The Journal of the New York State Nurses Association, Volume 50, Number 1

THE JOURNAL

of the New York State Nurses Association

Volume 50, Number 1

n Editorial: Time Well Spent

by Anne Bové, MSN, RN-BC, CCRN, ANP; Audrey Graham-O’Gilvie, DNP, RN, ACNS-BC, CCRN-k; Meredith King-Jensen, PhD, MSN, RN; Alsacia L. Sepulveda-Pacsi, PhD, DNS, RN, FNP, CCRN, CEN; and Coreen Simmons, PhD(c), DNP, MSN, MPH, RN

n Self-Care as a Nurse’s Right and Responsibility by Carol Lynn Esposito EdD, JD, MS, RN-BC, NPD

n NCLEX-RN First-Time Passing Predictors

by Elizabeth B. Simon, PhD, RN, ANP, and Susan Joseph, PhD, RN, CNE

n Preventing Hospital-Acquired Sacral Pressure Injuries With Silicone Foam Dressing by Carol Blagrove, DNP, MSN/NEd, RN, CCRN, MEDSURG-BC

n What’s New in Healthcare Literature

n CE Activities: Self-Care as a Nurses Right and Responsibility; NCLEX-RN First-Time Passing Predictors

THE JOURNAL

by Anne Bové, MSN, RN-BC, CCRN, ANP; Audrey Graham-O'Gilvie, DNP, RN, ACNS-BC, CCRN-k; Meredith King-Jensen, PhD, MSN, RN; Alsacia L. Sepulveda-Pacsi, PhD, DNS, RN, FNP, CCRN, CEN; and Coreen Simmons, PhD(c), DNP, MSN, MPH, RN

by Elizabeth B. Simon, PhD, RN, ANP, and Susan Joseph, PhD, RN, CNE

Carol Blagrove, DNP, MSN/NEd, RN, CCRN, MEDSURG-BC

THE JOURNAL

of the New York State Nurses Association

n The Journal of the New York State Nurses Association editorial board

Anne Bové, MSN, RN-BC, CCRN, ANP Alsacia L. Sepulveda-Pacsi, PhD, DNS, RN, FNP, CCRN, CEN Clinical Instructor Registered Nurse III New York, NY New York-Presbyterian Adult Emergency Department New York, NY

Audrey Graham-O’Gilvie, DNP, RN, ACNS-BC, CCRN-k Coreen Simmons, PhD(c), DNP, MSN, MPH, RN Assistant Professor Professional Nursing Practice Coordinator Touro College School of Health Sciences Teaneck, NJ

Hawthorne, NY

Meredith King-Jensen, PhD, MSN, RN Nurse Consultant, Veterans Administration

Bronx, NY

Adjunct Instructor, Mercy College

Dobbs Ferry, NY

n Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD, Co-Managing Editor Lucille Contreras Sollazzo, MSN, RN-BC, NPD, Co-Managing Editor Christina Singh DeGaray, MPH, RN-BC, Editorial Assistant

The information, views, and opinions expressed in The Journal articles are those of the authors, and do not necessarily reflect the official policy or position of the New York State Nurses Association, its Board of Directors, or any of its employees. Neither the New York State Nurses Association, the authors, the editors, nor the publisher assumes any responsibility for any errors or omissions herein contained.

The Journal of the New York State Nurses Association is peer reviewed and published biannually by the New York State Nurses Association. ISSN# 0028-7644. Editorial and general offices are located at 131 West 33rd Street, 4th Floor, New York, NY, 10001; Telephone 212-785-0157; Fax 212-785-0429; email info@nysna.org. Annual subscription: no cost for NYSNA members; $17 for nonmembers.

The Journal of the New York State Nurses Association is indexed in the Cumulative Index to Nursing, Allied Health Literature, and the International Nursing Index. It is searchable in CD-ROM and online versions of these databases available from a variety of vendors including SilverPlatter, BRS Information Services, DIALOG Services, and The National Library of Medicine’s MEDLINE system. It is available in microform from National Archive Publishing Company, Ann Arbor, Michigan.

©2023 All Rights Reserved  The New York State Nurses Association

n eDITorIAl

Time Well Spent

For nurses, nursing instructors, and nursing students, there is nothing as valuable as time well spent. Nurses are constantly under pressure to meet standards of care, to increased acuity of patients, make up for vacancies that have remained unfilled, and manage the consequences of short staffing. Nursing instructors are struggling to graduate enough new students to address the nursing shortage. Nursing schools are challenged with admitting qualified students, improving patient outcomes, and introducing processes such as the PICOT approach to evidence-based practice (EBP). The articles in this volume of the Journal reflect and address the importance of improving processes to recruit and retain a knowledgeable, skilled, and healthy nursing workforce.

The American Nurses Association (ANA) Code of Ethics for Nurses was revised in 2015 to include the prioritization of self-care for nurses. In the article “Self-Care as a Nurses Right and Responsibility,” the author emphasizes that traditional occupational stressors, such as short staffing, are now appended to modern stressors, such as environmental electromagnetic field (EMF) and electromagnetic radiation (EMR) emitted from electronic devices, both which have impacts on health and resilience. However, stressors can be counteracted by limiting exposure to EMF and EMR and implementing specific health and nutrition practices. With this knowledge, nurses can equip themselves to handle certain environmental stressors and the tolls of toxins on their bodies in order to maintain optimal health.

In the article “NCLEX-RN First-Time Passing Predictors,” the authors seek to uncover factors that can predict nursing students’ chances of passing the NCLEX-RN on the first attempt. Correlation studies reveal that the success of nursing students, such as the core nursing program, correspond to increased chances of passing the NCLEX-RN. They find that coaching and mentoring on core programs by nursing instructors help students achieve their goals and help meet student and school goals of passing the NCLEX-RN on the first attempt.

Prevention of decubiti is the topic of “Preventing Hospital-Acquired Sacral Pressure Injuries With Silicone Foam Dressing,” the last article featured in this volume of the Journal. Despite decades of effort to improve procedures, skin care remains a critical topic in addressing quality of care and patient outcomes. The author’s report shares the results of one surgical intensive care unit’s success in reducing sacral ulcers from 2.6% to 0%. Working collaboratively, the researcher and nursing staff initiated specific decubiti prevention measures within 24 hours of patients’ admissions, including performing regular team reassessments and ensuring the availability of supplies. Positive outcomes from this study can be used to better meet the challenge of improving lasting skin integrity for patients.

Nursing’s power in all settings includes reliance on perseverance, the ongoing search for process improvements, and using evidencebased practice. Through collaboration at all levels of education and practice, across-the-board collaboration results in increased individual nurse empowerment, improved self-care, elevated advocacy, and strengthened resilience.

Anne Bové, MSN, RN-BC, CCRN, ANP Audrey Graham-O’Gilvie, DNP, RN, ACNS-BC, CCRN-k Meredith King-Jensen, PhD, MSN, RN Alsacia L. Sepulveda-Pacsi, PhD, DNS, RN, FNP, CCRN, CEN Coreen Simmons, PhD(c), DNP, MSN, MPH, RN

Self-Care as a Nurse’s right and responsibility

Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD

n Abstract

Self-care for nurses is not an indulgence. It is a right and a responsibility. It is an expression of one’s deep and personal conviction of one’s priorities. It is engaging in behavior that seriously protects one’s mental health, energetic capacity, physical condition, and worth in order to restore and sustain inner balance. It is a commitment to oneself to uphold a regular, daily practice to stay healthy.

In this literature review paper, the author discusses how nurses can honor their personal and ethical commitment by engaging in daily self-care strategies in response to a workplace replete with potentially harmful stressors—including electromagnetic fields (EMF) and electromagnetic radiation (EMR), which have become a substantial new pollution source in modern civilization—so that they can ultimately better care for others.

Keywords: Self-care, nurse, electromagnetic fields (EMF), electromagnetic radiation (EMR)

Introduction

More than 4 million registered nurses comprise the largest and one of the most trusted groups of healthcare professionals in the United States today. In 2022, the American Nurses Association (ANA) published an updated Bill of Rights for Nurses outlining the inherent rights that must be afforded to nurses in the workplace to protect them and the patients entrusted to their care. Those rights include (American Nurses Association [ANA], 2022):

1. Full authority for nurses to practice at the top of their license, credentials, and professional standards without barriers, and in a manner that fulfills their obligations to society, patients, and communities.

2. Continuous access to training, education, professional development, as well as pathways for nurses to be recognized as leaders and in

roles to direct shared decision-making on nursing practice, resources, staffing concerns, and patient safety issues.

3. Work and practice in environments that ensure respect, inclusivity, diversity, and equity with leaders who are committed to dismantling systemic racism and addressing racist behaviors that negatively impact nurses of color.

4. Just care settings that facilitate ethical nursing practice, standards, and care in accordance with the Code of Ethics for Nurses With Interpretive Statements.

5. Safe work environments that prioritize and protect nurses’ well-being and provide support, resources, and tools to stay psychologically and physically whole [emphasis added].

6. Freedom for nurses to advocate for their patients and raise legitimate concerns about their own personal safety without the fear of

Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD Nursing Education and Practice, New York State Nurses Association, New York, New York

retribution, retaliation, intimidation, termination, and ostracization [emphasis added].

7. Competitive compensation consistent with nurses’ clinical knowledge, experience, and professional responsibilities and that recognizes the value and rigor of nursing practice.

8. Collective and individual rights for nurses to negotiate terms, wages, and work conditions of their employment in all practice settings.

Self-care as a nurse’s right is embodied in provisions 5 and 6 above as one of the most imperative of nurses’ rights. The ANA Code of Ethics for Nurses states that nurses must practice self-care and, according to the ANA, there are seven areas of self-care: mental, physical, emotional, spiritual, social, personal, and professional (Gruzd, 2021). Provision 5 of the ANA (2015) code articulates, “The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal professional growth.” Provision 5.2 of the code’s Interpretive Statements articulates:

As professionals who assess, intervene, evaluate, protect, promote, advocate, educate, and conduct research for the health and safety of others and society, nurses have a duty to take the same care for their own health and safety. Nurses should model the same health maintenance and health promotion measures that they teach and research, obtain health care when needed, and avoid taking unnecessary risks to health or safety in the course of their professional and personal activities…. To mitigate these effects, nurses should eat a healthy diet, exercise, get sufficient rest, maintain family and personal relationships, engage in adequate leisure and recreational activities, and attend to spiritual or religious needs. These activities and satisfying work must be held in balance to promote and maintain their own health and well-being. Nurses in all roles should seek this balance, and it is the responsibility of nurse leaders to foster this balance within their organization. (p. 19)

Self-care reduces stress, replenishes a nurse’s capacity to provide compassion and empathy, and improves the quality of care provided to patients. The literature has shown that in addition to reducing stress and anxiety, self-care can also improve concentration, minimize frustration and anger, increase happiness, improve energy, and more. From a physical health perspective, self-care has been linked in the literature to reductions in heart disease, stroke, and cancer. From a spiritual perspective, self-care has been shown to help keep nurses in tune with their sense of a higher power and/or a higher meaning and sense of worth in life (Glowiak, 2020).

Sources of occupational Stressors for Nurses

For practicing nurses, some of the commonly reported occupational stressors include: protecting patients’ rights; autonomy and informed consent to treatment; staffing patterns; advanced care planning; surrogate decisionmaking; greater patient acuity; unpredictable and challenging workspaces; violence; increased paperwork; reduced managerial support; and role-based factors such as lack of power, role ambiguity, and role conflict (Blum, 2014). These are not the only stressors nurses face on the job, however.

Rapid technological advancement in the past 30 years has vastly increased human exposure to ionizing radiations. High exposures to

Self-care reduces stress, replenishes a nurse’s capacity to provide compassion and empathy, and improves the quality of care provided to patients.

electromagnetic fields (EMFs) and electromagnetic radiation (EMR) can occur when near certain medical devices in the hospital environment. Some medical devices use high levels of EMF and EMR for diagnostic or therapeutic aims. Recent technological advances have increased the diversity and potential strength of EMF and EMR emitted from medical sources and therefore raise questions about occupational safety and bodily stressors due to current awareness that EMF and EMR of sufficient strength can have negative and consequential biological effects (Stam & YamaguchiSekino, 2018).

electromagnetic Fields vs. electromagnetic radiation

EMF are associated with electricity; they originate from sources either natural (such as solar and star radiation and thunder) or man-made (phone chargers, mobile phones, televisions, computers, printers, electrical cables, and antennas for telecommunications). EMR, on the other hand, consists of waves of electric and magnetic energy. Visible light is an example of electromagnetic radiation we can see. But there are many more wavelengths on the EMR spectrum than are invisible to the human eye, and they are potentially harmful, such as X-rays and gamma rays (see Figure 1 and Figure 2). Some examples of medical devices emitting EMR are magnetic resonance imaging (MRI), laser lithotripsy, X-rays, computed tomography (CT), radiation therapy, chemotherapy, immunotherapy, and positron emission tomography (PET). Both EMF and EMR are invisible areas of energy (Batool et al., 2019).

There are two general kinds of EMR: ionizing radiation and nonionizing radiation. Ionizing radiation is powerful enough to knock electrons out of their orbit around an atom. This process is called ionization. Ionizing, high-level radiation has the potential for cellular

Note. Image from “The Electromagnetic Spectrum,” by NASA, 2013 (https://imagine.gsfc.nasa.gov/science/toolbox/emspectrum1.html)

Figure 1

Electromagnetic Spectrum

Figure 2

Electromagnetic Waves and Common Radiation Sources With Frequency Ranges

Figure 3

Possible Pathways Leading to Behavioral Dysfunction and Other Biological Effects With EMF and EMR Exposure

Note. From “Microwave Radiation and the Brain: Mechanisms, Current Status, and Future Prospects,” by S. Mumtaz, J. N. Rana, E. H. Choi, and I. Han, 2022, International Journal of Molecular Sciences, 23(16), p. 9288 (https://doi.org/10.3390/ijms23169288).

and DNA damage. Non-ionizing radiation has enough energy to move atoms in a molecule around and cause them to vibrate, which makes the atom heat up, but not enough to remove the electrons from the atoms. Non-Ionizing, low-level radiation is generally described in the literature as harmless to humans (Yari et al., 2019).

However, due to certain aspects of man-made EMF and EMR (such as polarization), they are more bioactive and potent than naturally occurring EMF and EMR. For the most part, our body’s cells can respond negatively to man-made fields. The EMR effects on human body cells acts by removing calcium ions. Cells become distressed and trigger a defense response to the repetitive stress of EMF and EMR. Constant stress responses release masses of highly reactive free radicals, which have been shown to cause cellular dysfunction and inflammation, pain, and interfere with the body’s DNA repair processes. This in turn can lead to a weakened immune system, fetal abnormalities, mental disorders, cardiovascular diseases, disturbances of the nervous system, skin diseases, visual and hearing disturbances, and even tumors (see Figure 3) (Batool et al., 2019; Hu et al., 2021).

occupational exposure to electromagnetic Fields and radiation From Devices Found in the Workplace

EMF and EMR generated by medical sources in the hospital environment can be roughly divided into two categories: sources of static and low-frequency fields (i.e., frequencies from 0 Hz to 100 kHz) and sources of high-frequency fields (i.e., frequencies from 100 kHz to 300 GHz). Frequency is measured in the unit hertz (Hz), referring to a number of cycles per second. One thousand hertz is referred to as a kilohertz (kHz), 1 million hertz as a megahertz (MHz), and 1 billion hertz as a

Note. From “Radiofrequency Electromagnetic Radiation-Induced Behavioral Changes and Their Possible Basis, “ by S. N. Narayanan, R. Jetti, K. K. Kesari et al., 2019, Environmental Science and Pollution Research, 26, pp. 30693–30710 (https://doi.org/10.1007/s11356-019-06278-5).

gigahertz (GHz). The range of the radio spectrum is considered to be 3 kHz up to 3,000 GHz. Low-frequency EMF and EMR that are sufficiently strong can stimulate sensory organs and nervous or muscle tissue via magnetic induction of internal electric fields in electrically conductive body tissues. Depending on the strength of the fields, this may lead to retinal stimulation (magnetophosphenes), vestibular disturbances, tingling sensations, pain or muscle contractions. High-frequency EMF and EMR that are sufficiently strong can lead to excessive heating and tissue damage (see Table 1) (Batool et al., 2019; Stam & Yamaguchi-Sekino, 2018).

