both undergraduate and graduate Marquette nursing students have the opportunity to participate in clinical activity at the two new clinics to fulfill their community health
Milwaukee’s Hillside Family Resource Center, which provides women’s health and prenatal services in areas with high infant mortality rates.
institution can utilize its strengths — Children’s in administering clinics, and the College of Nursing in providing community-based health care education.” ✣
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Leaving their mark Retiring professors represent 90 years of collective contributions to teaching, research and the student experience
Dan Johnson
By Alexis Lozinak
Dr. Lea Acord
manage clinical settings and integrate your
professor of nursing
research,” Fehring says. “It’s a challenge,
A natural leader, Dr. Lea Acord served as dean of the College of Nursing from 2003–07,
Fehring’s early days in managed health
but says her true passion is in the classroom.
and wellness clinics have led to his current
“My return to teaching made me remember why I loved nursing education in the first place,” says Acord, who also contributed to university-wide policy-making through her role as vice-chair of the University Academic Senate, which advises senior
to the website that has provided natural family planning counseling to more than 4,000 women.
academic mission.
his research efforts with natural family planning, but with greater travel flexibility.
from her expertise in health policy and the
Dr. Mary Ann Lough
nursing workforce, including how nursing
assistant professor of nursing
modate the health care challenges the nation faces.
During her three decades of service to the College of Nursing, Dr. Mary Ann Lough has worn many hats: professor, associate
“Curricula have to change because health
dean, clinical nurse leader and director of
care is changing so quickly,” says Acord.
graduate operations. In 2008, she helped
“The College of Nursing is at the forefront
found the college’s doctor of nursing practice
of these changes and is shaping where
program, the first of its kind in the state.
nursing will go.”
As director of the Marquette Clinic for
Never one to sit still for long, Acord will
Women and Children for 13 years, Lough
take on a new role in retirement as president
was instrumental in bringing health care to
of the Wisconsin Nurses Association.
vulnerable populations in the city’s poorest
Dr. Richard Fehring professor of nursing
ZIP codes. “The core curriculum is so important to Jesuit education,” says Lough, who taught
Since coming to Marquette in 1980, Dr.
at Marquette for 34 years. “That’s why I
Richard Fehring has taught research methods
came to Marquette.”
— both in the classroom setting and in clinical practice — as a way students can extend knowledge. “You get a lot of variety when you not only teach, but also maintain a clinical practice,
Marquet te Un i versity
dedicates time each day to contribute
In retirement, Fehring plans to continue
education will need to change to accom-
4
work as director of the College of Nursing’s Institute for Natural Family Planning. He
leadership on matters central to Marquette’s
Acord’s nursing students have benefited
(Left to right): Dr. Lea Acord, Dr. Mary Ann Lough and Dr. Richard Fehring
but it keeps things exciting.”
Lough plans to volunteer, travel with her husband and spend more time with her children and grandchildren during retirement. ✣
Student perspective: the reimagined curriculum During fall 2012, the College of Nursing introduced a reimagined pre-licensure curriculum that addresses the health care demands of tomorrow through enhanced simulation opportunities and a greater focus on nursing in the Jesuit tradition. Marquette Nurse caught up with nursing students to hear their thoughts on the new curriculum:
“The best part of using the Wheaton Franciscan Healthcare Center for Clinical Simulation is that we’re in a safe, nurturing environment, so this is the time to challenge ourselves to try new things so that
Students participate in a simulation in the Wheaton Franciscan Healthcare Center for Clinical Simulation.
when the time comes to make decisions affecting real lives, we are
“Everything in the new curriculum ties into the fact that we’re
comfortable and prepared to handle whatever comes our way.”
Marquette Nurses for a reason.”
— Kat Clark, Nurs ’13
— Chrystal Mattappillil, sophomore
“We are told that in the Jesuit tradition, we are called to be ‘servant
“Part of being Jesuit means really delving into a world where we are
leaders.’ From outside the program, it sounds like an oxymoron, but by
a person for others. Nursing is a career that needs just that —
being servants to our patients we become leaders in health care.”
individuals who can give of themselves to aid those in need and really
— Ryan Schaefer, junior
work as children of God for the good of the greater community.” — Erin Brauer, junior
Nursing alumna starts scholarship to increase diversity By Andrea Petrie Instead of receiving gifts for her birthday this year, Joan (Roets)
Mulligan knows firsthand the dedication and hard work it takes to
Mulligan, Nurs ’42, decided she would rather give a gift to
complete a nursing degree. “I grew up during the Great Depres-
today’s nursing students. In honor of her 92nd birthday, she
sion. I’m a Depression nurse,” says Mulligan. “I’m compelled to
started the Joan Mulligan College of Nursing Scholarship, which
help others because I know what it’s like to be in a difficult place.
will provide financial support to a deserving College of Nursing
I want all students to have the best chance to be successful.” ✣
student with a diverse background. Mulligan met her husband, Jim Mulligan, Eng ’41, while singing in the Marquette chorus. (He was the handsome band leader.) Courtesy of University Special Collections and University Archives
They married in 1945 and started a family, which now includes a son and daughter, six grandchildren and two great-grandchildren. More than two decades after receiving her undergraduate degree at Marquette, Mulligan returned to campus as a graduate student, earning a master’s degree in nursing in 1968. She then worked as an assistant professor in the College of Nursing for 15 years, earning the nickname “Mrs. Marquette” by students because of
Joan (Roets) Mulligan and fellow members of the class of 1942.