Three main EMF and EMR applications in medicine are magnetic resonance imaging (MRI), radiofrequency ablation (RFA) used in cardiology and tumor therapy, and localized dielectric heating (short wave diathermy) used in physiotherapy. The strongest sources of lowfrequency EMF and EMR are devices for magnetic stimulation of brain, nerves, or muscles as a diagnostic or therapeutic tool (Hallett, 2007; Stam & Yamaguchi-Sekino, 2018). Most other sources of low EMF and EMR (frequencies from 50 Hz to 60 Hz) in the hospital environment come from cardiac monitors, wireless data, mobile phones, wireless telemetry, microwaves, stimulation devices, low-frequency pain relief devices, and laptops (Stam & Yamaguchi-Sekino, 2018).

Strong high-frequency EMF and EMR are used deliberately to heat patient tissues in therapeutic diathermy and hyperthermia. Electrosurgery and ablation are common techniques for procedures such as endometrial excision or arrest of bleeding in the hospital operating room by applying high-frequency electrical currents. Other high-frequency EMF and EMR have been developed more recently, such as radar applications used to monitor vital functions like heart rate and respiration and for imaging of tumors, by exploiting varying surface reflections and differences in

1

Medical Devices Frequency Ranges and Potential Biological Effects

f = 0

low frequency

Affecting vestibular organs and large blood vessels, resulting in disturbed equilibrium, reduced blood flow, cardiac arrhythmia

• MRI (static field)

As the static magnetic field of an MRI scanner is always on, MRI personnel moving around the scanner will be exposed to timevarying extremely low frequency magnetic fields that induce electric fields and currents in their bodies.

0 < f < 105 [0-10 kHz]

low frequency

Affecting sensory organs, resulting in vertigo, nausea, metallic taste, magnetophosphenes, nerve and muscle stimulation

• MRI (movement within static fields)

0 < f < 105 [0-10 kHz]

low frequency

Affecting musculoskeletal and nervous system, resulting in stimulation and potential damage

• MRI (switching gradient fields 500-5000 Hz)

A magnetic field gradient refers to a variation in the magnetic field across space. High-performance gradient systems of rapidly switching, large magnetic fields on the human body can induce peripheral nerve stimulation.

• Magnetic stimulation

0 < f < 50-60 Hz

Affecting the heart and blood vessels by causing a histopathological changes and disturbances in the functions of the organs of the cardiovascular system resulting in arrythmia, MI

MRIs produce a strong magnetic field that forces protons in the body to align with that field. When a radiofrequency current is pulsed through the patient, the protons are stimulated, and spin out of equilibrium, straining against the pull of the magnetic field.

• Magnetotherapy (chronic pain Rx)

Magnets are placed close to the body in order to effectuate bones to heal faster, relieve pain, and induce other therapeutic effects.

• Power frequency equipment

Typically used to describe electrical equipment operation, such as cardiac monitors.

105 < f < 1011 [10 kHz-10 GHz]

Heating affecting tissues, resulting in tissue damage

• MRI (radiofrequency field generated by imaging coils)

• Diathermy

• Electrosurgery (ablation)

• Hyperthermia

• Microwave imaging (thermoacoustic echography)

• Radar monitoring (heart rate, respirations) therapeutic ultrasound

Note. MRI produces three different fields to generate images: (1) a static magnetic field of zero frequency; (2) low power time-varying magnetic field gradients (100 Hz to 1kHz); and (3) RF fields (10 to 400 MHz). From “The Use of Electromagnetic Fields in Medicine and its Effect on Patient and Health Care Workers,” RF Toolkit–British Columbia Centre for Disease Control/National Collaborating Centre for Environmental Health, 2013 (http://www.bccdc.ca/resource-gallery/Documents/Guidelines%20 and%20Forms/Guidelines%20and%20Manuals/EH/EH/Section7Final06062013.pdf)

Table adapted from “Exposure to Electromagnetic Fields Induces Oxidative Stress and Pathophysiological Changes in the Cardiovascular System,” by A. E. Azab and S. A. Ebrahim, 2017, Journal of Applied Biotechnology and Bioengineering, 4(2), pp. 540–545 (https://doi.org/10.15406/jabb.2017.04.00096) and “Occupational Exposure to Electromagnetic Fields From Medical Sources,” by R. Stam and S. YamaguchiSekino, 2018, Industrial Health, 56(2), pp. 96–105 (https://doi.org/10.2486/ indhealth.2017-0112).

dielectric properties of healthy and diseased tissues. Microwave-induced thermoacoustic echography uses modifications of the reflection of acoustic waves by thermal expansion (Stam & Yamaguchi-Sekino, 2018).

literature review

Stress is a critical issue within nursing. Stress that occurs in an individual’s place of work is occupational stress, and in nursing is strongly associated with absenteeism, illness, diminished capacity to deliver quality patient care, and staff turnover. When the demands placed on the individual exceed their ability to cope, a stress response is generally triggered. As a result, the individual moves along a continuum from feelings of eustress to moderate stress to severe distress. Severe distress is a negative response to the environment resulting in negative physical and psychological adaptation (O’Donovan et al., 2013).

The physical capacity for performing a job is determined primarily by cardiovascular, pulmonary, nervous, musculoskeletal, endocrinal, and other regulating body systems. Work-related stress can modify an individual’s physiological functions which, in turn, can be additionally affected by exposure to EMF and EMR, which affects the electric field in the body through the movement of ions, heat, neuromuscular stimulation, and various other effects. The biological effects of these waves depend strongly on the waveform, frequency, and angle between the applied fields and the Earth’s magnetic field, as well as their continuity or pulsation. The effects of low-frequency EMF are different from the effects of high-frequency fields. This is because at low frequency, the voltage of the current is higher. Electromagnetic fields with different frequencies and high intensities have been considered a significant factor in the environment.

According to the frequency range, EMFs are divided into very low frequency (VLF) and extremely low frequency (ELF) ranges. Generally, the ELF region of the electromagnetic spectrum is defined as frequencies from 3 Hz to 3,000 Hz. These fields are generated by telecommunication devices (such as phones, TV, radio, computers, and the internet) and human exposure to low frequencies without protection occurs on a daily basis. The effects of low-frequency EMF are different from the effects of high-frequency fields (Moslemi et al., 2023). Electromagnetic energy is absorbed by the body where it is converted to thermal energy. If the energy absorption rate exceeds roughly 4 watts per square meter, it increases the body temperature by 1 to 2 °C (1.8 to 3.6 °F). Frequencies of about 50 to 80 Hz

Table 2

Health Risks Due to Long-Term Exposure to EMF From Telecommunication Devices

Device

Health risk

Mobile phone Fatigue, headache, dizziness, sleep disturbances, vision changes, hearing loss, memory loss

Wi-Fi DNA fragmentation, oxidative stress in kidney, fall in brain antioxidants

Microwaves Hyperactivity, sleep disorders, emotional instability

TV, cell phones Leukemia, tumors, cardiovascular problems, skin diseases, irritability, visual disruptions, hearing problems, depression

Note. Table adapted from “Benefits and Hazards of Electromagnetic Waves, Telecommunication, Physical and Biomedical: A Review,” by S. Batool, A. Bibi, F. Frezza, and F. Mangini, 2019, European Review for Medical and Pharmacological Sciences, 23, pp. 3121–3128 (https://www.europeanreview.org/wp/wp-content/uploads/ 3121-3128.pdf).

are usually the most dangerous, since at these frequencies, even very small currents cause significant biological effects (Yari et al., 2019). The health problems and long-term effects of EMF and EMR from telecommunication and biomedical devices (see Table 2) have been addressed by the World Health Organization (WHO), Federal Communication Commission (FCC), and International Commission on Non-Ionization Radiation Protection (ICNIRP) in their recommended safety guidelines for the protection of all living beings (see Centers for Disease Control and Prevention, EMF, https:// www.cdc.gov/niosh/topics/emf/default.html).

Similarities in biological effects between Workplace Stressors and exposure to em F and emr

Occupational stress resulting from a demanding job with poor concomitant support, shortages of resources and staff, difficult relationships with patients and families, complicated relationships with other staff, and low institutional commitment to nursing are some of most-reported causes of physical and mental illnesses for nurses in the literature. Short-term exposures to these stressors can lead to a variety of disorders, such as burnout, chronic fatigue, depression, muscle aches, headaches, anxiety, lack of appetite, and lack of concentration. Extreme, long-term exposures to these stressors can lead to unhealthy and dysfunctional behaviors, such as smoking, excessive drinking, poor eating habits, diminished interest in former activities, and lack of exercise. Symptomatically, nurses exposed to these long-term stressors may experience physical and mental illnesses, chest pains, palpitations, sleep disturbances, increased susceptibility to respiratory infections, aggression, mood swings, and job dissatisfaction (Blaug et al., 2007; O’Donovan et al., 2013).

Similarly, some of the reported effects of short-term EMF and EMR on the body include sleep disturbances, lethargy, headaches, depression and depressive symptoms, fatigue, dysesthesia, palpitations, lack of concentration, memory changes, dizziness, and anxiety (Batool et al., 2019). Indeed, school nursing records often indicate an increase in one or more common symptoms among students and staff following the installation

Figure 4

Effects of Extremely Low-frequency EMF

Neurological diseases

(Alzheimer’s, dementia, etc.)

Suicide and depression

Spontaneous abortion and other e ects in women

Genital abnormalities in men

of wireless systems: headaches, tachycardia, bloody noses, ear bleeds, skin rashes, nausea, tinnitus (loud ringing in the ears), vertigo, inability to concentrate, depression, anxiety, lack of energy, fatigue, flu-like symptoms, and insomnia (Belyaev et. al., 2016; Doucette, n.d.).

Other more significant effects of long-term exposure to EMF and EMR include increased cancer risk, cellular stress, increase in harmful free radicals, genetic damages, structural and functional changes of the reproductive system, learning and memory deficits, neurological disorders, changes in heart rhythm, damage to erythrocytes, disturbed glucose metabolism in the brain, and negative impacts on general well-being in humans (Hedendahl et al., 2015). Still other effects of long-term exposure to EMF and EMR described in the literature are shown in Figure 4 and Table 3.

Non-cancerous e ects of extremely low frequency

Discussion

Heart disease and palpitations

ALS syndrome

Blood diseases

Note. From “Biological Effects of Electromagnetic Waves With Emphasis on Radio and Microwave: An Environmental Carcinogen,” by S. Yari, A. F. Asadi, A. M. Jarrahi, and M. Nourmohammadi, 2019, Asian Pacific Journal of Environment and Cancer, 2(1) (http:// waocp.com/journal/index.php/apjec/article/view/308).

Table 3

WHO defines self-care as the ability to prevent disease, promote and maintain health, and cope with stress, disability, and illness. WHO recommends self-care interventions as a means by which individuals can take accountability and manage their health and well-being. Self-care interventions promote individuals’ active participation in their own health care and constitute a push toward greater self-determination, self-efficacy, autonomy, and engagement in health (World Health Organization [WHO], 2022).

Self-care interventions are tools which support self-care. Self-care interventions include evidence-based behaviors, actions, and strategies that go beyond a conventional health-sector response and which can be provided fully or partially outside of formal health services. Available, accessible, affordable, acceptable, and good quality self-care interventions are core components of promoting and protecting a nurse’s right to health.

Research Studies Showing Correlation Between EMF and EMR Exposure and Illness Study Description Finding

“Long-Term Exposure of 2450 MHz Electromagnetic Radiation Induces Stress and Anxiety-Like Behavior in Rats,” by S. K. Gupta, S. K. Patel, M. S. Tomar, S. K. Singh, M. K. Mesharam, and S. Krishnamurthy, 2019, Neurochemistry International, 128, pp. 1–13 (https://doi.org/10.1016/j.neuint.2019.04.001)

“Health Implications of Electromagnetic Fields, Mechanisms of Action, and Research Needs,” by S. Sarika Singh and N. Kapoor, 2014, Advances in Biology, (https://doi. org/10.1155/2014/198609)

Researchers investigated the effects of repeated exposure of discrete frequencies of EMR in experimental animals.

Literature review on studies conducted to determine whether increased exposure to electromagnetic fields (EMF) decreases melatonin production with a concomitant effect of increasing the likelihood of developing tumors.

Long-term exposure of EMR (2450 MHz) induced anxiety-like behavior, deregulated the hypothalamic pituitary adrenal (HPA) axis as observed by increase in plasma corticosterone levels apart from decreased corticotrophin releasing hormone-2 (CRH-2) and glucocorticoid receptor (GR) expression in amygdala, and impaired mitochondrial function and integrity.

Melatonin is highly accepted for its antioxidant and tumor-inhibiting properties. Continuous exposure to EMF emission produced noticeable depression in melatonin and corticosterone levels in multiple studies.

“Genotoxic Effects in Human Fibroblasts Exposed to Microwave Radiation,” by V. Franchini, E. Regalbuto, A. De Amicis, S. I. De Sanctis et al., 2018, Health Physics, 115(1), pp. 126–139 (http://doi.org/10.1097/HP.0000000000000871)

Study evaluated the potential genotoxic and cellular effects associated with in vitro exposure of human fetal and adult fibroblasts to microwave radiation at the frequency of 25 GHz.

Increased exposure to microwave radiation resulted in aneuploidy induction due to chromosome loss. Errors in chromosome segregation led to aneuploidy, a state where the number of chromosomes in a cell or organism deviates from multiples of the haploid genome. Aneuploidy arising through chromosome mis-segregation during meiosis is a major cause of infertility and inherited birth defects.

Table 3 (continued)

Research Studies Showing Correlation Between EMF and EMR Exposure and Illness

“Biological Effects of Electromagnetic Waves With Emphasis on Radio and Microwave: An Environmental Carcinogen,” by S. Yari, A. F. Asadi, A. M. Jarrahi, and M. Nourmohammadi, 2019, Asian Pacific Journal of Environment and Cancer, 2(1) (https:// doi.org/10.31557/APJEC.2019.2.1.35-41)

This study evaluated the correlation between human tissue damage and proximity to EMF and EMR.

Electromagnetic energy is absorbed by the body and converted to thermal energy, which increases the body temperature by 1 to 2 °C if the energy absorption rate exceeds about 4 watts per square meter, and also increases nerve stimulation. Frequencies of about 50 to 80 Hz are usually the most dangerous frequencies for the body. At these frequencies, even very small currents cause significant biological effects and tissue damage.

“Extremely Low-Frequency Electromagnetic Fields Cause DNA Strand Breaks in Normal Cells,” by C. T. Mihai, P. Rotinberg, F. Brinza, and G. Vochita, 2014, Journal of Environmental Health Science & Engineering, 12(1), p. 15 (https://doi. org/10.1186/2052-336X-12-15)

“Microwave Radiation and the Brain: Mechanisms, Current Status, and Future Prospects,” by S. Mumtaz. J. N. Rana. E. H. Choi, and I. Han, 2022, International Journal of Molecular Sciences, 23(16), p. 9288 (https://doi.org/10.3390/ ijms23169288)

The aim of this study was to evaluate late effects of normal Vero cells that were exposed to extremely lowfrequency electromagnetic fields (100 Hz, 5.6 mT) for 45 minutes.

The analysis of the registered comet indices and of cell cycle showed that extremely low-frequency electromagnetic field of 100 Hz and 5.6 mT had a genotoxic impact on Vero cells. Exposed samples presented an increase of the number of cells with high damaged DNA as compared with nonexposed cells.

“Effects of Radiofrequency Electromagnetic Radiation on Neurotransmitters in the Brain Front,” by C. Hu, H. Zuo, and Y Li, 2021, Public Health, 9, pp. 1–15 (https://doi.org/10.3389/ fpubh.2021.691880)

This study analyzed the interactions of microwaves with biological systems and the effects of microwave radiations on the brain, specifically learning and memory capabilities, as well as the mechanisms of brain dysfunction.

This study evaluated the effects of EMR on the metabolism and receptors of neurotransmitters (dopamine, norepinephrine, epinephrine, serotonin, amino acid, acetylcholine, peptides) in the brain.

EMR has an impact on molecular ions and electrons, as well as ROS, protein, and DNA/RNA levels. Furthermore, the EMR has cytotoxic effects on cells by causing degeneration, apoptosis, and necrosis. EMR has a strong impact on the central nervous system, reproductive system, cardiovascular system, and hematological system. The constant and long-term exposure of EMR to a biological system raises tissue temperature, which is a frequent effect of different stimuli.

Because of the complex diversity of neurotransmitters in the brain, the interaction, co-transmission and co-regulation of neurotransmitters make it difficult to distinguish the primary and secondary changes of each neurotransmitter. However, there are impairments to cognitive functioning and structural and functional changes in the nervous system.

“Radiofrequency Electromagnetic Radiation-Induced Behavioral Changes and Their Possible Basis,” S. N. Narayanan, R. Jetti, K. K. Kesari et al., 2019, Environmental Science and Pollution Research, 26, pp. 30693–30710 (https://doi. org/10.1007/s11356-019-06278-5)

“Measurement of Personal Radio Frequency Exposure in Japan: The Hokkaido Study on the Environment and Children’s Health,” by K. Yamazaki, A. Ikeda-Araki, C. Miyashita, N. Tamura, T. Yoshikawa, T. Hikage, M. Omiya, M. Mizuta, M. Ikuyo, K. Tobita, T OnishI, M. Taki, A. Watanabe, and R. Kishi, 2022, Environmental Research, 216(Pt 1), p. 114429 (https:// doi.org/10.1016/j.envres.2022.114429)

“Electromagnetic Hypersensitivity (EHS, Microwave Syndrome)—Review of Mechanisms,” by Y. Stein and I. G. Udasin, 2020, Environmental Research, 186, p. 109445 (https:// doi.org/10.1016/j.envres.2020.109445)

This study evaluated the effects of EMF and EMR on learning, memory, anxiety, and locomotion.

Exposure to EMF and EMR induces an imbalance in the oxidant/ antioxidant defense system in the brain indicating that the internal environment of each brain cell was getting disturbed by the insult from EMF and EMR.

This study evaluated the association between EMF and EMR and inattention/hyperactivity among children aged 10–15 years.

Positive correlations were noted between the associated increases in the use of mobile phones, video viewing, text messaging, and online gaming and inattention/hyperactivity.

This study explored the association between electromagnetic hypersensitivity and non-specific multiple organ symptoms.

Repeated exposures to EMF and EMR resulted in impaired detoxification systems that become overloaded by excessive oxidative stress and changes in calcium signaling cascades, signification activation of free radical process and overproduction of reactive oxygen species in living cells. Also noted were neurological and cognitive functions and disruptions in the blood-brain barrier.

Self-care is a part of a holistic approach to health and well-being. Selfcare allows nurses to take account of their circumstances, needs, and desires across a lifetime, as well as in the environments in which they live and work. Self-care places real power in the hands of the individual to prevent and treat stressors that can result in diseases. While self-care does not replace the healthcare system, it does provide irreplaceable additional options for optimal well-being (WHO, 2022). Nurses who commit to upholding the ANA’s imperative to actively participate in self-care and who adopt quality, evidence-based self-care interventions on a daily basis, can reduce mortality and morbidities and improve health and well-being.

evidence- based Self-Care Strategies and Actions for Protection Against Stress- related Illnesses

Internal inflammation is pervasive in our modern lifestyles. It plays a major role in many diseases, including in the onset of heart disease, in the incidence of depression, and in the onset of cancer. With such widespread

Table 4

Plants and Herbs as Self-Care Tools*

Source (common name)

Aegle marmelos (Indian bael, Japanese bitter orange, wood apple)

Ageratum conyzoides (billygoat-weed, chick weed)

Amaranthus paniculatus (red amaranth)

Aphanamixis polystachya (pithraj tree)

Centella asiatica (gotu kola, Indian pennywort)

Emblica officinalis (Indian gooseberry)

Gingko biloba

Hippophae rhamnoides (sea buckthorn, seaberry)

Mentha arvensis (wild mint, corn mint, field mint)

Mentha piperita (peppermint)

Osimum sanctum (holy basil)

Panax ginseng (Asian ginseng)

Phyllanthus amarus (gale of the wind, carry me seed)

Piper longum (long pepper)

Podophyllum hexandrum (Himalayan may apple)

Resveratrol (red wine, blueberry, raspberry, blackberry)

Syzigium cumini (Java plum, black plum)

Tinospora cordifolia (heart-leaved moonseed)

Vaccinium myrtillus (European blueberry, bilberry, whortleberry)

Zingiber officinale (ginger)

inflammation and such powerful negative effects, finding effective and easily accessible ways of reducing or combating internal inflammation is of huge importance in self-care for nurses.

Internal inflammation may be caused by a number of things. Two major categories of internal inflammation have been highlighted in this article: workplace stressors and exposure to EMF and EMR. There are, however, other sources of internal inflammation, such as consuming processed meats, exposure to pollution, alcohol consumption, recreational and prescription drugs, and a lack of exercise.

Plants, Herbs, and Supplements as Self-Care Tools

There is an old adage, “You are what you eat.” Many supplements, plants, and herb-based foods have been documented in the literature as having anti-inflammatory, antioxidant, antimicrobial, immunomodulatory, and free radical scavenging or anti-stress properties. This means that to reduce systemic inflammation, one should include a diet with lots of

Protective effect

Micronuclei, free radicals, radiation-sickness, gastrointestinal (GI) and diarrhea-related deaths, lipid peroxidation, glutathione (GSH), colony forming units (CFU), villus height, crypt cells, goblet cells

Radiation-sickness, GI and diarrhea-related deaths, DPPH radical

Survival, CFU, spleen weight, lipid peroxidation, GSH, improves learning

Aberrant cells, chromatid breaks, chromosome breaks, dicentrics, acentric fragments and total aberrations, antitoxin

Weight loss, taste aversion, skin conditions, wound healing

Survival, weight loss, respiratory disorders, fatigue, malaise

Brain edema, clastogenic factors (those agents that break the chromosome and cause mutation)

Survival, CFU, adrenocorticotropic hormone, micronuclei, cardiovascular system, cancer, antioxidant

Radiation-sickness, GI and diarrhea-related deaths, asthma, inflammation

Hematological constituents, serum phosphatase, CFU, spleen weight, goblet cells/villus section and chromosomal damage

Survival, CFU, chromosome damage, lipid peroxidation, glutathione, respiratory ailments, skin diseases, GI

Survival, CFU, apoptosis, testicular enzymes, antioxidant, anti-inflammatory

White blood cells, superoxide dismutase (SOD), catalase, GST, GSHPx, glutathione reductase, antiviral

WBC, α-esterase, glutathione pyruvate transaminase, alkaline phosphatase, lipid peroxidation, GI, respiratory system, spleen

Survival, GI damage, nervous system of developing mice, GST, SOD, tumor inhibitor (antimitotic)

Oxidative stress, immune response

Micronuclei, respiratory system, GI, ulcers

Survival, CFU, blood cells, bone fracture, tumors, GI

Blood glucose levels, inflammation, vision, CV system, brain function, ulcerative colitis, vision

Radiation-sickness, GI and diarrhea-related deaths, free radicals, GSH lipid peroxidation

Note.* If you choose to incorporate an herbal remedy into your daily diet, be sure to talk to your doctor first. Table adapted from “Radioprotective Potential of Plants and Herbs Against the Effects of Ionizing Radiation,” by J. C. Jagetia, 2007, Journal of Clinical Biochemistry and Nutrition, 40(2), pp. 74–81 (https://doi.org/10.3164/jcbn.40.74).

inflammation-fighting foods. Targeted nutritional support works to reduce symptoms of chronic stress and EMF and EMR sensitivity, and bolster the body’s natural protection while concomitantly actively combating physical and mental damage. Sources of anti-inflammatory food interventions are noted in Tables 4 and 5.

The addition of any herbal supplement should first be discussed with a doctor beforehand, as herbal therapies can interact with other medications and cause side unexpected side effects. According to Reddy (2021), caution and good judgment need to be exercised when taking herbs:

 The formulations available are not regulated or studied in the same way as prescription medications. Although there have been studies done to evaluate the claimed benefits of some herbs, most remain debatable.

Table 5

Supplements as Self-Care Tools*

Supplement (natural food source of supplement)

Curcumin (mango ginger, curry)

Ginseng

Glutathione (onions, garlic, cruciferous vegetables)

Green tea

Iodine (seaweed, yogurt, dried prunes)

Kombucha (black tea)

Magnesium (legumes, nuts, dark chocolate over 70%, leafy green vegetables)

Melatonin (exposure to sunlight)

Molecular hydrogen-enriched water

NADH (vitamin B3)

Olive leaf

Polygonum (knotweed)

Propolis (bee honey)

Pycnogenol (maritime pine)

Reishi mushroom

Self-Care as a Nurse’s Right and Responsibility

 Possible side effects can be mild or severe, ranging from allergies to effects on the liver and heart to thinning of the blood.

 Many current formulations have more than one ingredient, which can increase the chance of side effects or interactions.

 Combining herbal therapy with prescription medications increases the potential for interactions and side effects.

 The dose of herbs required for the claimed effect remains largely unknown.

Natural Food Sources as Self-Care Tools

Food provides not only essential nutrients required for life, but also bioactive compounds useful in maintaining good health and preventing

Protective effect

Immune function

Physical stamina, concentration, memory, immune function, respiratory and cardiovascular (CV) disorders, diabetes mellitus (DM)

Oxidative stress, brain function, liver function, cell repair

Immune function

Metabolism, cell repair, free radicals

Gut microbe

Calcium channel blocker, mitochondria/cellular energy

REM sleep

Free radicals, glutathione peroxidase

Brain cells, nervous system

Anti-inflammatory, CV, DM, weight loss, antibiotic, antioxidant

Blood cells, GI, antioxidant, LDL oxidation inhibition, antiulcer, analgesic, anti-inflammatory, antimicrobial, cytotoxic activity

Wound healing, oxidative stress, inflammation, virus, vision

UVB ray, anti-inflammatory, skin cancer

Immune function

Rosemary REM sleep, brain function

Turmeric

Vitamin C and vitamin E

Zinc (pumpkin seeds, turkey, lentils, cashews, seafood, grass-fed beef)

Blood cells

Free radicals, oxidative stress, cell membranes

Lipid peroxidation in brain

Note.* If you choose to incorporate supplements into your daily diet, be sure to talk to your doctor first. Used properly, dietary supplements can be beneficial, but dietary supplements have not proven to be totally safe under all circumstances. Side effects from dietary supplements happen when people take high doses or take them with certain prescription medications. Remember, most of what you hear or read about supplements is based on anecdotal evidence (personal experience or opinion evidence) rather than research. Also remember, supplements do not have to get approval from the Food and Drug Administration. Use good judgment when choosing which supplement you want to add to your diet. Talk with your healthcare team about any supplements you are taking or are thinking about taking. Your doctor or pharmacist can tell you about any known interactions with medicines you may be taking. Lastly, keep in mind that with new medicines and supplements, interactions may not yet be known. Table adapted from “13 Powerful Healing Supplements to Protect Against the Effects of EMFs,” by Conscious Spaces, September 3, 2020, (https://consciousspaces.com/blogs/science/13-powerful-healing-supplements-to-protect-againstthe-effects-of-emfs) and “How To Protect Yourself From Electromagnetic Frequencies (EMFs),” by the Restorative Wellness Center, May 28, 2020 (https://www.restorativechiro.com/ blog/2020/4/5/how-to-protect-yourself-from-electromagnetic-frequencies-emfs).

Table 6

Best sources of Food Antioxidants Using ORAC Score

disease. Foods that score high in an antioxidant assay, called oxygen radical absorbance capacity (ORAC), may protect cells and their components from damage by oxygen radicals. The ORAC unit, ORAC value, or ORAC score is a method developed by scientists at the National Institutes of Health (NIH) to measures the antioxidant capacity of different foods. Considerable epidemiological evidences suggest that consumption of food rich in antioxidants can prevent cell damage caused by free radicals as well as degenerative diseases such as cancer, cardiovascular disease, cataracts, brain dysfunction, and immune dysfunction. Foods with higher ORAC scores have greater antioxidant capacity, and more effectively neutralize harmful free radicals (Apak et al., 2013; Cao et al., 1998; Holford, 2021; Vinson et al., 1998; Wu et al., 2004). Researchers in the area of ORAC and antioxidants state that the body can effectively use 3,000 to 5,000 antioxidant or ORAC units per day. Any amount ingested over 5,000 ORAC units will simply be excreted by the kidneys with no greater beneficial effect. The best sources of food antioxidants found in the literature are shown in Table 6.

Nrf2 Foods as Self-Care Tools

The nuclear factor erythroid 2–related factor 2 (Nrf2) is known as the “master regulator” of the body’s antioxidant pathway. When the Nrf2 pathway is activated, it creates more antioxidant proteins. These proteins control how certain genes that help protect cells from damage caused by free radicals (unstable molecules made during normal cell metabolism), are expressed. Free radicals may play a part in cancer, heart disease, stroke, and other diseases of aging. The Nrf2 pathway is essential for battling injury, disease, inflammation, and any kind of cell-level oxidative damage in the body.

The Nrf2 pathway can be activated by eating certain kinds of foods and supplements. NrF2-boosting foods and supplements include vitamin D, hydrogen water, cauliflower, bok choy, broccoli, brussels sprouts, apples, quercetin, curcumin, cloves, garlic, ginger, cinnamon, red grapes, oregano, thyme, dark chocolate, and berries. Essentially, anything that contains a lot of polyphenols, a type of phytonutrient with a range of antioxidant and anti-inflammatory properties, will activate the Nrf2 pathway (Anderson Stewart, 2020).

Other Self-Care Tools

There are further lifestyle changes that can be made in order to achieve and maintain optimal health. One natural way to detox is through grounding (earthing). We are extremely fortunate to live on the biggest negative ionic charge of all: the Earth. That’s why grounding is a great way to detox from

Note. Table adapted from the articles “Methods of Measurement and Evaluation of Natural Antioxidant Capacity/Activity (IUPAC Technical Report),” by R. Apak, S. Gorinstein, V. Böhm, K. Schaich, M. Özyürek, and K. Güçlü, 2013, Pure and Applied Chemistry, 85(5), pp. 957-998 (https://doi.org/10.1351/PAC-REP-12-07-15); “Know Your Antioxidant Rating,” by P. Holford, 2021 (https://www.patrickholford.com/ advice/know-your-antioxidant-rating/); and “Lipophilic and Hydrophilic Antioxidant Capacities of Common Foods in the United States,” by X. Wu, G. R. Beecher, J. M. Holden, D. B. Haytowitz, S. E. Gebhardt, and R. L. Gebhardt, 2004, Journal of Agricultural and Food Chemistry, 52, pp. 4026–4037 (https://doi.org/10.1021/ jf049696w).

EMF and EMR exposure. Walking barefoot on natural ground, such as grass, sand, and rocks, allows your body to absorb electrons and help banish electromagnetic radiation right into the earth.

Some additional lifestyle changes refer to changes in personal habits (see Figure 5), while other changes refer to our surroundings (see Table 7). A healthy, well-rounded lifestyle will help you thrive throughout life. But most importantly, don’t forget to make time for yourself so you can maintain a healthy outlook. Stay in touch with family and friends, be involved in your community, maintain your curiosity, and continue to engage in lifelong learning. Take that quilting class you say you never have time for. Join that book club. As hard as it may be, advocate for yourself for balance in your life as vigorously as you advocate for your patients.

Conclusion

In the words of Leslie K. Lobel (2001): “You cannot keep giving to others if you do not give to yourself, first. It is like pouring water from a vessel: You cannot pour and pour without ever refilling it—eventually it will run dry.” It’s important to monitor yourself and make sure to realize when you’re feeling overwhelmed or overworked. Keep it all in perspective. Try to stay focused on maintaining health with mind, body, and spirit. That can be easier said than done. By striving to be your best through good nutrition, exercise, time with loved ones, fun moments and laughter, the bad days can be better, and the good days can be amazing.

Effective Self-Care Habits

Disconnec t from social media, especially before sleep.

Strive for 7 to 9 hours of sleep each night.

Table 7

Effective Self-Care Environment

Avoidance

Do 30 minutes of yoga or mindfulness 3 times per week.

Substitution Utilize

Consider using earthing products such as grounded blankets or mats. Turn off your Wi-Fi router at night. Replace all dimmer switches in your home with simple on/off switches. Buy an EMF blocking cover for your home’s Smart Water Meter.

Don’t carry your phone against your body. Use only incandescent near infrared saunas rather than LED lighted infrared sauna.

Limit your use of smart devices. Use an air tube headset rather than a wireless headset. Switch off circuit breakers to specific rooms at night (kitchen, TV, and computer room).

Limit Wi-Fi calling and Wi-Fi options for smart appliances. Use ethernet cables for connectivity needs. Use an EMF blocking phone case. Get rid of all LED and fluorescent light bulbs. Put phone on airplane mode if you need to keep it next to your bed.

Unplug or move anything that is within five (5) feet of your bed. Use a hot water bottle rather than electric heating pad for pain.

Do not place your computer, cell phone, or Wi-Fi -connected watch next to your body. Use analog monitors (baby monitor, video monitor) rather than digital or wireless.

Use an EMF blocking pad underneath your computer.

Use electric stoves/ovens as opposed to induction stoves/ovens.

Use the speaker function on your phone.

Do not sleep with an electric blanket on. Replace silver tooth fillings with ceramic. Place house plants in your rooms. Plants can help absorb radiation.