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R e s e a rch a n d Innovati on
New graduate programs respond to changing marketplace By Paula Wheeler As health care systems and providers adapt to policy reform,
Pediatric specialists can add the skills to care for adults and older
new care delivery models increasingly require more and better
adults, and vice versa. The program can be completed in 12 months.
primary care — something advanced practice nurses are well suited to provide. To help meet the growing demand for advanced nurse professionals, the College of Nursing is rolling out three new graduate programs that offer students efficient options for gaining these critical skills. Nursing continues to be a high-demand occupation, according to the Bureau of Labor Statistics. A 2012 study in Medical Care predicts that the nurse practitioner population will nearly double by 2025, with the profession’s growth most notable in primary care. “Research has shown that advanced practice nurses can provide quality care for the majority of patient needs seen in a primary care setting,” says Dr. Maureen O’Brien, associate dean for graduate programs. These practitioners “can contribute substantially to ensuring that high quality health care is accessible and affordable for all who need it,” she adds. The college’s new post-master’s family nurse practitioner certificate program, which started this fall, prepares primary care nurse practitioners who already specialize in a given population to take the FNP certification exam and expand their scope of patient care.
O’Brien points to more primary care clinics springing up in retail establishments, such as Walgreens, as one driver of the growing demand for FNPs. “By completing this post-master’s program, students will have a greater depth of preparation and ability to care for patients across the full life span than they would if they had just earned a master’s degree as a FNP,” O’Brien says. The new generalist master’s for non-nursing graduates will debut in May 2014, replacing the current master’s direct-entry program for non-nursing graduates. An intensive and accelerated program, the GEM curriculum enables students with non-nursing bachelor’s degrees to become licensed for nursing practice and earn a generalist master’s degree in just 18 months. The current 15-month pre-licensure phase of the direct-entry program prepares students only to sit for the Wisconsin R.N. licensure exam. To earn their master’s degree, students then need to choose a specialty and complete, on average, an additional three years of education. “We found that some students really want the nursing degree, but they’re not sure what specialization they want to pursue at first. Or they want to come to our program, then go back to where they moved here from. This program meets those needs,” O’Brien explains. The GEM program also includes a higher percentage of graduate-level courses focusing on health and safety, quality, and outcomes management. The college’s new post-master’s doctor of nursing practice for nurse leaders program, largely built around distance learning and tailored for busy nurse executives, welcomed its first cohort this fall. A key impetus for the program is the American Nurses Credentialing Center’s Magnet Recognition Program for nursing excellence and quality patient care. Magnet criteria require health care organizations to have a chief nursing officer trained at the doctoral level. “The combination of the competencies we can provide and the primarily online format makes the program attractive to busy nurse leaders,” O’Brien explains.
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Tipping the scales toward healthier body weight By Alexa Porter One such leader is Mary Ouimet, Nurs ’86, vice president of patient care and chief nursing officer at Wheaton Franciscan
Three Marquette researchers were
Healthcare–All Saints in Racine, Wis., who recently joined the
recently awarded a nearly $200,000
new DNP program. She says the timing of all three new
grant through the Healthier Wisconsin
programs couldn’t be better.
Partnership Program to investigate
“Having a well-prepared core of advanced practice nurses is really critical if we are to actively manage care in this new health care environment,” Ouimet says. “So these kinds of graduate programs
healthy body weight among AfricanAmerican women in Milwaukee’s central-city neighborhoods.
that really focus on supporting that need in the marketplace are
Dr. Robert Topp, professor and associate
very helpful.” ✣
dean for research in the College of Nursing; Dr. Mary Ann Lough, assistant professor of nursing; and Dr. Angelique Harris, assistant professor of social and cultural studies in the Helen Way
At a glance:
Klingler College of Arts and Sciences,
Marquette’s new advanced practice programs
from the Medical College of Wisconsin and the Bread
Doctor of nursing practice for nurse leaders
The grant’s aim is to promote healthy body
are collaborating with research partners of Healing Clinic, a free clinic on the city’s north side.
• Built around distance learning
weight through nutrititional changes and increased
• Tailored for nurse executives
physical activity. Participants will be paired with a
• Two-year part-time program
community health advocate who will individualize
Generalist master’s for non-nursing graduates • 18-month full-time program • Generalist nursing master’s degree program for students with a non-nursing bachelor’s degree • Intensive and accelerated program
Post-master’s family nurse practitioner certificate program • Expands scope of patient care for primary care nurse practitioners • Ability to add adult/older-adult skills (for current pediatric nurse practitioners) or pediatric skills (for current adult nurse practitioners) • 12-month part-time program
and implement the program through a series of in-person and phone meetings. An earlier study of 300 African-American women at the Marquette Neighborhood Health Center and the Marquette Clinic for Women and Children found that 80 percent were overweight or obese. “This gives the clinic managers and their staff some idea of how pervasive the problem of obesity is, as well as how that problem is contributing to other problems that they see,” Topp says. “They’ve got a large contingent of women who are diabetic, hypertensive or have cardiovascular disease. Perhaps, if we work on healthy body weight, it would also help those other issues.” ✣
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Dan Johnson
Doctoral student Pete Kallio and Dean Margaret Faut Callahan connect by Skype with a medical team in northern Wisconsin to discuss best practices for diabetes management prior to surgery.