Figure 5

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NCleX-rN First-Time Passing Predictors

Elizabeth B. Simon, PhD, RN, ANP Susan Joseph, PhD, RN, CNE

n Abstract

The first-time passing rate in National Council Licensure Exam for Registered Nurses (NCLEX-RN) depicts the quality of a nursing program. Therefore, nurse academics must be engaged in educational research to identify predictors for passing the NCLEX-RN on the first attempt. Grounded on the application of general systems theory, this study investigated the predictability of academic variables in achieving first-time passing in the NCLEX-RN. Multiple logistic regression demonstrated the predictive ability of tests of essential skills (TEAS) and grade point average (GPA) toward the outcome. Pharmacology, leadership, and adult health nursing courses showed a statistically significant positive correlation with the first-time passing status. This study contributed to a substantial change: establishing a minimum score in the TEAS exam to progress to the clinical phase. Before this, the only requirement was that the students take the TEAS exam and send in the results.

Keywords: NCLEX-RN, first-time passing, predictor variables, clinical courses, nursing prerequisites, systems theory

Introduction

This ex post facto study was designed to identify predictors of success in the National Council of Licensure Examination for Registered Nurses (NCLEX-RN). The public and regulatory agencies evaluate the undergraduate nursing programs by the published NCLEX-RN first-time pass rate. Therefore, predictors of the NCLEX-RN first-time passing status pass/ fail were explored in the study and the results shared below as “predictors of a first-time pass in a baccalaureate program.”

background

There is a high demand for registered nurses (RNs), and at the same time, not 100% of the graduates from the nursing program obtain RN licensure to begin their entry-level nursing practice. Nursing graduates are required to take the NCLEX-RN to ensure their minimum competence as entry-level practitioners. As health care becomes more complex, the National Council of State Board of Nursing (NCSBN) considers public safety a priority and periodically raises the passing standards. To meet such demands for nursing and healthcare quality and quantity, nursing programs must achieve a high pass rate. Therefore, nurse educators must research and explore evidence-based strategies to improve the NCLEX-RN pass rate. Educators should study the influential variables of educational success

Elizabeth B. Simon, PhD, RN, ANP School of Nursing, Alliance University, New York, New York

Susan Joseph, PhD, RN, CNE School of Nursing Montefiore Medical Center, New York, New York

and adopt policies to facilitate quality outcomes. With that idea in mind, the study was conducted to identify academic predictors contributing to the program’s outcome. The study used general systems theory (GST) to explore the predictors influencing the passing status.

Theoretical Framework

The application of general systems theory in education can be compared to an organism with input, throughputs, outputs, and feedback loops to accomplish its goals through profound learning, instructional design, and educational technology in the present-day milieu (Bertalanffy, 1969; CarrChellman & Carr-Chellman, 2020). The input becomes the personal system of students, such as motivation to learn, cognitive skills, manual dexterity, organization, and prioritization skills. The throughput is the interpersonal system that encompasses students and faculty in the clinical learning environment. This throughput influences the output, which is a licensure for effective clinical practice. When Kroposki et al. (2019) applied GST in their study, input was quantified as cumulative GPA, TEAS composite score, and interview scores. Throughput was mastery learning, active and collaborative learning, faculty resources, and other support systems. The feedback loops are remediation, and the output is the successful completion of the program. Throughput and feedback loops produce changes in the

personal system of the student with knowledge, skills, and values. Thus, like a living organism, education influences, transforms, and maintains changes in personal, interpersonal, and social systems. In our study, we investigated the effect of input variables on the NCLEX-RN first-time passing status.

literature review

Input

Literature has a plethora of evidence that predictor variables influence the outcome of high NCLEX-RN first-time pass rate. However, it is difficult to isolate one single variable as the best predictor of student success. Therefore, a combination of variables can provide a reliable prediction approach (Al Alawi et al., 2020). The main predictors of success in nursing school as input are pre-nursing overall GPA, science GPA, and admission test scores.

Admission criteria are an input variable that influences the outcome, and there is evidence from past studies. Nursing programs use any one of the admission tests by these vendors: Health Education System Incorporated (HESI) admission exam, Test of Essential Academic Skills (TEAS), Kaplan Nursing Admission Test, or National League for Nursing Pre-Admission Exam (NLN PAX-RN). Robert (2018) affirmed a positive correlation between admission exams and first-time passing status. For example, the NCLEX-RN pass rate improved from 77.60% to 95.49% with a revised admission criterion, including the admission score requirement on HESI raised from 75.00% to 80.00% (Pullen, 2017). HESI exit exams given at the end of the program predicted first-time NCLEX-RN passing more than any other investigated variable (Johnson et al., 2017).

TEAS composite score is an average in English, reading, math, and science. In addition to the average or composite scores, researchers identified correlations between specific components of the TEAS exam and program success. TEAS Version V science component has correlated with fundamentals of nursing (Liu & Codd, 2018). However, Flowers and colleagues (2022) did not find TEAS composite scores to predict NCLEX-RN success; on the other hand, they found that a GPA of higher than 3.5 and an Assessment Technology Institute (ATI) TEAS B score above 60 predicted NCLEX-RN success.

Critical thinking (CT) scores are another specific input predictor for student success in the nursing program (Porter, 2018). In addition to program success, the above input variables influence first-year courses such as fundamentals of nursing, pharmacology, and health assessment (Gartrell et al., 2020; Kroposki et al., 2019). The study also found GPA to be the single factor that best predicted NCLEX-RN success; nevertheless, mentoring students with lower GPAs will enhance retention and assist in passing the exam on the first try (Havrilla et al. 2022). Overall preadmission GPA, entrance assessment scores, interview scores, and exit assessment scores were significantly correlated with nursing students’ success (Kroposki et al., 2019). Despite challenging input variables, appropriate mentoring as throughput will promote student success.

There were nonacademic gender factors that predicted first-time NCLEX-RN success. Banks and others (2022) at a historically Black college and university (HBCU) conducted a descriptive study. They found female students (93.15%) were more likely to pass the NCLEX-RN on the first attempt than males (82.61%). We need to explore further to determine whether these gender-based challenges correlate only to HBSU students or not.

Throughput

The input and throughput variables predict and influence the output: competent practitioners who can pass the licensure exam on their first try. The authors support Havrilla and others’ (2018) findings that even if the input variables are not optimal, instructional and technological resources may enhance learning and test-taking. The throughput is a support system that includes faculty, technology, and pedagogical resources. Institutional and program resources, such as mentoring, are also components of throughput. There is sparse literature on the impact of qualitative variables on throughput. Currently, to improve diversity and inclusion, many nursing programs adopt holistic admission strategies, taking into account considerations such as the life experiences of candidates and interview results as qualitative measures in the admission decision.

Students require systematic orientation to deep learning, quality and safety education for nurses (QSEN) competencies, adoption of NCLEX-RN review book as a required textbook, adaptive quizzing, review of the wrong answers in course exams and standardized exams, and remediation. Wallace (2021) recommended a criterion-based proactive curriculum, active learning modalities, and implementation of problemsolving strategies throughout the program to improve outcomes. Faculty mentoring has a significant impact as a throughput measure. Stuckey and Wright (2021) shared how mentoring by the faculty through email, texts, and messages from commencement day until the students took the NCLEX-RN influenced the exam performance positively. Faculty mentors guided the graduates and emotionally supported them throughout their preparation. Therefore, developing, monitoring, and evaluating a comprehensive mentoring program must be a strategy in nursing schools.

In addition to mentoring, Sanderson et al. (2021) studied the concept of learning. They explored social determinants of learning and developed a holistic support system to improve achievement gaps based on social and economic status. Students who spoke English as an additional language face specific challenges to timely NCLEX-RN completion and success, while nontraditional students, such as those over the age of 25 or obtaining their second degree, may have successful outcomes (Spurlock et al., 2019). Chamberlain University, with 59% of its student population hailing from diverse backgrounds, instituted a language and social support environment to reduce financial and psychological stress that can hinder learning. This measure aims to promote equitable education in nursing. Mindfulness training was also incorporated in the first nursing class to enhance the overall psychological health of the students (Petges, 2019). In addition, virtual and high-fidelity simulation, NCLEX-RN exam preparation using delegation and prioritization questions, and exam blueprints and test item analysis evaluation by annual curriculum committee review are other measures that enhance quality throughput.

Retention strategies are throughput factors that include a professional education program and academic support. Meehan and Barker (2021) found that a prescribed remediation protocol helped six cohorts achieve the required score in a predictor exam, demonstrating increased likelihood of passing the NCLEX-RN. There is a significant difference in predictor exam scores among those who were in a remediation program and those who were not in a remediation program.

This strategy resulted in 100% graduation and passing NCLEX-RN on the first attempt (Murray et al. 2016). Davis and Morrow (2021) explored faculty

experience and recommended that the nursing faculty assume counselor and leadership roles in encouraging self-accountability in students to achieve better NCLEX-RN outcomes. In an older article, Bonis et al. (2007) recommended strategies such as assessment testing, independent studies, and simulated NCLEX-RN examinations to improve NCLEX-RN first-time pass rates. Czekanski and colleagues (2018) emphasized the value and effectiveness of a tutoring and a retention coordinator (TRC) as throughput factors improving the NCLEX-RN pass rate from 64.86% to 94.29% with cognitive behavioral techniques, content review, and test-taking strategies. Such a comprehensive approach to NCLEX-RN success should start from a program’s beginning and progress until after graduation. Successful outcomes are based on the collective effort of students, faculty, and administration.

Additionally, specific clinical courses influence the successful program completion and first-time passing status outcomes. Clinical courses are throughput variables. Banks and others (2022) did a retrospective descriptive study and found that academic predictors of first-time NCLEX-RN success were final course grades in Adult I, Adult II, or Child Health. There was 100% success for students who earned an A in Adult I, Adult II, or Child Health. Many nursing programs use predictor exams to determine the learning in clinical courses (throughput) and graduation status (output). The results of the predictor exams are influenced by the content knowledge of the clinical courses. Test-taking and critical thinking skills are essential factors that influence outcomes. Gillespie and Nadeau (2019) found a strong correlation between the Kaplan Integrated Exam score and the output.

Wilson-Anderson identified three variables contributing to nursing students’ first-time passing status: (a) nursing content knowledge, a principal component; (b) test-taking skills; and (c) external variables that affect the learners against their optimal performance (2022). Quinn and colleagues (2018) added critical thinking skills, in addition to test-taking skills and psychological well-being, as an essential component of NCLEX-RN success. A qualitative study on students’ perspectives for NCLEX-RN preparation showed that having a study plan, note-taking, staying focused, commitment, and constant practice of NCLEX-style questions were essential variables to passing NCLEX-RN on the first attempt (Joseph, 2021). Group learning among nursing students is a common practice on many campuses. Yet, Lown and Hawkins (2022) found a negative correlation between group learning and NCLEX-RN success.

All graduates should be prepared to be successful on NCLEX-RN. Therefore, finding at-risk students and implementing a timely intervention is another faculty role in nursing education. The input and throughput components influence the output: program completion and licensure. Many nursing programs use predictor exams to determine graduation status the output.

Purpose of the Study

Purpose of the study is to determine academic predictors of firstattempt outcomes pass/fail on the NCLEX-RN and statistically significant correlation with specific courses.

research Questions

What academic variables are predictors of first-attempt outcomes pass/fail on the NCLEX-RN for newly graduated nurses?

What is the relationship between first-attempt pass rates on the NCLEX-RN and the specific courses?

methods & Design

A retrospective quantitative study investigated variables influencing NCLEX-RN success pass/fail of 118 students in the nursing program located in the northeastern United States. Data collected included the pass/fail results of students’ first-time NCLEX-RN and students’ academic scores for various courses they had taken leading up to the NCLEX-RN. Correlation coefficients were computed between the score variables in an exploratory manner. Pearson correlation coefficients were computed between the two continuous variables and point-biserial correlation coefficients between a continuous variable and a dichotomous variable. A simple logistic regression model was fitted to data to study each score variable’s predictability of the pass/fail results of the first-time NCLEX-RN pass rate. A multiple logistic regression model was also fitted to data to check those variables identified as significant with preceding simple logistic regression as a group predicting the pass/fail results for the first-time NCLEX-RN pass rate. IBM SPSS Statistics 27 was employed for all the analysis. Statistical significance was evaluated with α = 0.05.

Sampling

A bachelor of science (BS) in nursing program in the northeast collected academic data from the sample of 118 transcripts of the candidates who took the exam in 2018, 2019, and 2020 from the program. All letter grades in the transcripts were converted to a percentage score by taking the midpoint of that grade range. All transfer course grades were assigned a score equivalent to letter grade B as that was the minimum requirement for a course to be transferred. Any transcript with incomplete information was not included in the study. The academic variables in this study were course grades for prerequisite science courses microbiology, chemistry, anatomy, and physiology I & II, pathophysiology) and nursing courses (Introduction to Nursing (NURS 102), Adult Health Nursing I & II (NURS 310, NURS 360), Pharmacology in Nursing (NURS 315), Maternal and Child Health Nursing (NURS 410), Community Health Nursing and Population Health (NURS 421), Mental Health Nursing (NURS 461), Research in Nursing (NURS 430), Nursing Capstone (NURS 480), and Leadership in Nursing (NURS 470)). The scores of nursing entrance exams were taken from the ATI database and total GPA from the transcripts. Data were entered in the Excel spreadsheet, and the researcher deleted the student identifiers. This study was granted an exemption from IRB approval as this study involved academics documents alone without any human participants. In addition, study methods affirmed measures to maintain student confidentiality.

Findings

Exploratory correlation analysis found that higher TEAS scores and GPAs were significantly correlated with the first-time passing of NCLEX-RN. Among the nursing courses, NURS 315 (Pharmacology in Nursing), NURS 310 (Adult Health Nursing I), and NURS 470 (Leadership in Nursing) demonstrated a statistically significant positive correlation with the firsttime passing of NCLEX-RN. None of the prerequisite science courses were significantly correlated with the first-time passing of NCLEX-RN (not shown in tables). Results of simple logistic regression analysis indicated that the first-time passing of NCLEX-RN was significantly associated with TEAS, GPAs, NURS 315, NURS 310, and NURS 470 (see Table 1). TEAS scores predicted better first-time passing of NCLEX-RN. Pharmacology was the second important course with predictor ability. Multiple logistic regression with all those individually significant predictors in a single model demonstrated that

TEAS and NURS 315 were the most important predictors of the first-time passing of NCLEX-RN (see Table 2).

TEAS exam scores may reflect test-taking strategies, decision-making capacity, and critical thinking ability. In addition, the predictive power of Course 315, Pharmacology (Nagelkerke R2 20.9%, p-value < 0.001) was interesting to the faculty. This significant finding places Pharmacology in Nursing as an essential course that mandates a review of teaching-learning methods, content, evaluation, and instruction. The predictive ability of the TEAS score (Nagelkerke R2 16.8%, p-value 0.002) was a desirable finding for implementing changes.

With all five variables put together, the multiple logistic regression model accounts for 27.1% of the variability in the passing or failure of NCLEX-RN.

For every additional point increase of TEAS, the odds of passing NCLEX-RN increases by 4% (95% CI: 1%, 8%).

For every additional point increase of Nursing Course 315, the odds of passing NCLEX-RN increases by 19% (95% CI: 5%, 34%).

Conclusion/Implication

The nursing department decided that the input variable (TEAS score) and throughput variables should be strengthened based on the results. The

NCLEX-RN First-Time Passing Predictors

Among the nursing courses, N urS 315 (Pharmacology in Nursing), N urS 310 (Adult Health Nursing I), and N urS 470 (leadership in Nursing) demonstrated a statistically significant positive correlation with the first-time passing of NCleX- r N.

university did not have a minimum TEAS score requirement for admission. Nursing recommended changes in admission strategies beginning from Fall 2022, requiring a minimum score to enter the nursing program. The university approved this recommendation. Likewise, the throughput and feedback loops of the NURS 310 first adult health nursing course, NURS 315 pharmacology course, and NURS 470 leadership course need to be reevaluated for concepts, course delivery, instructional methods, and content to impact the output.

Educators must select effective, accurate, cost-effective admission tools to screen for qualified nursing candidates. Liu et al.’s (2018) study also showed similar results that utilizing content areas such as mathematics, reading, and English in conjunction with science contributes significantly to predicting early nursing school success.

limitations of the study

Nonacademic factors such as age, ethnicity, transfer status, gender, and socioeconomic status were not included. Ten transcripts needed to be excluded because of the incomplete unavailability of corresponding TEAS scores.