Stronger together Faculty-student collaboration strengthens research results By Chris Jenkins It would be easy for nursing doctoral
because of encouragement and support
Undergraduates are not left out of these
candidate Pete Kallio, Nurs ’84, to get
from faculty.
types of meaningful faculty-student
wrapped up in the day-to-day demands of his job and the research projects that come along with it. So when it comes to the nuts and bolts of publishing research, he sometimes needs a gentle shove in the right direction. That’s where Marquette’s
Kallio, who is pursuing his doctor of nursing practice degree, is the clinical director of the high-risk/pre-operation clinic at the Clement J. Zablocki VA Medical Center in Milwaukee. His doctoral research involves diabetes
College of Nursing faculty come in.
management and control prior to surgery,
“The fun part is doing it,” Kallio says of
as total joint replacements. There are no
his research. “The hard part is writing the papers and getting them submitted. That encouragement to get it submitted really has helped.”
particularly large elective procedures such existing industry standards for diabetes management prior to surgery, and Kallio’s research indicates that perhaps there should be.
Kallio’s research success underscores the
“Starting in 2009, we were sending
importance of faculty-student research
patients back and saying, ‘No, you need to
collaboration. In his case, that success
get it [your diabetes] under better control
includes a prestigious $5,000 grant awarded
prior to surgery,’” Kallio says. “We cut our
by the New York-based Jonas Center for
complication rate in half in 2009, and that
Nursing Excellence, a grant he sought
has remained steady.”
research opportunities. Dr. Robert Topp, professor and associate dean for research, says both faculty and students benefit from these collaborative projects. Students get hands-on experience and tangible results for their work, while faculty members get the satisfaction of helping to educate the next generation of scientists. Topp advises undergraduate students who are studying obesity among female African-American patients at Marquette’s nursing clinics, along with other students studying the topical analgesic Biofreeze. “It’s a tremendously symbiotic relationship,” Topp says. “I couldn’t do this work without them and they couldn’t do it without me.” ✣
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This iPad app, developed by Dr. Jill Guttormson, helps patients on mechanical ventilators communicate without speaking.
Creating a pp s to aid Patien ts Nursing faculty “go digital” to improve patient care
Proloquo2Go® is an AssistiveWare® product. Used with permission.
By Chris Jenkins
The easy-to-use touch screens and slick navigation systems that make tablet-style computers such a hit with users also make them a great platform to help solve issues in health care — from easing the anxiety of patients with autism to simplifying the complexities of family planning. “Because it’s a social trend, it’s important for us to keep up-to-date with how people are communicating,” says Dr. Margaret Sebern, an associate professor in the College of Nursing who is developing an application to help Alzheimer’s patients and their families put together a care plan. With this trend in mind, several Marquette nursing professors are developing their own apps, often teaming up with faculty and students from Marquette’s Department of Mathematics, Statistics and Computer Science, other colleagues with expertise in technology, and partners at other institutions.
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Putting children with autism at ease Going through a medical test can make any child uncomfortable. The process can be even more difficult for children with autism, who might be upset by unfamiliar experiences that are not part of their daily routines. Dr. Norah Johnson, an assistant professor of nursing, has developed a method to help children with autism cope better. By tapping into the technological capabilities of the iPad, she helps them understand what they’ll experience during an upcoming test. “It’s all about expectations, and they need their expectations delivered visually,” Johnson says. When she previously worked at Children’s Hospital of Wisconsin, Johnson published a series of books to help children with autism prepare for medical procedures. But Johnson, whose son has autism, says the visual and multimedia capabilities of the iPad create a far more lifelike and accurate roadmap that helps put children at ease. Through the use of photos and sound recordings from the room where a procedure will take place, patients are better prepared for what they’ll see and hear. Johnson’s app, funded by the Autism Society of Southeastern Wisconsin and Marquette, and developed in partnership with Marquette’s computer science program, is in testing at Children’s and its affiliated practices. There is already enough data to show that children who have used the app are able to successfully complete medical imaging tests more quickly. Children in the
control group who didn’t use the app tended to be more anxious and ask more questions, leading to frustrating and potentially costly delays. With the app, Johnson says, “They have it planned out that, ‘This is what I’ll do, and when it’s over, I’ll get a prize and I go home.’ It’s amazing how it all works.”
Family planning made easy The Marquette model for natural family planning has an established track record for reliably predicting fertility, helping couples either achieve or avoid pregnancy. Now it’s going digital. Several thousand people already use Marquette’s Institute for Family Planning website, nfp.marquette.edu, to chart their fertility. The site uses an algorithm to analyze data from an electronic fertility monitor. The next step is making that technology available in an app for tablets and smart phones that is being developed by nursing professor Dr. Richard Fehring with help from Marquette’s computer science program. There are many fertility apps on the market already, but Fehring says none of them are backed up by the 20 years’ worth of research that went into the Marquette model. Once released, some versions of the app also will give users access to consultation with health care professionals and include a social networking component. Fehring believes the app will be competitive. “We have our own algorithms that integrate data from the hormonal monitoring devices,” Fehring says. “And we’ll have the credibility of our faculty serving as consultants, which adds another dimension to the application.” After beta testing, Fehring intends to make the app commercially available. The basic version will cost $4.99, with upgraded versions including added levels of interactivity costing up to $49.99. The highest-priced version will include three professional consultations. Fehring says monitoring and charting menstrual cycles isn’t just about pregnancy. Irregularities can be an indication of health problems that might go undetected in women who use birth control pills. “It’s huge that way,” Fehring says. “I think even health professionals don’t realize the information they can get by charting (to help identify) potential health problems that are coming.”