2

Multiple Logistic Regression

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Preventing Hospital-Acquired Sacral Pressure Injuries With Silicone Foam Dressing

Carol Blagrove, DNP, MSN/NEd, RN, CCRN, MEDSURG-BC

n Abstract

Problem: A hospital-acquired sacral pressure injury is a preventable adverse event related to unsafe care that impacts patient outcomes. The institution’s hospital-acquired pressure injury rate was below the benchmark, but the 16-bed surgical intensive care unit (SICU) rate remained higher than the overall hospital rate.

Purpose: The quality improvement (QI) project aimed to reduce the hospital-acquired sacral pressure injuries rate using education and the application of a silicone foam dressing within 24 hours of patient admission.

Methods: Educational sessions were provided to nursing staff before project implementation. Outcomes were assessed by comparing pre- and post-implementation sacral pressure injury rates. Chi-square was used to analyze the data.

Interventions: Actions taken included applying silicone foam dressing to the sacral area within 24 hours of admission, assessing beneath the dressing daily, and removing and replacing the dressing every third day or when needed.

Results: No patients developed a sacral pressure injury during the eight weeks of project implementation. The chi-square test was statistically significant ( p = 0.044) between the pre- and post-implementation hospital-acquired sacral pressure injury rates.

Conclusions: The application of silicone foam dressing to the sacral area may reduce hospital-acquired pressure injuries in high-risk patients, improve quality patient care, and enhance staff assessment skills by implementing a preventative intervention.

Keywords: Hospital-acquired sacral pressure injury, silicone foam dressing, intensive care unit (ICU)

Preventing Hospital-Acquired Sacral Pressure Injury With Silicone Foam Dressing

Hospital-acquired pressure injuries (HAPI) are a patient safety issue that affects approximately 3 million people (Centers for Medicare & Medicaid Services [CMS], 2018). Individuals admitted to the intensive care unit (ICU) are at a 27% to 47% higher risk for HAPI (Fulbrook et al.,

2019; Gazineo et al., 2020; Stankiewicz et al., 2019) due to factors such as immobility, malnutrition, incontinence, excessive moisture, dehydration, multiple comorbidities, advanced age, lengthy surgical procedures, and educational deficits (Amoldeep et al., 2019; Ebi et al., 2019; Lin et al., 2020). Although the institution’s HAPI rate was below benchmark, the 16-bed surgical intensive care unit (SICU) prevalence rate remained

Carol Blagrove, DNP, MSN/NEd, RN, CCRN, MEDSURG-BC New York-Presbyterian Columbia University Irving Medical Center, New York, New York

high, specifically for sacral HAPIs. The evidence-based interventions implemented for all patients included turning and positioning every two hours, moisture cream barriers, fluidization beds, early mobilization, and early nutritional interventions. These interventions to reduce sacral HAPIs were ineffective at reducing prevalence; therefore, the following practice question served as the foundation for a quality improvement (QI) project at the practicum site: For the patients in the SICU, does the routine application of a silicone foam dressing to the sacral area impact the rate of sacral HAPI over an 8-week period in comparison to the rate of sacral HAPI with the current practice?

Available Knowledge

Pressure injuries (PI) form where skin covers boney areas of the body, including the occiput, ears, shoulders, elbows, sacrum and buttocks, trochanter, inner knees, and heels in the setting of unrelieved pressure from an external surface (Forni et al., 2018; Oe et al., 2020; Teo et al., 2018). PI are classified into different stages based on the degree and depth of injury to the skin and soft tissues. The PI staging guidelines, developed in collaboration by the National Pressure Injury Advisory Panel (NPIAP), the European Pressure Ulcer Advisory Panel (EPUAP), and the Pan Pacific Pressure Injury Alliance (PPPIA), guide both grading and the treatment of PIs.

Developing sacral HAPIs can result in life-threatening complications, increased morbidity and mortality, and have severe economic ramifications (Amoldeep et al., 2019; CMS, 2018; Lin et al., 2020; Padula et al., 2019) that can cost twice that of prevention strategies. Researchers have found that HAPIs cost organizations approximately $43,180 per patient to treat and manage annually, ranging from $20,900 to $151,700 per patient (CMS, 2018; Roberts et al., 2017). Organizations absorb the cost because they are not reimbursed for hospital-acquired condition (CMS, 2018). Treating subsequent pain from sacral PIs also adds to hospital expenditure. Therefore, early intervention to prevent or treat HAPIs is vital to the patient’s recovery, reduced length of stays (LOSs), and improving hospital expenditure (Lin et al., 2020; Roberts et al., 2017).

The PI-related mortality rate in the United States accounts for 11.6% of hospital deaths (Padula et al., 2019), or 60,000 deaths annually (Joint Commission Center for Transforming Health, 2021). According to an analysis by American Nurse Today (2018), HAPIs increased patient LOS by seven days and increased mortality rate from 1.8% to 9.1%.

Standard evidence-based interventions, including turning and positioning (T&P) patients at least every two hours, use of moisture cream barriers, fluidization beds, early mobilization, and early nutrition, alone have been ineffective in preventing sacral HAPIs. The additional evidence-based intervention of applying a silicone-foam dressing on to the patient’s sacral area within 24 hours of admission is recommended to reduce and/or prevent HAPI (Fulbrook et al., 2019; Gazineo et al., 2020).

Specific Aim

This QI project aimed to reduce the rate of sacral HAPIs in the SICU. The objectives were (a) to assess the current practice and its effect on HAPI prevention, (b) to educate staff on the application of the silicone foam dressing, and (c) to verify staff implementation of the intervention (dressing application within 24 hours of admission and daily skin assessment under

Standard evidence-based interventions, including turning and positioning (T&P) patients at least every two hours, use of moisture cream barriers, fluidization beds, early mobilization, and early nutrition, alone have been ineffective in preventing sacral HAPIs.

the dressing) (Aloweni et al., 2017; Walker et al., 2017). Based on the organizational assessment data, patients in the SICU develop sacral HAPIs at a higher rate than those admitted to other comparable units.

method

A silicone foam dressing was implemented over the span of eight weeks in a 16-bed SICU in a large, academic northeastern New York health system. Staffing skill mix included (a) RNs (bedside nursing staff, float pool RNs, traveling RNs, a certified wound care specialist, and a clinical nurse specialist); (b) ICU technicians; (c) nursing management; (d) medical providers (medical directors, residents, interns, and physician assistants); (e) physical therapist (PT); (f) occupational therapist (OT); and (g) registered dieticians (RD). Bedside nursing staff work 12.5-hour day or night shifts. The patient population in the SICU are adult patients over 18 years of age requiring a surgical procedure: transplant, gastrointestinal, thoracic, otolaryngologic, vascular, oncologic, and overflow cardiac. Other patients may include medicine overflow, acute decompensation from lower levels of care, and post-arrest patients. All patients are acutely ill, and many have multiple complex comorbidities and chronic conditions.

One hundred and forty-two patients were recruited for this project. Patients were assessed by trained staff RNs and the intervention was instituted for patients who met the following the inclusion criteria: adults 18 years and older, intact sacral skin, decreased mobility, and requiring assistance with T&P. Exclusion criteria were based on the literature review: patients with existing PI, allergy to silicone or adhesive, current diarrhea, and patients with a contraindication for inserting a rectal tube.

Intervention

Integrating evidence-based practice (EBP) into the daily routine of nursing care can improve the practice environment, patient outcomes, and safety. Standard practices such as T&P, proper skin products like barrier creams, specialty beds to aid wound healing, and early enteral nutrition were evident in the SICU, but ineffective at reducing HAPI prevalence. The expected outcome of early implementation of a silicone foam dressing in the sacral area is PI prevention (Teo et al., 2018).

The educational plan to reduce sacral HAPIs was a process that required leadership engagement, a cultural change, and the HAPI interdisciplinary team creation. The pre-implementation phase included acquiring buy-in from nursing and medical leadership by presenting the proposal to key stakeholders and the executive team. The ten weeks prior to project implementation consisted of using a data extraction tool (chart review) on skin assessment. Next, the project manager identified skin-care champions, prepared teaching tools, and organized information to disseminate during

Preventing Hospital-Acquired Sacral Pressure Injuries With Silicone Foam Dressing

the implementation phase. In addition, a laminated adherence checklist was created and posted in each patient’s room. Finally, the project manager and nursing manager partnered with the hospital central supply team to increase the unit par of silicone foam dressings to ensure availability.

Educating staff on the implementation process was crucial for the intervention to succeed. The project manager distributed the assessment algorithm to understand the state of current RN and ICU technician knowledge, deliver re-education on staging PIs, and reviewed proper use of the evidence-based Braden scale risk skin assessment tool. The staff was then instructed on the (a) inclusion and exclusion criteria for the project, (b) dressing type and application, (c) assessing the skin beneath the dressing daily, (d) the length of time the dressing should remain on the sacrum, (e) documentation, and (f) completion of the adherence checklist. The project manager and HAPI interdisciplinary team were present daily to provide and receive feedback on the implementation.

Each day, the project manager completed an electronic medical record (EMR) review to identify all newly admitted patients and the presence of a documented comprehensive skin assessment, adherence checklist’s utilization, and compliance with the appropriate dressing and skin assessment documentation per policy/project protocol. The project manager participated in a daily unit safety huddle, just-in-time education, and observational rounds daily to facilitate one-on-one discussions with staff. The instructions for applying the silicone foam dressing were delivered daily during safety huddles by the team leads, the project manager, CNS, wound care specialist, nursing management, charge nurses, or skin care champions. Throughout the eight weeks, the project manager’s presence ensured the support of frontline nurses by establishing relationships and rapport. The project manager was accessible by phone and email during all shifts.

measures

Pre- and post-implementation data were obtained from chart reviews, observations, and the units quality scorecard. Data was collected using chart audits/reviews in the pre-implementation phase to establish current state. Data included in the collection process were (a) skin integrity on admission, (b) Braden risk assessment on admission, (c) HAPI assessment, and (d) documentation. Additional data collected during the review process were gender, race, ethnicity, type of surgery, nutritional status, post-arrest status, mobility, comorbidities, and vasoactive medication use. In addition, the project team reviewed the chart for PI stages and treatment options ordered for the different stages. The outcome measures were based on the monthly report conducted by the wound care specialist, nursing staff accuracy in the documentation of skin ad provided care, and adherence to the project checklist. The wound care specialist and project manager conducted a monthly assessment in the unit and completed chart reviews on the patients identified as high risk for developing sacral PIs.

The HAPI rate was calculated in two ways: prevalence and incidence. The prevalence rate depicts the percentage of patients who have a PI specific time (Agency for Healthcare Research and Quality [AHRQ], 2017). Prevalence data was collected on the first Wednesday of each month per hospital practice. The incidence rate represents the percentage of patients that develop a new PI in the hospital or a specific unit during a particular time (AHRQ, 2017).

Analysis

To implement the silicone foam dressing, the project manager collected data pre-implementation via chart review to assess HAPIs in the SICU. The post-implementation data were collected using the compliance checklist, chart review, and observation of staff activity. “Yes” and “No” responses separated the data items on the compliance checklist and observation activities. The statistical plan to analyze the data included determining if a silicone foam dressing reduced HAPIs compared to the existing standard interventions. The data analysis method for the evidence-based intervention was the chi-square test. Additional demographic variables were collected to ensure the pre-implementation patient sample was similar to post-implementation.

ethical Considerations

The intervention was considered an improvement to the standard of care to augment patient care outcomes. Therefore, no consent was required for this QI project. Patient information was protected for obscurity and confidentiality, and the Health Insurance Portability and Accountability Act (HIPAA) was followed. Data collection and patient data were passwordprotected, patient information was de-identified, and only room numbers were used during the implementation phase.

results

The pre-implementation data was collected over eight weeks during the second quarter (Q2) of 2021. In the pre-implementation group, 58.6% (n = 85) were male and 41.4% (n = 60) were female with an average age of 64.7 (SD = 15.5). Participants were 35.2% (n = 51) Hispanic, 34.5% (n = 50) white, 22.8% (n = 33) Black, and 7.6% (n = 11) Asian. A majority (39.3%, n = 57) of patients were admitted to the SICU post-operatively. Other common admitting diagnoses were hypotension or respiratory distress from the emergency department (ED) (13.1%, n = 19), COVID-19 (9%, n = 13), and gastrointestinal bleed (GIB) (8.3%, n = 12). The other 30.3% (n = 44) were admitted for cardiac arrest, transplant, and acute decompensation on a lower level of care. All patients received the current standard of care and evidencebased PI interventions per hospital policy and unit guidelines that did not include applying the silicone dressing to the sacral area within 24 hours of admission. During the eight weeks of pre-implementation data collection, 145 patients were admitted to the unit and four patients developed a HAPI (2.6%).

The post-implementation group consisted of 142 patients. Of these, 40.8% (n = 58) were female and 59.2% (n = 84) were male with an average age of 62 (SD = 15.8). Participants were 36.6% (n = 52) Hispanic, 35.2% (n = 50) white, 23.9% (n = 34) Black, and 4.2% (n = 6) Asian. Most patients (58.5%, n = 81) were admitted to the SICU postoperatively. Other common admitting diagnoses were acute respiratory decompensation (6.3%, n = 9), ED admission for hypotension and respiratory distress (4.9%, n = 7), GIB (4.2%, n = 6), and cardiac arrest (1.4%, n = 2). The remaining 32.9% (n = 37) of patients were admitted for other miscellaneous medical reasons (see Table 1). A total of 92% (n = 131) of SICU patients received preventative treatment for a sacral HAPI in the post-implementation group. This consisted of applying a silicone foam dressing to a patient’s sacral skin within 24 hours, assessing beneath the dressing daily, and changing and reapplying the dressing

Percentage of Patients With a Sacral HAPI Preand

Discussion

This project utilized an evidence-based intervention to reduce the sacral HAPI rate in the SICU. Applying a silicone foam dressing to the sacral area within 24 hours of admission, assessing beneath the dressing daily, and changing and reapplying the dressing every third day demonstrated a significant reduction in HAPI rates in critically ill patients. This QI project was aligned with other peer-reviewed scholarly articles in its findings that these interventions reduce sacral HAPI rates (Aloweni et al., 2017; Forni et al., 2018; Fulbrook et al., 2019; Gaspar et al., 2019; Gazineo et al., 2020; Hahnel et al., 2020; Lee et al., 2018; Oe et al., 2020; Stankiewicz et al., 2019; Teo et al., 2018). Consistent use of formative evaluation and regular staff education may have impacted the positive outcome of this project. The evidence made it abundantly clear that continuous education is required for the continued reduction of HAPI (Forni et al., 2018; Hahnel et al., 2020; Lee et al., 2018). Although results were statistically significant, the sample size was small and homogenous. Therefore, the external validity of these results should be applied with caution. Furthermore, since this was a QI project, the generalizability of the findings is specific to the practicum site and ICU population.

Potential barriers

Note. HAPI = hospital-acquired pressure injury

every third day to prevent the development of a sacral HAPI. Eleven (8%) patients in the post-implementation group were excluded from the project for not meeting inclusion criteria.

During the first three weeks of implementation, 85% (n = 43) of nurses completed the bedside checklist, 78% (n = 40) documented it in the EMR, and 22% (n = 11) of nurses needed to be reminded to document assessments and/or interventions. Compliance for the remaining five weeks of the intervention checklist and documentation were 100% (N = 51). Of the 131 patients included in the post-implementation data, 0% developed a sacral HAPI. A Chi-squared test was used to identify statistical significance in the reduction of sacral decrease in sacral HAPI from pre- to post-implementation. The 2.6% decrease was a statistically significant ( p = 0.044) in the post-implementation group (see Figure 1).

Potential barriers to implementing an evidence-based intervention included workload and task burden for staff (e.g., checklist completion, dressing application, increased documentation). The SICU team was usually resistant to workflow changes unless augmented with an improved staffto-patient ratio (Correa-de-Araujo, 2017). The workflow concerns were remedied by clustering care and collaborating with the ICU technicians to assess skin integrity and dressings during care rounds. The project manager and stakeholders collaborated with central supply to ensure that silicone foam dressings were readily available to the staff to reduce inefficiencies during project implementation.