A care plan for people with Alzheimer’s and their families
Dr. Jill Guttormson, assistant professor of nursing, helps an ICU patient communicate using an app she developed.
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For people with Alzheimer’s and the family members who care for them, developing a care plan carries unique challenges. And while an iPad app can’t make those emotionally charged decisions easy, it may be able to help.
Marquette ROTC students participate in a field hospital triage simulation in the Wheaton Franciscan Healthcare Center for Clinical Simulation. 14
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The
ripple effect Already a sought-after resource within the College of Nursing, the cutting-edge simulation center has become an interdisciplinary hub for other students, faculty and professionals
Courtesy of Army ROTC
By Kurt Chandler
In 1982, an all-purpose room in the basement of Emory T. Clark Hall was turned into a skills lab for students in the College of Nursing. Outfitted with video players, Murphy beds and a manikin on a gurney, it was lowtech and no frills, a place where students could review and practice only the most basic procedures. That changed dramatically with the advent of human patient simulation. Today, the skills lab has been transformed into the 10,000-square-foot Wheaton Franciscan Healthcare Center for Clinical Simulation, and the solo low-tech manikin has been replaced with 17 medium- and highfidelity manikins — adults, children and infants — that are capable of blinking, bleeding, talking and sweating.
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Courtesy of Wheaton Franciscan Healthcare Courtesy of Wheaton Franciscan Healthcare
(Top and bottom): Wheaton Franciscan Healthcare nurses’ involvement at the Center for Clinical Simulation helps improve patient safety outcomes.
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Student nurses aren’t the only ones relying on the center for vital practice. From ROTC cadets and biomedical engineering students to university professors and practicing professionals, the “sim lab” has attracted interest from across disciplines and beyond Marquette. “Human patient simulation is taking off in a big way,” says College of Nursing Dean and Interim Provost Margaret Faut Callahan, “and we’re very excited about that synergy. My goal when I came here in 2008 was to have a university-based human patient simulation lab.” Funded through donations to Marquette along with $1 million from Wheaton Franciscan Healthcare and $450,000 in equipment from GE Healthcare, the $4 million simulation center opened in August 2012. Since then, all nursing undergrads and many graduate students have used the center. “When they walk in the door of this place, they are in a health care facility,” says Mary Paquette, director of the center. Army cadets from several local colleges and universities have trained for years at the College of Nursing. And now, Navy and Air Force ROTC have eagerly signed on for simulations. Dressed in combat uniforms and clustered around four hospital beds, Marquette’s Army ROTC cadets recently performed triage as if in a field hospital. One simulation: a soldier who had lost a limb in an IED explosion. Cadets
Courtesy of Wheaton Franciscan Healthcare
learned how to stop the bleeding and treat the soldier for shock while placing a request for medical evacuation. It’s an experience that will benefit all cadets, even those who aren’t headed for medical duty. “It’s training that cadets probably won’t get once they cross into the real Army,” says Stephanie Butkowski, Nurs ’13, an Army ROTC cadet and nursing graduate who will transition to active duty after taking the nurse licensing exam. Engineering students in a senior design class will use the center to test medical device prototypes. And this fall, biomedical engineering freshmen will observe nursing students as they use the center’s technology. “That observation is very important,” says Dr. Kris Ropella, executive associate dean of the College of Engineering. “We know, as engineers, that if we don’t have a real appreciation of the customer needs and how the clinical users are interacting with patients and technology, we don’t do a very good job designing those technologies.” The simulation center could also be a valuable resource for physical therapy students, says Dr. Dennis Sobush, associate professor of physical therapy in the College of Health Sciences. In the distant past, critical care recovery may have over-emphasized a regimen of bed rest and sedation. Today’s guidelines advise mobilizing stable patients within 24-48 hours of admission into the ICU following surgery. “Getting patients upright sooner rather than later is very critical,” says Sobush, “because it avoids complications and, practically, gets people out of the ICU and out of the hospital sooner.” Each fall semester, Sobush shepherds 60 sixth-year PT doctoral students through the various ICUs at Froedtert Hospital, where he also works as a physical therapist. But because classes are so large and patients are so ill, students can only observe. “I’m not able to have them get the patients up while connected on mechanical ventilators and other monitoring systems,” he says. Sobush submitted a proposal to the College of Nursing to allow PT students to use the center jointly with nursing students. Although the manikins cannot stand, PT students can practice maneuvering manikins into a partially sitting position. The manikins display certain physiological parameters — EKG, blood pressure, oxygen saturation and respiratory rates — that PT students can monitor to determine whether a “patient” is stable. Likewise, a patient showing signs of crashing could demand an emergency response and provide a student hands-on training in formulating a therapeutic plan. “Having that opportunity is precious,” says Sobush.
Dr. Kris Ropella, executive associate dean of the College of Engineering (right), with a student. The College of Engineering will use the Center for Clinical Simulation to test medical device prototypes.
As a contributing partner, Wheaton Franciscan Healthcare is guaranteed 200 hours each year to train health care professionals at the center. “Patient simulation is fairly new for Wheaton,” says registered nurse Lynne Delfosse, an education manager with the organization. “Outside of the center at Marquette, in Southeastern Wisconsin, [Wheaton has] only one high-fidelity manikin.” Wheaton nurses use the center to gain experience in specialized areas, such as intensive care. In the future, emergency room nurses will rotate through. “The goal is to increase the clinical reasoning of novice nurses and experienced nurses so they can come to a clinical action quicker,” Delfosse says. Simulation training can play a huge role in improving patient safety. “I didn’t have the formal training that nurses do now,” says Delfosse, a registered nurse with 33 years of experience. “We practiced on each other, or with oranges when giving medications. We spent more of our time in the individual units practicing on real patients. The theme with human patient simulation is that nurses shouldn’t have to practice on live patients. It’s a win-win situation.” Callahan is buoyed by the attention the center is drawing. “I knew it was only a matter of time before other departments and groups would say, ‘Wow, we would love to use that,’” she says. “It’s the old adage: ‘If we build it, they will come.’” ✣
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A l u m n i p e rs p e ct i v e
Blazing a trail By Lynn Sheka Dorothy J. Klofta, Nurs ’59, began her career at the Clement J. Zablocki VA Medical Center in 1949. Fifty-seven years later, in 2006 at age 83, Klofta retired from the Milwaukee VA after an illustrious nursing career. Her impressive record of achievements dates back to 1949, when she graduated with an associate degree from Milwaukee’s Mount Sinai Hospital School of Nursing, earning an award for compassionate patient care. Klofta then worked for the physical medicine and rehabilitation unit at the Milwaukee VA until going back to school to earn a
Dorothy Klofta, Nurs ‘59, interacts with a nursing student at a scholarship luncheon on Marquette’s campus.
bachelor’s degree in nursing at Marquette in 1959. It wasn’t long after graduation and her return to the VA that Klofta was promoted to surgical supervisor. At the time, the hospital did not have an intensive care unit and the open-heart surgery program was just getting underway. Finding that most of her time as surgical supervisor was spent recruiting nurses to handle patients who required specialized care following surgeries, Klofta self-financed a trip to examine new intensive care units at hospitals in Pittsburgh, to learn how they treated post-surgical patients with complicated needs. She returned to Milwaukee’s VA and set up a new room that enabled health care professionals to provide specialized care to post-surgical veterans, a precursor of the facility’s first ICU. Her initiative and proactive efforts caught the attention of the chief nurse, who assigned Klofta to be the VA’s first head nurse. Klofta also helped launch a program for training ward clerks and later worked in the VA’s surgical clinic and emergency room, expanding her range of practice to include enterostomal therapy and wound care, which she administered until her retirement in 2006. Recently, Klofta sat down to discuss her career with Marquette Nurse.
What do you remember most about your time at Marquette? I remember that the program was very serious and we took it seriously because we knew we were learning to save lives. I liked the smaller class sizes and how close the classes were because of that. When I was a student at Marquette, only 10 students were admitted twice each year to the nursing program so it was a big honor to be a part of it.
What propelled you to keep working into your 70s and to work at the Zablocki VA your entire career?
18
My favorite part was interacting with patients and making sure they felt cared for. I remember when we were developing the ICU at the VA, I had a good relationship with the chief nursing officer, and I told her that we absolutely could not put it in the basement like they originally wanted to. I said, “Those patients are sick. They want to see the sun to feel hopeful, and they won’t get that in a basement without windows.” And sure enough, they listened to me and the ICU wasn’t put in the basement. I later became head nurse of the ICU, and I was a real stickler. I expected my nurses to take care of their patients physically but also to go above and beyond to
It sounds simple, but I just really enjoyed my job.
make sure their rooms were clean and their families
My aunt was chief nurse at a VA hospital in Tucson,
had what they needed. Those patients had served
Ariz. She told me, “Don’t go anywhere but the VA.” I
our country in war — they deserved the best care we
wanted to be just like her.
could give them. ✣
Marquet te Un i versity
Part of the Marquette legacy By Andrea Petrie Marquette legacy families have a layered relationship with the university. Being part of a legacy family means at least one family member has previously attended the university. Through
Then and now Class of 1963 returns to campus for Golden Jubilee By Andrea Petrie
the years, many students in the College of Nursing have been members of these special families. Maura Falk, Nurs ’13, was one of those students. Her mother, Anne, is a 1980 graduate of the College of Nursing, and her sister, Kathleen, is a 2007 graduate of the college. But her legacy connections don’t end there. Her father, Michael, Arts
Marquette student nurses practice clinical techniques in the College of Nursing’s lab at Saint Joseph’s Hall (circa 1960).
’79, and brothers, John, Bus Ad ’06; Patrick, H Sci ’09; and Brian, Bus Ad ’11; all graduated from Marquette. Maura also has aunts, uncles and cousins who attended Marquette. “Growing up in a large Marquette legacy family, Marquette was part of my life from the very beginning,” Maura says. “I chose nursing because I can use my passion for helping others. But I chose nursing at Marquette because I knew it would give me the knowledge and experience to become an inspirational, successful nurse — just like my mom and my sister.” ✣
In 1963 … Sister Mary Thomas, O.S.F., was dean of the College of Nursing. Nursing students from outside of Milwaukee lived together in a dormitory on the St. Joseph’s Hospital campus. The Class of 1963 lived together, worked together and attended class as a cohort. Of the Marquette nursing Class of 1963, 75 percent of graduates entered institutional nursing, while the remaining 25 percent
Staying connected
entered public-health nursing.