Finally, to change the organization’s culture, the project manager utilized numerous strategies to implement the evidence-based intervention successfully. Effective communication and shared leadership were essential in strategic planning; transparency throughout the planning and preparation phases of the project fostered communication. The project team was available to clarify and answer questions via email, phone, and face-to-face meetings. Providing guidance and support

Figure 1

Preventing Hospital-Acquired Sacral Pressure Injuries With Silicone Foam Dressing

to frontline staff was essential during this phase. The wound care specialist, clinical nurse specialist (CNS), and nurse manager assisted with education and attended safety huddles and meetings to enhance the projects implementation and success. Collaboration with the unit staff and the leadership team assisted in capitalizing on the facilitators and mitigating barriers (Belkadi et al., 2017).

limitations

The limitations of the QI project include success based on frequent oneto-one educational sessions, follow-ups, and continuous feedback to staff. These efforts could pose a challenge in a larger project setting. The project had a small sample size, and in order to provide substantial, consistent evidence, a larger sample is needed. Longer project duration would reveal more conclusive evidence on intervention effectiveness. Risk factors that could potentially lead to the development of sacral HAPIs were not addressed in the QI project, such as vasoactive medication use. Finally, the project only looked at one type of silicone foam dressing to prevent sacral HAPIs.

Conclusions

A HAPI is a direct and preventable threat to patient morbidity and mortality and poses a tremendous financial burden to treat within the healthcare system. This is especially true for patients in the ICU. Many studies, including this QI project, demonstrate that utilization of a silicone foam dressing within 24 hours of admission can reduce sacral HAPI rates.

Therefore, implementation of this intervention in conjunction with standard PI prevention can improve patient care outcomes (Forni et al., 2018; Fulbrook et al., 2019; Gaspar et al., 2019; Gazineo et al., 2020; Hahnel et al., 2020; Lee et al., 2018; Oe et al., 2020; Stankiewicz et al., 2019; Teo et al., 2018). While this QI project indicates positive results, additional research requiring a more rigorous methodology is needed to strengthen its generalizability to nursing practice.

Nursing educational opportunities are vital to improve nursing practice. Clinical nurse educators, CNSs, and nursing management can enhance nursing skills and reinforce expert knowledge to enculturate safety and evidence-based strategies into practice. According to Trautman et al. (2018), working with inter- and intra-disciplinary teams to bring change to nursing practice directly improves patient care and outcomes. This preventative intervention can improve nursing practice by enhancing assessment skills and communication within teams.

Sustainability

To maintain post-project success, the institution needs an updated policy and procedure to reflect the change in practice. Staff education is vital to the sustainability of a practice change, and well as continued surveillance of compliance. In this instance, the SICU created a system of continued education and competency assessment during bi-yearly skills days. Other barriers such as insufficient EMR documentation must be addressed to ensure success and accurate data abstraction.

Agency for Healthcare Research and Quality. (2017). Pressure injury prevention in hospitals https://www.ahrq.gov/patient safety/settings/ hospital/resource/pressureinjury/webinars.html

Aloweni, F., Lim, M. L., Chua, T. L., Tan, S. B., Lian, S. B., & Ang, S. Y. (2017). A randomized controlled trial to evaluate the incremental effectiveness of a prophylactic dressing and fatty acids oil in the prevention of pressure injuries. Wound Practice and Research, 25(1), 24–34.

American Nurse Today. (2018). Pressure injuries: Prevention across the acute-care continuum https://www.myamericannurse.com/wpcontent/uploads/2018/05/DabirSupplement_May2018.pdf

Amoldeep, Baby, Khurana, D., Pooja, Reshu, Saloni, & Sarin, J. (2019). Practices followed by nurses for prevention of pressure ulcers among patients admitted in tertiary rural care hospitals. International Journal of Nursing Education, 11(3), 1–6. https://doi.org/10.37506/ijone. v11i3.4059

Belkadi, F., Messaadia, M., Bernard, A., & Baudry, D. (2017). Collaboration management framework for OEM—suppliers’ relationships: A trustbased conceptual approach. Enterprise Information Systems, 11(7), 1018–1042. https://doi.org/10.1080/17517575.2016.1250166

Centers for Medicare & Medicaid Services. (2018). CMS patient safety efforts and the AHRQ national scorecard on hospital-acquired conditions. https://www.cms.gov/newsroom/fact-sheets/cmspatient-safety-efforts-and-ahrq-nationalscorecard-hospital-acquiredconditions

Correa-de-Arajuo, R. (2017). Evidence-based practice in the United States: Challenges, progress, and future directions. Health Care Women International, 37(1), 2–22. https://dx.doi.org/10.1080 %2F07399332.2015.1102269

Ebi, W. E., Hirko, F. G., & Mijena, D. A. (2019). Nurses’ knowledge to pressure ulcer prevention in public hospitals in Wollega: A crosssectional study design. Bio-Med Central Nursing, 18 (20). https:// doi.org/10.1186/s12912-019-0346-y

Forni, C., D’Alessandro, F., Gallerani, P., Genco, R., Bolzon, A., Bombino, C., Mini, S., Rocchegiani, L., Notarnicola, T., Vitulli, A., Amodeo, A., Celli, G., & Taddia, P. (2018). Effectiveness of using a new polyurethane foam multi-layer dressing in the sacral area to prevent the onset of pressure ulcer in the elderly with hip fractures: A pragmatic randomized controlled trial. International Wound Journal, 15(3), 383–390. https://doi.org/10.1111/iwj.12875

Fulbrook, P., Mbuzi, V., & Miles, S. (2019). Effectiveness of prophylactic sacral protective dressings to prevent pressure injury: A systematic review and meta-analysis. International Journal of Nursing Studies, 100, 103400. https://doi.org/10.1016/j.ijnurstu.2019.103400

Gaspar, S., Peralta, M., Marques, A., Budri, A., & Gaspar de Matos, M. (2019). Effectiveness on hospital-acquired pressure ulcers prevention: A systematic review. International Wound Journal, 16(5), 1087–1102. https://doi.org/10.1111/iwj.13147

Gazineo, D., Chiarabelli, M., Cirone, R., Chiari, P., & Ambrosi, E. (2020). Effectiveness of multilayered polyurethane foam dressings to prevent hospital-acquired sacral pressure injuries in patients with hip fracture. Journal of Wound Ostomy Continence Nurses, 47(6), 582-587. https:// doi.org/10.1097/WON.0000000000000715

Hahnel, E., El Genedy, M., Tomova-Simitchieva, T., Hauß, A., Stroux, A., Lechner, A. C., Richter, C., Akdeniz, M., Blume-Peytavi, U., Lober, N., & Kottner, J. (2020). The effectiveness of two silicone dressings for sacral and heel pressure ulcer prevention compared with no dressings in high-risk intensive care unit patients: A randomized controlled parallel-group trial. British Journal of Dermatology, 183, 256–264. https://doi.org/10.1111/bjd.18621

Lee, Y. J., Kim, J. Y., & Shin, W. Y. (2018). Use of prophylactic silicone adhesive dressings for maintaining skin integrity in intensive care unit patients: A randomised controlled trial. International Wound Journal, 16(1), 36–42. https://doi.org/10.1111/iwj.13028

Lin, F., Wu, Z., Song, B., Coyer, F., & Chaboyer, W. (2020). The effectiveness of multicomponent pressure injury prevention programs in adult intensive care patients: A systematic review. International Journal of Nursing Studies, 102(2020), 103483. https://doi.org/10.1016/j. ijnurstu.2019.103483

Oe, M., Sasaki, S., Shimura, T., Takaki Y, Sanada H. (2020). Effects of multilayer silicone foam dressings for the prevention of pressure ulcers in high-risk Patients: A randomized clinical trial. Advances in Wound Care, 9(12), 649–656. https://doi.org/10.1089/wound.2019.1002

Padula, W. V., Pronovost, P. J., Makic, M. B. F., Wald, H. L., Moran, D., Mishra, M. K., & Meltzer, D. O. (2019). Value of hospital resources for effective pressure injury Prevention: A cost-effectiveness analysis. BMJ Quality & Safety, 28(2), 132–141. https://doi.org/10.1136/bmjqs2017-007505

Roberts, S., Wallis, M., McInnes, E., Bucknall, T., Banks, M., Ball, L., & Chaboyer, W. (2017). Patients’ perceptions of a pressure ulcer prevention care bundle in hospital: A qualitative descriptive study guides evidence-based practice. Worldviews on Evidence-Based Nursing, 14(5), 385–393. https://doi.org/10.1111/wvn.12226

Stankiewicz, M., Gordon, J., Dulhunty, J. M., Brown, W., Pollock, H., & Barker-Gregory, N. A. (2019). Cluster-controlled clinical trial of two prophylactic silicone sacral dressings to prevent sacral pressure injuries in critically ill patients. Wound Practice and Research, 27(1), 21–26. https://doi.org/10.33235/wpr27.1.21-26

Teo, K. Y., Ang, S. Y., Bian, L., Cheah, E. S., Somera, M. A., Ahmad, N. H., Lim, S. H., Goh,H. Q. I., & Aloweni, F. A. B. (2018). Evaluating the effectiveness of silicone multilayer foam dressing in preventing heel pressure injury among critically ill patients in Singapore. Wound Practice and Research, 26(2), 76–82.

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n Preventing Hospital-Acquired Sacral Pressure Injuries With Silicone Foam Dressing

The Joint Commission Center for Transforming Health. (2021). Hospitalacquired pressure ulcers/injuries (HAPU/I) prevention. https://www. centerfortransforminghealthcare.org/improvement-topics/hospitalacquired-pressure-ulcers-prevention/

Walker, R., Huxley, L., Juttner, M., Burmeister, E., Scott, J., & Aitken, L. M. (2017). A pilot randomized controlled trial using prophylactic dressings to minimize sacral pressure injuries in high-risk hospitalized patients. Clinical Nursing Research, 26(4), 484–503.http://doi. org/101177/1054773816629689

n WHAT’S NeW IN HEALTHCARE LITERATURE

n

Had

CoVID?

Part of

the

Virus may Stick Around in Your brain

n McNamara, D. (2023, April 13). https://www.medscape.com/ viewarticle/990741

For those experiencing “brain fog” after COVID-19, scientists now have a possible explanation—and it might not bring much comfort. Researchers found that part of the virus, the spike protein, remains in the brain long after viral infection. Researchers in Germany discovered the spike protein from the virus in brain tissue of animals and people after death. The finding suggests these virus fragments build up, stick around, and trigger inflammation that causes long COVID symptoms.

About 15% of COVID patients continue to have long-term effects of the infection despite their recovery, said senior study author Ali Ertürk, PhD, director of the Institute for Tissue Engineering and Regenerative Medicine at the Helmholtz Center Munich in Germany. Reported neurological problems include brain fog, brain tissue loss, a decline in thinking abilities, and problems with memory, he said. “These symptoms clearly suggest damages and long-term changes caused by SARS-CoV-2 in the brain, the exact molecular mechanisms of which are still poorly understood,” Ertürk said. Delivered by circulating blood, the spike protein can stay inside small openings in the bone marrow of the skull called niches. It can also reside in the meninges, thin layers of cells that act as a buffer between the skull and the brain. From there, one theory goes, the spike protein uses channels to enter the brain itself.

The hope is researchers can develop treatments that block one or more steps in this process and help people avoid long COVID brain issues. The spike protein may accumulate in structures outside the brain and cause ongoing inflammation. The clustering of spike proteins would trigger an immune response from this niche reservoir of immune cells that cause the

inflammation associated with long COVID and the symptoms such as brain fog, researcher Topol said. Problems with thinking and memory after COVID infection are relatively common. One research team found 22% of people with long COVID specifically reported this issue, on average, across 43 published studies. Even people who had mild COVID illness can develop brain fog later, Ertürk and colleagues note.

So why are researchers blaming the spike protein and not the whole COVID virus? As part of the study, they found SARS-CoV-2 virus RNA in some people after death and not in others, suggesting the virus does not need to be there to trigger brain fog. They also injected the spike protein directly into the brains of mice and showed it can cause cells to die. Researchers also found no SARS-CoV-2 virus in the brain parenchyma, the functional tissue in the brain containing nerve cells and non-nerve cells, but they did detect the spike protein there. Researchers found COVID can change how proteins act in and around the brain. Some of these proteins are linked to Parkinson’s disease and Alzheimer’s disease, but have never before been linked to the virus. Another unexpected finding was how close the findings were in mice and humans. There was a “remarkable similarity of distribution of the viral spike protein and dysregulated proteins identified in the mouse and human samples,” Ertürk said. Tests for protein changes in the skull or meninges would be invasive but possible compared to sampling the parenchyma inside the brain. Even less invasive would be testing blood samples for altered proteins that could identify people most at risk of developing brain complications after COVID illness. It will take more brain science to get there. “Designing treatment strategies for these neurological symptoms requires an in-depth knowledge of molecules dysregulated by the virus in the brain tissues,” Ertürk said.

n Individual response to bP meds Shows “Substantial” Variation

n Hughes, S. (2023, April 13). https://www.medscape.com/ viewarticle/990739

A new study has shown a substantial variation in the blood pressure response to various antihypertensive medications between individuals. Some people may be better treated with one antihypertensive drug rather than another. This raises the possibility of future personalized therapy. The study’s lead author, Johan Sundström, MD, Uppsala University Hospital, Sweden described findings where “using the optimal antihypertensive drug for a particular patient resulted in an average of a 4.4 mm Hg greater reduction of blood pressure compared with a random choice of the other drugs. That is quite a substantial difference, and could be equivalent to adding in another drug.”

Authors note that despite global access to multiple classes of highly effective blood pressure-lowering drugs, only 1 in 4 women and 1 in 5

men with hypertension reach treatment targets. While most hypertension guidelines advocate combination pharmacotherapy, many patients in routine care continue to be treated with monotherapy, with adverse effects and nonadherence being important clinical problems. “One drug often does not give enough blood pressure reduction, but patients are often reluctant to up-titrate to two drugs,” Sundström said. “While we know that the four recommended classes of antihypertensives lower blood pressure equally well on average, we don’t know if their efficacy is the same in individual patients. “We wondered whether there could be different optimal drugs for different people, and if we could identify the optimal drug for each person then maybe more patients could get to target levels with just one drug,” he said.

The researchers conducted a randomized, double-blind, repeated crossover trial at an outpatient research clinic in Sweden, studying 280 men and women with grade 1 hypertension at low risk for cardiovascular

n Individual response to bP meds Shows “Substantial” Variation (continued)

events. Each participant was scheduled for 2 months’ treatment in random order with each of four different classes of antihypertensive drugs:

 an angiotensin-converting enzyme (ACE) inhibitor, lisinopril

 an angiotensin II blocker, candesartan

 a thiazide diuretic, hydrochlorothiazide

 a calcium channel blocker, amlodipine

Taking into consideration that lisinopril was found to be on average the most efficacious of the drugs at the selected doses, personalized treatment compared with lisinopril still led to a 3.1 mm Hg improvement in systolic blood pressure. The researchers note that the mean additional blood pressure reduction achievable by using the optimal agent was of a magnitude twice that achieved by doubling the dose of a first drug, and more than half that of adding a second drug on average. While there were only small differences between certain drugs (e.g., candesartan vs lisinopril; amlodipine vs hydrochlorothiazide), for all other comparisons tested, the choice was important, with particularly large gains to be made by personalizing the choice between candesartan vs amlodipine and between lisinopril vs amlodipine. Some people showed very large differences in response to different drugs, whereas others did not have much difference at all.

To identify the best drug for each individual patient two approaches were discussed. In the study, the researchers suggest that personalizing therapy could be achieved either by identifying the phenotypic characteristics that are associated with enhanced response to one treatment vs another or by directly measuring the individual’s responses to a series of treatments to ascertain which is most effective. Sundström explained, “We can analyze the characteristics of patients who did best on each drug. There are many variables we can look at here such as age, diet, baseline blood pressure, exercise levels, smoking status, race, body weight, salt intake, and findings from genetic tests. We are going to try to look into these to see if we can find any predictors of response to various different drugs.” A second

strategy, he suggested is that patients starting pharmacologic therapy could try a few different treatments. “For example, we could give patients two different drugs and ask them to alternate treatment periods with each of them and measure their blood pressure with a home monitoring kit and record adverse effects.” Nonadherence “is such a big problem with antihypertensives,” he added. “This approach may allow patients to be more empowered [when choosing] the right treatment, which should help adherence in the longer term.”

Commenting on the study in an accompanying editorial, Robert Carey, MD University of Virginia Health System, Charlottesville, writes: “At this stage, the findings are more theoretical than immediately practical for the implementation of personalized antihypertensive drug therapy, but the study does provide proof-of-principle and the authors suggest a few scenarios in which a personalized approach could be used in the future.” He believes the practical ramifications of personally targeted therapy remain unclear, given that determination of an individual’s response to a series of short test treatments before selecting long-term therapy may be considered too cumbersome, and currently few phenotypic markers are currently available that would be likely to accurately predict the individual response to a particular therapy.

Carey concludes that the results of this study “encourage the further pursuit of larger randomized trials using similar repeated crossover designs to validate this concept and eventually in trials with longer follow-up data to determine whether there is improvement in long-term clinical outcomes compared with current strategies.” He adds that the results also support the possibility that personalized medical treatment of hypertension “may ultimately supplement or even supplant the current method of antihypertensive drug decision-making in the future.”