By Carol Winkel
Now …
You could say that the College of Nursing’s Class of 1961 is close. Beginning in 1957, they spent countless hours in class together and shared memorable clinical experiences at hospitals throughout Milwaukee. When the time came for the close-knit group of women to graduate, they knew their families and nursing careers would spread them across the country, so they hatched a plan to stay connected.
Although students have access to a state-of-the-science simulation facility that their predecessors did not have — the Wheaton Franciscan Healthcare Center for Clinical Simulation — the core of Marquette’s nursing education remains; students are taught to make judgments and decisions based on practical knowledge, and
That’s how the Tel-Us-Scoop, coined by 1961 classmate
to attend to both the
Mary Mayer, was born. Mary-Lou Holloway became editor and
physical and spiritual
publisher, a role that she has held since the first edition hit
needs of their patients. ✣
mailboxes in 1962. What does the future hold for the Tel-Us-Scoop? According to Holloway, “I plan to continue with it until my health, my death or my classmates cease to have interest in it.” Judging from her classmates’ excitement at receiving each edition of the Tel-Us-Scoop, none of those seem likely any time soon. ✣
Members of the Class of 1963 celebrate their Golden Jubilee on campus during Alumni Weekend, July 25-28, 2013.
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Publications Abir Bekhet, Ph.D., R.N., H.S.M.I., assistant professor “Effects of Positive Cognitions and Resourcefulness on Caregiver Burden Among Caregivers of Persons with Dementia,” International Journal of Mental Health Nursing, Vol. 22, No. 4 (August 2013). “Psychometrics of the Depressive Cognition Scale in Caregivers of Persons with Autism Spectrum Disorders,” Archives of Psychiatric Nursing, Vol. 27, No. 2 (April 2013), pp 96100, with J.A. Zauszniewski. “Measuring Use of Positive Thinking Skills Scale: Psychometric Testing of a New Scale,” Western Journal of Nursing Research, PMID: 23509101, (March 2013), with J.A. Zauszniewski.
Ruth Ann Belknap, Ph.D., R.N., P.M.H.C.N.S.-B.C., associate professor “A Theater Intervention to Prevent Teen Dating Violence for MexicanAmerican Middle School Students,” Journal of Adolescent Health, Vol. 53, No. 1 (July 2013), pp 62-67, with Dr. Kristin Haglund, College of Nursing, H. Felzer, J. Pruszynski and J. Schneider. “Integrative Review: Parent Perspectives on Care of Their Child at the End of Life,” Journal of Pediatric Nursing, Vol. 27, No. 5 (October 2012), pp 514-22, with J. Winters and A. Aschenbrenner. “Transformative Learning Through Study Abroad in Low-Income Countries,” Nurse Educator, Vol. 37, No. 4 (July/August 2012), pp 157-61, with C. Forondoa.
“Methodological Triangulation: An Approach to Understanding Data,” Nurse Researcher, Vol. 20, No. 2 (November 2012), pp 40-43, with J.A. Zauszniewski.
“Short of Transformation: American ADN Students’ Thoughts, Feelings,” International Journal of Nursing Scholarship, Vol. 9, No. 1 (2012), pp 1-16.
“Resourcefulness, Positive Cognitions, Relocation Controllability, and Relocation Adjustment Among Older People: A Cross-Sectional Study of Cultural Differences,” International Journal of Older People Nursing, doi: 10.1111/j.1748-3743.2012.00341 (July 2012), with J.A. Zauszniewski.
See entry for Dr. Kristin Haglund.
“Effects on Resilience of Caregivers of Persons with Autism Spectrum Disorder: The Role of Positive Cognitions,” Journal of the American Psychiatric Nurses Association, Vol. 18, No. 6 (2012), pp. 337-344, with Dr. Norah Johnson, College of Nursing, and J.A. Zauszniewski. “Resilience Indicators of Caregivers of Persons with Autism: A Review of the Literature,” Issues in Mental Health Nursing,” Vol. 33, (2012), pp. 650-656, with Dr. Norah Johnson, College of Nursing, and J.A. Zauszniewski.
Kathleen Bobay, Ph.D., R.N., N.E.A.-B.C., associate professor “Quality Improvement Project: Analysis of Efficiency of Current Order Set for the Diagnostic Workup Used to Evaluate Neurogenic Stress Myocardium in Aneurysmal Subarachnoid Hemorrhage,” Journal of the American Academy of Nurse Practitioners, Vol. 25, No. 6 (June 2013), pp 314-319. “Methodology Issues in Implementation Science,” Medical Care, Vol. 51, No. 4 (April 2013), pp S32-S40, with R.P. Newhouse, P.C. Dykes, K.R. Stevens and M. Titler. “Nurses’ Perceptions of Sustainability of Magnet Efforts,” Journal of Nursing Administration, Vol. 43, No. 3 (March 2013), pp 166-171, with H. Vartanian and Dr. Marianne Weiss, College of Nursing. “Identification of Patients at Risk for Falls in an Inpatient Rehabilitation Program,” Rehabilitation Nursing, Vol. 37, No. 6 (November/December 2012), pp 292-297, with L. Salamon and M. Victory.
Maureen O’Brien, Ph.D., R.N., P.C.N.S.-B.C., associate dean and clinical associate professor
“Factors Associated with Nurses’ Perceptions of Patient Safety Culture in China: A Cross-Sectional Survey Study,” Journal of Evidence-Based Medicine, Vol. 5, No. 2 (June 2012), pp 50-56, with Dr. Barrett McCormick, Department of Political Science, College of Arts and Sciences, X. Feng and J. Krejci. Marilyn Bratt, Ph.D., R.N., assistant professor “Nurse Residency Program: Best Practices for Optimizing Organizational Success,” Journal for Nurses in Staff Development, Vol. 29, No. 3 (May/June 2013), pp 102-110. “Are Rural and Urban Newly Licensed Nurses Different? A Longitudinal Study of a Nurse Residency Program,” Journal of Nursing Management, doi: 10.1111/j.1365-2834.2012.01483.x, (November 2012), with M. Baernholdt and J. Pruszynski. Susan Breakwell, D.N.P., A.P.H.N.-B.C., clinical associate professor “Embracing a CompetencyBased Specialty Curriculum for Community-Based Nursing Roles,” Public Health Nursing, doi: 10.111/phn.12042, (April 2013), with P. Levin, S. Swider, J. Cowell and V. Reising. “A Retrospective Review of Sliding Scale vs. Basal/Bolus Insulin Protocols,” The Journal for Nurse Practitioners, Vol. 9, No. 4 (April 2013), pp 214-218, with H. Rymaszewski.
Margaret Bull, Ph.D., R.N., professor “A Framework of Ethnically Diverse Graduate Nursing Students’ Academic Persistence and Success,” Nursing Education Perspectives, Vol. 33, No. 5 (September 2012), pp 322-327, with J. Veal and J. Miller. Margaret Faut Callahan, Ph.D., C.R.N.A., F.N.A.P., F.A.A.N., dean and interim provost “Outcomes Assessment in Nurse Anesthesia,” Outcome Assessment in Advanced Practice Nursing 3rd Edition, (2013), Ruth M. Kleinpell (editor), pp 259-289, Springer Publishing Company, with M. Kremer. Kelly Campbell, M.S.N., R.N., C.C.M., director of the Marquette Neighborhood Health Center, clinical instructor See entry for Dr. Norah Johnson. Diane Dressler, M.S.N., R.N., C.C.R.N., clinical assistant professor “Coagulopathy in the ICU,” Critical Care Nurse/American Association of Critical Care Nurses, Vol. 32, No. 5 (October 2012), pp 48-59. Richard Fehring, Ph.D., R.N., F.A.A.N., professor emeritus “Current Medical Research,” The Linacre Quarterly, Vol. 80, No. 2 (May 2013) pp 167-184.
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N o t a b l e Sc h o l a r ly Acc o m p l i s h m e n t s Presentations continued Lesley Boaz, Ph.D., APNP, clinical assistant professor “Utilization of Dental Professionals in Nursing Education,” Annual National Oral Health Conference, Fort Worth, Texas, April 28, 2013, with J. Hjertstedt and Stacy Barnes, College of Nursing. “Development of a Learning Module for Older Adult Episodic Care: Clinical Conundrums,” Association for Gerontology in Higher Education’s Annual Meeting and Educational Leadership Conference, St. Petersburg, Fla., Feb. 28, 2013, with J.S. Sjostedt. “Development of a Learning Module for Older Adult Episodic Care: Clinical Conundrums,” Canadian Association of Gerontology, Vancouver, Oct. 18, 2012, with J. Sjostedt. Marilyn Bratt, Ph.D., R.N., assistant professor “Nurse Residency Programs and Preceptor Education: Worth the Investment?” Meeting of Nurse Administrators, Milwaukee, Nov. 19, 2012. “Nurse Residency Program: Best Practices for Optimizing Organizational Success,” American Association of Colleges of Nursing Baccalaureate Nursing Education Conference, San Antonio, Nov. 15, 2012. “Nursing Education Without Borders: The State of Nurse Residency in Wisconsin,” Wisconsin League for Nurses Annual Conference, Waukesha, Wis., Nov. 2, 2012. “State of the Science Nurse Residency Programs,” Wisconsin Center for Nursing’s Setting the Stage for Collaborative Education and Practice Among Health Care Professionals Conference, Wisconsin Dells, Wis., June 4, 2012. Margaret Bull, Ph.D., R.N., professor “Information Modalities for Older Adults: A Review,” Gerontological Society of America, San Diego, November 2012, with J Sjostedt.
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Marquet te Un i versity
“Information Modalities for Older Adults: A Review,” National Gerontological Nursing Association, Boston, October 2012, with J. Sjostedt. Margaret Faut Callahan, Ph.D., C.R.N.A., F.N.A.P., F.A.A.N., dean and interim provost “Developing a Strong Research Grant Proposal,” American Association of Nurse Anesthetists Annual Meeting, San Francisco, Aug. 4, 2012. “Clinical Doctorates: A Dean’s Perspective,” American Association of Nurse Anesthetists Annual Meeting, San Francisco, Aug. 3, 2012. “Developing a Curriculum that Meets the National Standards for Similar Degrees,” American Association of Nurse Anesthetists Annual Meeting, San Francisco, Aug. 3, 2012. Richard Fehring, Ph.D., R.N., F.A.A.N., professor emeritus “The Marquette Method of NFP and Evidence-Based Applications to Women’s Health Transitions,” Georgetown University School of Medicine, Washington, D.C., May 15, 2013. “Influence of Motivation on Efficacy of Natural Family Planning Methods,” Midwest Nursing Research Society Annual Research Conference, Chicago, March 8, 2013. “Spiritual Care of Fertility,” Annual Regional Bioethics Conference, Milwaukee Guild of the Catholic Medical Association, Milwaukee, May 4, 2013. “Web-based Innovations and the Continuum of Spiritual Care of Fertility,” Mayo Spiritual Care Research Conference, Rochester, Minn., Nov. 2, 2012. “Randomized Comparison of Two Internet-supported Fertility Awareness Based Methods of Family Planning,” American Academy of Nursing Annual Meeting and Conference, Washington, D.C., Oct. 12, 2012. “Efficacy of Natural Family Planning Among Older Women,” Catholic Medical Association Annual Educational Conference, St. Paul, Minn., Sept. 27, 2012.