The study was published April 2023 in the Journal of the American Medical Association and can be accessed through this link: https:// jamanetwork.com/journals/jama/article-abstract/2803518.

n Celiac Disease Clinical Practice Guidelines (ACG, 2023)

n American College of Gastroenterology. (2023, March 2) https://reference. medscape.com/viewarticle/988963

Below are recently published guidelines for the diagnosis and management of celiac disease by the American College of Gastroenterology (ACG) in  https://journals.lww.com/ajg/Fulltext/2023/01000/American_ College_of_Gastroenterology_Guidelines.17.aspx

 Esophagogastroduodenoscopy (EGD) with multiple duodenal biopsies is recommended for confirmation of diagnosis in both children and adults suspected to have celiac disease (CD).

 Combination of high-level tissue transglutaminase (TTG) IgA (>10× upper limit of normal) with a positive endomysial antibody (EMA) in a second blood sample is a reliable test for diagnosing CD in children.

 Intestinal healing is recommended as the goal of gluten-free diet (GFD) therapy in CD patients.

 Use of gluten detection devices in food or biospecimens among patients with CD is not recommended.

 Consumption of gluten-free oats in the diet of those with CD is recommended.

 Vaccination to prevent pneumococcal disease is recommended in patients with CD.

 Immunoglobulin IgA anti-TTG antibody (TTG-IgA) is the preferred single test for the detection of CD in children younger than 2 years who are not IgA-deficient.

 Testing for CD in children with IgA deficiency should be performed using IgG-based antibodies.

n Aortic Disease Clinical Practice Guidelines (ACC/AHA, 2022)

n American College of Cardiology/American Heart Association (2022, Dec 9). https://reference.medscape.com/viewarticle/985190

The following are highlights of recently published guidelines on the diagnosis and management of aortic disease by the American College of Cardiology (ACC) and the American Heart Association. These recommendations replace the 2010 ACC Foundation (ACCF)/AHA guidelines for diagnosing and managing thoracic aortic disease and the 2015 ACC/AHA clarifying statement on surgery for aortic dilation in patients with bicuspid aortic valves. The new guidelines focus on considerations in surgical intervention, consistent imaging practices, genetic and familial screenings, and the importance of multidisciplinary care. They are intended be used with the 2020 ACC/AHA guideline managing patients with valvular heart disease. Full guidelines may be accessed in the ACC/AHA publication, https://www.jacc.org/doi/10.1016/j. jacc.2022.08.004.

Key guidelines

 Screen first-degree relatives of individuals diagnosed with aneurysms of the aortic root or ascending thoracic aorta, or those with aortic dissection to identify individuals most at risk for aortic disease. Screening would include genetic testing and imaging.

 Use consistency in obtaining and reporting computed tomography (CT) scanning, magnetic resonance imaging (MRI), or echocardiography findings; in measuring aortic size and features; and in how often images are used for monitoring before and after repair surgery or other intervention. Ideally, all surveillance imaging for an individual should be performed using the same modality and in the same lab.

 For individuals who require aortic intervention, note that outcomes are optimized when surgery is performed by an experienced surgeon working in a multidisciplinary aortic team.

 At centers with multidisciplinary aortic teams and experienced surgeons, the threshold for surgical intervention for sporadic aortic root and ascending aortic aneurysms is now 5.0 cm (from 5.5 cm)

in select individuals, and it is even lower in specific settings among patients with heritable thoracic aortic aneurysms.

 In patients who are significantly smaller or taller than average, surgical thresholds may incorporate indexing of the aortic root or ascending aortic diameter to either patient body surface area or height, or aortic cross-sectional area to patient height.

 Rapid aortic growth is a risk factor for rupture, and the definition for rapid aneurysm growth rate has been updated. Surgery is recommended for patients with aneurysms of aortic root and ascending thoracic aorta with a confirmed growth rate of ≥0.3 cm per year across 2 consecutive years or ≥0.5 cm in 1 year.

 It is reasonable for patients undergoing aortic root replacement surgery to receive valve-sparing aortic root replacement if the valve is suitable for repair and when performed by experienced surgeons in a multidisciplinary aortic team.

 Consider transferring clinically stable patients with acute type A aortic dissection to a high-volume aortic center to improve survival. Operative repair of type A aortic dissection should entail at least an open distal anastomosis rather than just a simple supracoronary interposition graft.

 An increasing role exists for thoracic endovascular aortic repair in the management of uncomplicated type B aortic dissection. For patients with suitable anatomy, a potential option might be endovascular repair of thoracoabdominal aortic aneurysms with endografts.

Shared decision-making between the patient and multidisciplinary aortic team is highly encouraged in the following patients:

 Those on the borderline of thresholds for repair or those who are eligible for different types of surgical repair.

 Individuals with aortic disease who are pregnant or may become pregnant, for consideration of their risks of pregnancy.

n opioids for Pain Clinical Practice Guidelines (CDC, 2022)

n U.S. Centers for Disease Control and Prevention (2022, Dec 8). https://reference.medscape.com/viewarticle/985106

Guidelines for prescribing opioids for adults with acute and chronic pain were published in November 2022 by the U.S. Centers for Disease Control and Prevention (CDC) in the Morbidity and Mortality Weekly Report (MMWR). These are some of the highlights of the guidelines.

Initiating opioids for pain

 Before initiating opioid therapy, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy.

 Clinicians should maximize use of nondrug and nonopioid drug

therapies, as these are at least as effective as opioids for many common types of acute pain and are preferred for subacute and chronic pain.

Selecting opioids for pain

 When initiating opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release and long-acting (ER/LA) opioids.

 Clinicians should prescribe the lowest effective dosage when opioids are initiated for opioid-naïve patients with acute, subacute, or chronic pain.

n opioids for Pain Clinical Practice Guidelines (CDC, 2022) (continued)

Deciding duration of opioid prescription

 When opioids are needed for acute pain, clinicians should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids.

 Clinicians should evaluate benefits and risks with patients within 1–4 weeks of starting opioid therapy for subacute or chronic pain or of dosage escalation.

Assessing risk of opioid abuse

 Clinicians should evaluate risk for opioid-related harms and discuss risk with patients before starting and periodically during continuation of opioid therapy.

 When prescribing initial opioid therapy for pain, clinicians should review the patient’s history of controlled substance prescriptions to determine whether the patient is receiving opioid dosages or combinations that put the patient at high risk for overdose.

 For patients with opioid use disorder, clinicians should offer or arrange treatment with evidence-based medications.

n eating Disorders Clinical Practice Guidelines (APA, 2023)

n American Psychiatric Association (2023, April 4). https://reference. medscape.com/viewarticle/990312

The following are some of the highlights of guidelines for the treatment of eating disorders, published in February 2023 by the American Psychiatric Association (APA) in the American Journal of Psychiatry

Assessment and Treatment

 Screening for the presence of an eating disorder should be part of an initial psychiatric evaluation.

 The initial evaluation of a patient with a possible eating disorder should include assessment of multiple factors, including but not limited to, patient’s history of height and weight, eating-related behaviors, food repertoire, weight control behaviors, and family history.

 The initial psychiatric evaluation of a patient with a possible eating disorder should identify co-occurring health conditions and psychiatric disorders.

Anorexia

 Patients with anorexia nervosa (AN) who require nutritional rehabilitation and weight restoration should have individualized goals for weekly weight gain and target weight.

 Adults with AN should be treated with an eating disorder–focused psychotherapy.

Bulimia

 Adults with bulimia nervosa (BN) should be treated with eating disorder–focused cognitive-behavioral therapy and prescribed a serotonin reuptake inhibitor.

Binge-Eating Disorder

 Patients with binge-eating disorder (BED) should be treated with eating disorder–focused cognitive-behavioral therapy or interpersonal therapy, either individually or in a group.

 Adults with BED who prefer medication or have not responded to psychotherapy alone should be treated with either an antidepressant medication or lisdexamfetamine.

n All interactions With Grapefruit (Citrus Paradisi, Pomelo, Toronja)

n Medscape. (2023, April 14). https://reference.medscape.com/drug/citrusparadisi-pomelo-grapefruit-344597#3

Grapefruit interferes with many medications, dietary supplement and physiologic conditions. It does this by disrupting various enzyme-mediated metabolic pathways. Medscape maintains a current interactive list of indication-specific dosing for citrus paradisi, pomelo, toronja (grapefruit). Based on FDA labeling and updates from medical literature, frequency-based adverse effects, comprehensive interactions, contraindications, pregnancy & lactation schedules, and cost information are available. The listing of

medications that interact with grapefruit located in the Medscape article categorizes items into those which Medscape lists as contraindicated, produce minor to serious consequences, or require close monitoring. On Medscape, current details are available by simply selecting the individual item using the following link: https://reference.medscape.com/drug/citrusparadisi-pomelo-grapefruit-344597#3.

An additional resource listing of Medications that interact with Grapefruit: https://www.cmaj.ca/content/suppl/2012/11/26/cmaj.120951. DC1/grape-bailey-1-at.pdf.

n Cupping Therapy as an Alternative Pain management Treatment for Chronic Pain

n Junus, A., & Mendoza-Aguilar, M. (2023, June 24–27) N9151 Scholarly Writing and Dissemination II [Conference presentation]. Target Conference: 2023 Annual Research Meeting, Seattle, WA. https:// academyhealth.confex.com/academyhealth/2023arm/cfp.cgi

Abstract

Chronic pain affects a large portion of the world’s population making it a leading cause of disability and disease worldwide. Research shows that neck pain affects up to 50% of individuals, back pain affects up to 67% of individuals, and that migraines are the second most burdensome neurologic disease. One alternative treatment is cupping therapy. The objective of this article is to complete a scoping review of the currently published research on the use of cupping therapy for analgesia, primarily with chronic pain. In order to find the appropriate studies, the search terms (“cupping” or “cupping therapy”) and (“pain” or “pain manage” or “pain treat” or “pain therapy” or “pain relief”) and “adult” were used across three major databases: CLIO, CINAHL, and PubMed. Ultimately, the results show cupping therapy is effective in reducing primarily musculoskeletal pain with some improved functional status. However, while there is low-to-moderate-quality evidence to support such claims, there is little moderate-to-high-quality evidence that supports the reduction of pain with cupping therapy as an alternative therapy. Additional research, including higher-quality randomized controlled trials (RCTs), must be done to positively correlate therapy with pain improvement to generalize results and recommend the implementation of cupping therapy into policies or practice as alternative therapy for patients with chronic pain in either the acute care or outpatient setting.

Background

There are many pharmacological advances that assist in the care of chronic pain patients, there is a growing interest in complementary and alternative treatments. Research shows that neck pain affects up to 50% of individuals, back pain affects up to 67% of individuals, and that migraines are the second most burdensome neurologic disease. Additionally, there is a growing interest in populations where pharmacological solution might be too expensive (Ma et al., 2018). Cupping therapy uses cups made from bamboo, glass, or plastic to create localized, vacuum pressure over a person’s skin theorizing a release of pressure thus a reduction in pain (Ma et al., 2018). To compile what research there is regarding cupping therapy and chronic pain. We also aimed to identify areas where there needs to be more research before we can safely and effectively implement potential complementary or alternative pain treatments.

Purpose

There is a two-fold purpose. First, to complete a scoping review of research regarding cupping therapy and pain management and present it in an easily digestible manner. Secondly, to identify areas where there needs

to be more research before safely and effectively implementing cupping therapy as a complementary or alternative pain treatment.

Methods

We searched using three major databases: CLIO, CINAHL, and PubMed using the search terms (“cupping” or “cupping therapy”) and (“pain” or “pain manage” or “pain treat” or “pain therapy” or “pain relief”) and “adult.” We also looked at related articles that may have been referenced within systematic reviews and meta-analysis. We limited articles to the years 2017 to 2022 and only considered articles that had an English version available for reading. Out of 24 articles, we chose nine articles that had reliable statistical evidence of the effect of cupping on outcomes.

Discussion

There is low moderate-quality evidence that supports implementation of cupping therapy, most often dry cupping therapy, to reduce pain, primarily related to musculoskeletal pain in the neck, head, and back. However, there are many gaps. Some studies often didn’t have long periods of follow-up on patients, which is critical in studying chronic pain and adverse effects. Also, some studies were small in the number of included RCTs or a sample size, which can introduce a higher level of bias. Additionally, there is variability across different systematic analyses on what qualifies as effective cupping therapy. A lack of standardization of care in cupping therapy makes it difficult to determine if it was a specific type of cupping therapy or cupping therapy in general that we helpful in pain reduction. There are also gaps within this study due to the inability to research in other languages which, would be useful in researching complementary and alternative therapies.

Conclusion

While there is a consensus across studies that supports the efficacy of wet and dry cupping therapy in reducing primarily musculoskeletal pain, there is little moderate-to-high-quality evidence that supports the reduction of pain with alternative cupping therapy. There is too much variety in types of pain and too little research on long-term effects to generally recommend cupping therapy. Additionally, there is no standardization for cupping therapy, leading to the inability to control for variation in the quality and inability to provide reliable referrals for patients.

However, there is the possibility of cupping therapy reducing musculoskeletal pain in patients. Some pain treatments, even pharmacological, are supported by low-to-moderate-quality evidence that have anecdotally provided pain relief. Since pain is so individualized, it would be remiss to discount the potential benefits of cupping therapy, especially in chronic pain. To unlock the potential of cupping therapy as part of a multimodal analgesia plan, research into alternative and complementary therapies in medicine must continue. If complementary therapies such as acupuncture can take a rise in studies for pain relief, there is good reason to study cupping therapy as well.

Cupping Therapy as an Alternative Pain management Treatment for Chronic Pain (continued )

References

Abdulah, D. M., Mohammad Sadiq, H. A., & Mohammed, A. H. (2021). Effectiveness of wet cupping therapy on relieving pain in patients with chronic migraine: An observational study. Journal of Complementary & Integrative Medicine, 18(3), 569–577. https://doi-org.ezproxy.cul. columbia.edu/10.1515/jcim-2020-0183

Azizkhani, M., Ghorat, F., Sayed Mohammad, A. S., Karimi, M., & Yekaninejad, S. (2017). The effect of cupping therapy on non-specific neck pain: A systematic review and meta-analysis. Iranian Red Crescent Medical Journal, 20(6). https://doi-org./10.5812/ircmj.55039

Li, J. Q., Guo, W., Sun, Z. G., Huang, Q. S., Lee, E. Y., Wang, Y., & Yao, X. D. (2017). Cupping therapy for treating knee osteoarthritis: The evidence from systematic review and meta-analysis. Complementary Therapies in Clinical Practice, 28, 152–160. https://doi.org/10.1016/j. ctcp.2017.06.003

Ma, S. Y., Wang, Y., Xu, J. Q., & Zheng, L. (2018). Cupping therapy for treating ankylosing spondylitis: The evidence from systematic review and meta-analysis. Complementary Therapies in Clinical Practice, 32, 187–194. https://doi.org/10.1016/j.ctcp.2018.07.001

Moura, C. C., Chaves, É., Cardoso, A., Nogueira, D. A., Corrêa, H. P., & Chianca, T. (2018). Cupping therapy and chronic back pain: systematic review and meta-analysis. Revista latino-americana de enfermagem, 26, 3094. https://doi.org/10.1590/1518-8345.2888.3094

Saeidi, M., Yavari, H., & Fateh, H. (2021). The comparative effects of cupping massage and exercise training in patients with trapezius myofascial syndrome on pain, disability, and fatigue: A randomized controlled trial. Muscle Ligaments and Tendons Journal, 11(04), 712–718. https://doi.org/10.32098/mltj.04.2021.14

Seo, J., Chu, H., Kim, C. H., Sung, K. K., & Lee, S. (2021). Cupping therapy for migraine: A PRISMA-compliant systematic review and meta-analysis of randomized Controlled trials. Evidence-Based Complementary and Alternative Medicine: eCAM,  2021, 7582581. https://doi.org/10.1155/2021/7582581

Volpato, M. P., Breda, I. C., de Carvalho, R. C., de Castro Moura, C., Ferreira, L. L., Silva, M. L., & Silva, J. R. (2020). Single cupping therapy session improves pain, sleep, and disability in patients with nonspecific chronic low back pain. Journal of Acupuncture and Meridian Studies, 13(2), 48–52. https://doi.org/10.1016/j.jams.2019.11.004

Wood, S., Fryer, G., Tan, L., & Cleary, C. (2020). Dry cupping for musculoskeletal pain and range of motion: A systematic review and meta-analysis. Journal of Bodywork and Movement Therapies, 24(4), 503–518. https://doi.org/10.1016/j.jbmt.2020.06.024

Table 1

Cupping Therapy Study Results

Author/year Study type

Abdulah et al., 2021 Retrospective observational (CEBM 4)

Azizkhani et al., 2017 Systematic review & meta-analysis (CEBM 1)

Li et al., 2017 Systematic review & meta-analysis (CEBM 1)

Primary options

Changes in headache severity

Change in pain intensity, visual analog scale (VAS) & numerical rating scale (NRS)

Change in clinical efficacy measurement, pain (VAS), and physical function

Companion groups Methods Results

Ma et al., 2018 Systematic review & meta-analysis (CEBM 1)

Changes in physical function and pain (VAS)

N/A

Cupping therapy with Western medicine vs. Western medicine only

Cupping therapy with Western medicine vs. Western medicine only

Cupping therapy with Western medicine vs. Western medicine only

Data extraction and analysis Significant improvement of headache with wet cupping

Data extraction and analysis Significant pain relief with cupping therapy

Data extraction and analysis Non-statistically significant pain relief in cupping therapy combined with Western medicine compared to Western medicine alone

Data extraction and analysis Significantly greater improvement in physical function and pain in cupping therapy combined with Western medicine

Moura et al., 2018 Systematic review & meta-analysis (CEBM 1)

Saeidi et al., 2021 Randomized control trial (CEBM 2)

Seo et al., 2021 Systematic review & meta-analysis (CEBM 1)

Volpato et al., 2020 Randomized control trial (CEBM 2)

Wood et al., 2020 Systematic review & meta-analysis (CEBM 1)

Change in pain intensity, physical incapacity, and quality of life

Change in pain, disability, and fatigue

Changes in headache intensity treatment effectiveness rate (TER)

Change in pain or disability

Change in pain, function, and range motion

Cupping therapy vs. active standard medical treatment of wait list

Cupping therapy vs. conventional massage therapy

Cupping therapy vs. pharmacological therapy

Cupping therapy vs. placebo cupping therapy

Cupping therapy vs. standard medical treatment or no treatment

Data extraction and analysis Cupping therapy more effective in reduction of pain

Randomized 4-week intervention therapy

Cupping therapy effective in reducing pain, disability, and fatigue for myofascial trapezius pain

Data extraction and analysis Non-statistically significant higher TER of wet cupping therapy migraines

Randomized 1-week intervention therapy

Effective reduction in lower back pain and disability with cupping therapy

Data extraction and analysis Effective reduction chronic neck pain and lower back pain with dry cupping

Note: Nine studies showed reduction in pain scores and two studies showed reduction in disability. Five studies analyzed back pain, four studies analyzed headache/neck pain, and one study analyzed knee osteoarthritis pain. Seven studies compared cupping therapy to no therapy or standardized pain therapy, one study compared cupping therapy to placebo cupping therapy, and one study was a retrospective observational study.

Notice From NYS DoH

THE JOURNAL

of the New York State Nurses Association

Call for Papers

The Journal of the New York State Nurses Association is currently seeking papers.

Authors are invited to submit scholarly papers, research studies, brief reports on clinical or educational innovations, and articles of opinion on subjects important to registered nurses. Of particular interest are papers addressing direct care issues. New authors and student authors are encouraged to submit manuscripts for publication.

Information for Authors

For author’s guidelines and submission deadlines, go to the publications area of www.nysna.org or write to journal@nysna.org

Call for editorial board members

Help Promote Nursing research

The Journal of the New York State Nurses Association is currently seeking candidates interested in becoming members of the publication’s Editorial Board.

Members of the Editorial Board are appointed by the NYSNA Board of Directors and serve one 6-year term. They are responsible for guiding the overall editorial direction of The Journal and assuring that the published manuscripts meet appropriate standards through blinded peer review.

Prospective Editorial Board members should be previously published and hold an advanced nursing degree; candidates must also be current members of NYSNA. For more information or to request a nomination form, write to journal@nysna.org

n Ce Activity: Self-Care as a Nurse’s right and responsibility

Thank you for your participation in “Self-Care as a Nurse’s Right and Responsibility,” a new continuing education (CE) activity offered by NYSNA. NYSNA members and nonmembers are invited to take part in this activity, and you do not need to be a resident of New York State.

INSTRUCTIONS

In order to receive the contact hour (CH) for this educational activity, participants are to read the article presented in this issue of The Journal, complete and return the post-test and evaluation form, and earn 80% or better on the post-test.

This activity is free to NYSNA members and $10 for nonmembers. Participants can pay by check (made payable to NYSNA) or credit card. The completed answer sheet and evaluation form may be mailed or faxed back to NYSNA; see the evaluation form for more information.

The New York State Nurses Association is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

This program has been awarded 1.0 contact hour through the New York State Nurses Association Accredited Provider Unit.

The New York State Nurses Association is accredited by the International Accreditors for Continuing Education and Training (IACET) and is authorized to issue the IACET continuing education credits (CEUs). The New York State Nurses Association is authorized by IACET to offer 0.1 CEU for this program.

In order to receive contact hours and CEUs, participants must read the entire article, fill out the evaluation, and get 80% or higher on the post-test. Presenters disclose no conflict of interest.

NYSNA wishes to disclose that no commercial support or sponsorship was received.

NYSNA Program Planners, Presenters, and Content Experts declare that they have no financial relationship with an ineligible company.

Declaration of Vested Interest: None.

INTRODUCTION

Working conditions traditionally known to cause stress, such as under staffing , pair with modern hazards, such as exposure to electromagnetic fields (EMF) and electromagnetic radiation (EMR). These stressors increase nurses’ risks, for a host of undesirable social, emotional, and physical health consequences. These stressors challenge nurses to exercise rights within the Nurses Bill of Rights and fulfill professional responsibility. In its Nurses Bill of Rights and the Code of Ethics, the American Nurses Association emphasizes nurses’ rights and duties to practice self-care. Nurses must endeavor to mitigate overt as well as insidious workplace and household health hazards. The World Health Organization, Federal Communication Commission, and International Commission on Non-Ionization Radiation Protection recommend safety guidelines for EMF and EMR. Nurses lack knowledge of hazard sources at home and work and the potential health risks associated with them. Nurses are unaware that modifications to the ANA Code of

Ethics and Nurses Bill of Rights have changed their professional rights and added a duty to practice self-care. Through participation in this CE, nurses will gain awareness of professional expectations to meet stressors with “healthy habits” and self-care. This will enable nurses to meet an important professional obligation. In turn, those under the care of nurses would receive optimal quality and experience of nursing care.

LEARNING OUTCOMES

Participants will recognize workplace and household sources of stress. Participants will identify nurses’ rights and responsibilities to perform self-care.

OBJECTIVES

By completion of the article, the reader will be able to:

1. List items pertaining to nurse self-care within ANA’s guidelines for professionalism.

2. Identify traditional sources of occupational stressors for nurses.

3. Identify energy-related health hazards.

Please answer either True or False to the questions below. Remember to complete the answer sheet by putting the letter of your corresponding answer next to the question number. Each question has only one correct answer.

The 1.0 CH and 0.1 CEU for this program will be offered until June 1, 2026.

1) Lack of power, role ambiguity, and role conflict are role-based occupational stressors.

a. True

b. False

2) In hospitals, there is one source of electromagnetic field (EMF) and electromagnetic radiation (EMR).

a. True

b. False

3) Weak high-frequency electromagnetic fields can lead to excessive heating and tissue damage.

a. True

b. False

4) Cardiac monitors, wireless data, and mobile devices are sources of low EMF and EMR.

a. True

b. False

5) Targeted nutrition can reduce EMF and EMR sensitivity and enhance the body’s intrinsic protection against stress.

a. True

b. False

6) According to the ANA Nurses Bill of Rights, nurses have a right to a work environment that prioritizes and protects nurses’ well-being.

a. True

b. False

7) According to the ANA Code of Ethics, the nurse has a responsibility to promote personal health and safety, preserve wholeness of character and integrity, maintain competence, and continue professional growth.

a. True

b. False

8) Protecting patients’ rights and informed consent to treatment has been a long-standing occupational stressor for nurses.

a. True

b. False

9) EMR distresses the body’s cells and can trigger inflammatory responses.

a. True

b. False

10) Nurse leaders are responsible for fostering a balance of healthy diet, exercise, rest, and personal enrichment for nurses within their organization.

a. True

b. False

Answer Sheet

Self-Care as a Nurse’s right and responsibility

Note: The 1.0 CH and 0.1 CEU for this program will be offered until June 1, 2026.

Please print legibly and verify that all information is correct.

First Name: MI: Last Name:

Street Address: City: State: ZIP Code:

Daytime Phone Number (Include area code):

Email:

Profession: Currently Licensed in NY State? Y / N (Circle one)

NYSNA Member # (if applicable): License #: License State:

ACTIVITY FEE: Free for NYSNA members/$10 nonmembers

PAYMENT METHOD

Check—payable to New York State Nurses Association (please include “Journal CE” on your check).

Credit Card: Mastercard Visa Discover American Express

Card Number: Expiration Date: / CVV#

Name: Signature: Date: / /

Please print your answers in the spaces provided below. There is only one answer for each question.

Please complete the answer sheet above and course evaluation form on reverse. Submit both the answer sheet and course evaluation form along with the activity fee for processing. Email to: journal@nysna.org

Or Mail to: NYSNA, attn. Nursing Education and Practice Dept. 131 West 33rd Street, 4th Floor, New York, NY 10001 Or fax to: 212-785-0429

Journal of the New York State Nurses Association, Vol. 50, No. 1

learning Activity evaluation

Please use the following scale to rate statements 1–7 below:

1. The content fulfills the overall purpose of the CE Activity.

2. The content fulfills each of the CE Activity objectives.

3. The CE Activity subject matter is current and accurate.

4. The material presented is clear and understandable.

5. The teaching/learning method is effective.

6. The test is clear and the answers are appropriately covered in the CE Activity.

7. How would you rate this CE Activity overall?

8. Time to complete the entire CE Activity and the test? ____ Hours (enter 0–99) _____ Minutes (enter 0–59)

9. Was this course fair, balanced, and free of commercial bias? Yes / No (Circle one)

10. Comments:

11. Do you have any suggestions about how we can improve this CE Activity?

Self-Care as a Nurse’s right and responsibility

n Ce Activity: NCleX-rN First-Time Passing Predictors

Thank you for your participation in “NCLEX-RN First-Time Passing Predictors,” a new continuing education (CE) activity offered by NYSNA. NYSNA members and nonmembers are invited to take part in this activity, and you do not need to be a resident of New York State.

INSTRUCTIONS

In order to receive the contact hour (CH) for this educational activity, participants are to read the article presented in this issue of The Journal, complete and return the post-test and evaluation form, and earn 80% or better on the post-test.

This activity is free to NYSNA members and $10 for nonmembers. Participants can pay by check (made payable to NYSNA) or credit card. The completed answer sheet and evaluation form may be mailed or faxed back to NYSNA; see the evaluation form for more information.

The New York State Nurses Association is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

This program has been awarded 1.0 contact hour through the New York State Nurses Association Accredited Provider Unit.

The New York State Nurses Association is accredited by the International Accreditors for Continuing Education and Training (IACET) and is authorized to issue the IACET continuing education credits (CEUs). The New York State Nurses Association is authorized by IACET to offer 0.1 CEU for this program.

In order to receive contact hours and CEUs, participants must read the entire article, fill out the evaluation, and get 80% or higher on the post-test.

Presenters disclose no conflict of interest.

NYSNA wishes to disclose that no commercial support or sponsorship was received.

NYSNA Program Planners, Presenters, and Content Experts declare that they have no financial relationship with an ineligible company.

Declaration of Vested Interest: None.

INTRODUCTION

The NCLEX-RN is a pathway to licensure and job eligibility for registered nurses (RN). Given the ongoing RN shortage and limited capacity of RN programs, it is necessary to prepare students to pass the NCLEX-RN. The NCLEX-RN first time pass rate is an essential metric in nursing education. Accreditation bodies, academic institutions, and student applicants weigh the quality and competency of a registered nursing program based on this pass rate. A large body of evidence describes various predictive factors for students’ first-time pass rates. There is abundant data reported on the predictive power of academic variables such as the Test of Essential Academic Skills (TEAS) and performance on required coursework on NCLEX-RN firsttime pass rates. However, the correlation of course grades in specific required courses and NCLEX-RN first-time pass rates remains obscure. The study may give academic planners involved in nursing education additional insight into potential modifications to the admissions process and on course and curriculum planning to improve NCLEX-RN outcomes.

LEARNING OUTCOME

Participants will be able to identify which academic variables are predictors of first-attempt outcomes pass/fail on the NCLEX-RN for newly graduated nurses.

OBJECTIVES

By completion of the article, the reader will be able to:

1. Identify predictive factors for a first-time pass rate for the NCLEX-RN.

2. Identify input and throughput concepts that influence NCLEX-RN pass rates.

3. Identify changes that academic nursing departments can make to improve first-time NCLEX-RN pass rates.

Please answer either True or False to the questions below. Remember to complete the answer sheet by putting the letter of your corresponding answer next to the question number. Each question has only one correct answer.

The 1.0 CH and 0.1 CE for this program will be offered until June 1, 2026.

1) The Test of Essential Academic Skills (TEAS) is an entrance exam used by many nursing programs. The TEAS Version V science component has correlated with Fundamentals of Nursing.

a. True

b. False

2) Throughput is an interpersonal system variable that can influence a student’s success on the NCLEX-RN (output), by offering faculty resources and other support to provide a collaborative learning experience for the student with their instructor(s).

a. True

b. False

3) In this article’s study, the TEAS results and students’ performance in the Pharmacology in Nursing course were the most significant predictors of first-time passing on the NCLEX-RN.

a. True

b. False

4) The TEAS exam consists of sections in English, reading, math, and science and was an input for this study along with cumulative GPA and admission interview scores.

a. True

b. False

5) Authors found there was no correlation between the admissions selection process and first-time pass rate on the NCLEX-RN exam.

a. True

b. False

6) Student mentoring does not have a positive influence on NCLEX-RN pass rates.

a. True

b. False

7) Test-taking and critical thinking skills influence outcomes, like graduation and NCLEX pass rates.

a. True

b. False

8) Nursing faculty should analyze input and throughput factors that influence students’ ability to pass NCLEX-RN the first time and make policy and curriculum changes to improve first-time NCLEX-RN pass rates.

a. True

b. False

9) An important role for nursing faculty is to identify students who are at-risk for failing in their program or failing the NCLEX-RN in order to support the student’s success.

a. True

b. False

10) High grades in all core nursing program courses is required to pass the NCLEX-RN on the first attempt.

a. True

b. False

The Journal of the New York State Nurses Association, Vol. 50,

Answer Sheet

NCleX-rN First-Time Passing Predictors

Note: 1.0 CH and 0.1 CEU for this program will be offered until June 1, 2026.

Please print legibly and verify that all information is correct.

First Name: MI: Last Name:

Street Address:

City: State: ZIP Code:

Daytime Phone Number (Include area code):

Email:

Profession: Currently Licensed in NY State? Y / N (Circle one)

NYSNA Member # (if applicable): License #: License State:

ACTIVITY FEE: Free for NYSNA members/$10 nonmembers

PAYMENT METHOD

Check—payable to New York State Nurses Association (please include “Journal CE”on your check).

Credit Card: Mastercard Visa Discover American Express

Card Number: Expiration Date: / CVV#

Name: Signature: Date: / /

Please print your answers in the spaces provided below. There is only one answer for each question.

Please complete the answer sheet above and course evaluation form on reverse. Submit both the answer sheet and course evaluation form along with the activity fee for processing. Email to: journal@nysna.org

Or Mail to: NYSNA, attn. Nursing Education and Practice Dept. 131 West 33rd Street, 4th Floor, New York, NY 10001 Or fax to: 212-785-0429

learning Activity evaluation

NCleX-rN First-Time Passing Predictors

Please use the following scale to rate statements 1–7 below: Poor Fair Good Very Good Excellent

1. The content fulfills the overall purpose of the CE Activity.

2. The content fulfills each of the CE Activity objectives.

3. The CE Activity subject matter is current and accurate.

4. The material presented is clear and understandable.

5. The teaching/learning method is effective.

6. The test is clear and the answers are appropriately covered in the CE Activity.

7. How would you rate this CE Activity overall?

8. Time to complete the entire CE Activity and the test? ____ Hours (enter 0–99) _____ Minutes (enter 0–59)

9. Was this course fair, balanced, and free of commercial bias? Yes / No (Circle one)

10. Comments:

11. Do you have any suggestions about how we can improve this CE Activity?