“Randomized Comparison of Two Internet-Supported Methods of Natural Family Planning,” Office of Population Affairs Research Grantee Meeting, Bethesda, Md., Sept. 20, 2012. “Efficacy of a New Method of Family Planning for Breastfeeding Women,” Council for the Advancement of Nursing Science’s State of the Science Congress on Nursing Research, Washington, D.C., Sept. 15, 2012. “The Influence of Religiosity on Abortion and Contraceptive Use in the U.S.: Data from the 2002 and 2010 National Survey of Family Growth,” University Faculty for Life, Brigham Young University Law School, June 2, 2012. Jill Guttormson, Ph.D., R.N., assistant professor “Patients’ Recall and Evaluation of Mechanical Ventilation: Impact of Sedation,” Council for the Advancement of Nursing Science’s State of the Science Congress on Nursing Research, Sept. 13-15, 2012, with L. Chlan. “Mechanically Ventilated Patients’ Report of Communication: Associations with Emotions and Satisfaction,” Midwest Nursing Research Society Conference, Sept. 13-15, 2012, with L. Chlan. “Patients’ Descriptions and Interpretations of Delusional Memories of Intensive Care,” Annual Southeastern Wisconsin Nursing Research Conference, May 15, 2013. “Preliminary Usability Testing of an iPad Communication Device for Mechanically Ventilated Patients,” Midwest Nursing Research Society 2013 Conference, Chicago, March 2013. Kristin Haglund, Ph.D., P.N.P., F.N.P., A.P.R.N., associate professor See entry for Dr. Ruth Ann Belknap. Ronda Hughes, Ph.D., M.H.S., R.N., F.A.A.N., associate professor “Impact of Health Care Reform,” Rotary International, Brookfield, Wis., Dec. 4, 2012. “Driving Change,” Nursing Research Conference, Froedtert Hospital, Milwaukee, Nov. 27, 2012.
Norah Johnson, Ph.D., R.N., C.P.N.P., assistant professor “Effect of an iPad Application for Medical Imaging Procedure Preparation for Children with Autism Spectrum Disorder,” International Family Nursing Conference, Minneapolis, June 19, 2013. “Family Functioning for Parents of Children with Autism Spectrum Disorder (ASD): What Helps the Most and What Helps the Least,” International Family Nursing Conference, Minneapolis, June 19, 2013, with S. Feetham. “Translating Family Research to Practice and Policy: Examples from Practice Environments in Three Countries,” International Family Nursing Conference, Minneapolis, June 19, 2013, with S. Feetham, P. Hinds, R. Szylit Bousso, M. Santso, P. Vendramim, K. Sawin, K. Gralton and N. Hohashi. “Effect of an iPad Application for Medical Procedure Preparation for Children with Autism Spectrum Disorder,” Research Fly-in, Children’s Hospital of Wisconsin, Milwaukee, May 24, 2013, with Dr. Sheikh Iqbal Ahamed, Department of Mathematics, Statistics and Computer Science, College of Arts and Sciences, graduate students Octavia Kabobel, Erin Lalley, Md. Gani and Sara Haberlin, K. Rettler, P. Grande, R. Unteutsch and M. Coffrey. “Medical Imaging Procedure Preparation for Children with Autism with an iPad App Social Script,” Southeastern Wisconsin Nursing Research Conference, Milwaukee, May 15, 2013, with Dr. Sheikh Iqbal Ahamed, Department of Mathematics, Statistics and Computer Science, College of Arts and Sciences, and graduate students Octavia Kabobel, Erin lalley and Md. Gani. “The Nurse’s Approach to Enhancing the Patient Experience for Persons With Autism Spectrum Disorder,” Nurses’ Day, Wheaton Franciscan All Saints Hospital, Racine, Wis., May 8, 2013. “Apple Products and Autism: Feasibility of iPad App for Imaging,” Apple Accessibility Event Keynote Speaker, Apple Store, Glendale, Wis., May 4, 2013.
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C a r i ng f o r M i lw a u k e e ’ s u nd e r s e r v e d p o p u l at i o n s
Through stand-alone clinics and a partnership with a local health system, the Marquette College of Nursing is committed to bringing health care options to Milwaukee’s underserved neighborhoods. It’s a community-based solution with multiple winners: the city of Milwaukee, patients and our students, who receive communitybased nursing experience that is critical to their development as men and women in service to others. n
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Children’s Hospital Primary Care Clinics: nurse-managed clinics in partnership with Children’s Hospital of Wisconsin Marquette Neighborhood Health Center: nurse practitioners and certified nurse-midwives delivering women’s health and prenatal services in areas with high infant mortality rates
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Marquette Clinic for Women and Children: one of only 20 free clinics in the Milwaukee metro area
marquette.edu/nursing