The Journal of the New York State Nurses Association, Volume 47, Number 2 by New York State Nurses Association

THE

JOURNAL of the New York State Nurses Association

Volume 47, Number 2

Editorial : The Power of Education by Anne Bové, MSN, RN-BC, CCRN, ANP; Dana Deravin Carr, DrPH, MS, MPH, RN-BC, CCM; Audrey Graham-O’Gilvie, DNP, ACNS-BC; Meredith King-Jensen, PhD, MSN, RN; Caroline Mosca, PhD, MSN, RN, ANP; and Coreen Simmons, PhD-c, DNP, MSN, MPH, RN

in Healthcare Professionals’ “Ending the Epidemic” Training Needs and n Variations Experiences: Findings From a New York State Needs Assessment by Tamala David, PhD, MPA, MS, FNP; Kathleen Holt, PhD; Scott McIntosh, PhD; Monica Barbosu, MD, PhD, MSBA; José G. Pérez-Ramos, MPH, PhD; and Timothy Dye, PhD an Innovative Psychiatric-Mental Health Nurse Practitioner Program to Meet n Developing Current Mental Health Needs by Marissa D. Abram, PhD, RN, PMHNP-BC; Jane H. White, PhD, MSN, BSN; and William Jacobowitz, EdD, MPH, MSN, BSN

Breastfeeding Bundles to Reduce Readmission Risk for Late Preterm and Early Term Infants by Lynne Ponto, BSN, RN-C; and Christopher Kowal, DNP, RN, CCRN-K

Nurses’ Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue, Part 2 by Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD; Lucille Contreras Sollazzo, MSN, RN-BC, NPD; and Christina DeGaray, MPH, RN-BC

n What’s New in Healthcare Literature Activities: Variations in Healthcare Professionals’ “Ending the Epidemic” Training Needs n CE and Experiences: Findings From a New York State Needs Assessment; Developing an Innovative Psychiatric-Mental Health Nurse Practitioner Program to Meet Current Mental Health Needs

THE

JOURNAL of the New York State Nurses Association

Volume 47, Number 2

n E ditorial: The Power of Education ............................................................................................................ 3 by Anne Bové, MSN, RN-BC, CCRN, ANP; Dana Deravin Carr, DrPH, MS, MPH, RN-BC, CCM; Audrey Graham-O’Gilvie, DNP, ACNS-BC; Meredith King-Jensen, PhD, MSN, RN; Caroline Mosca, PhD, MSN, RN, ANP; and Coreen Simmons, PhD-c, DNP, MSN, MPH, RN

n Variations in Healthcare Professionals’ “Ending the Epidemic” Training Needs

and Experiences: Findings From a New York State Needs Assessment.............................. 5 by Tamala David, PhD, MPA, MS, FNP; Kathleen Holt, PhD; Scott McIntosh, PhD; Monica Barbosu, MD, PhD, MSBA; José G. Pérez-Ramos, MPH, PhD; and Timothy Dye, PhD

n Developing an Innovative Psychiatric-Mental Health Nurse Practitioner Program

to Meet Current Mental Health Needs.................................................................................................................... 18 by Marissa D. Abram, PhD, RN, PMHNP-BC; Jane H. White, PhD, MSN, BSN; and William Jacobowitz, EdD, MPH, MSN, BSN

n Breastfeeding Bundles to Reduce Readmission Risk for Late Preterm and Early

Term Infants.......................................................................................................................................................................................... 25 by Lynne Ponto, BSN, RN-C; and Christopher Kowal, DNP, RN, CCRN-K

n Nurses’ Unions Can Help Reduce Stress, Burnout, Depression, and Compassion

Fatigue, Part 2..................................................................................................................................................................................... 32 by Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD; Lucille Contreras Sollazzo, MSN, RN-BC, NPD; and Christina DeGaray, MPH, RN-BC

n What’s New in Healthcare Literature.......................................................................................................................45 n CE Activities: Variations in Healthcare Professionals’ “Ending the Epidemic”

Training Needs and Experiences: Findings From a New York State Needs Assessment; Developing an Innovative Psychiatric-Mental Health Nurse Practitioner Program to Meet Current Mental Health Needs ................................................ 47

THE

JOURNAL of the New York State Nurses Association

The Journal of the New York State Nurses Association Editorial Board

Audrey Graham-O’Gilvie, DNP, ACNS-BC Assistant Professor Touro College School of Nursing Hawthorne, NY Dana Deravin Carr, DrPH, MS, MPH, RN-BC, CCM Senior Care Manager/Transitions Care Coordinator Jacobi Medical Center Bronx, NY Meredith King-Jensen, PhD, MSN, RN Assistant Professor Touro College Bronx, NY

Anne Bové, MS, RN-BC, CCRN, ANP Clinical Instructor New York, NY

Caroline Mosca, PhD, MSN, RN, ANP Faculty Program Director – Team Lead BS/MS Nursing Program Excelsior College Albany, NY Coreen Simmons, PhD-c, DNP, MSN, MPH, RN Professional Nursing Practice Coordinator Teaneck, NJ

Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD, Co-Managing Editor Lucille Contreras Sollazzo, MSN, RN-BC, NPD, Co-Managing Editor David Gray, 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 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.

n EDITORIAL The Power of Education Education is the most empowering force in the world. It creates knowledge, builds confidence, and breaks down barriers to opportunity. Education means more than acquiring knowledge. It empowers people to develop personally and become politically active. Education helps us to create better societies, develop virtues, and gives us freedom. Education today should be used to uplift society since it helps to elevate the social and economic conditions in the marginalized sections of society. In “Variations in Healthcare Professionals’ ‘Ending the Epidemic’ Training Needs and Experiences: Findings From a New York State Needs Assessment,” New York State is identified as a hot spot for HIV and other significant health concerns. Governor Andrew Cuomo launched a plan in response to the crisis aimed at ‘ending the epidemic’ by 2020. Findings in this issue of the Journal emphasize how nurse education in HIV risk reduction and treatment is essential to achieving this noble goal. The article “Developing an Innovative Psychiatric-Mental Health Nurse Practitioner Program to Meet Current Mental Health Needs” notes that increases in opioid use and mental health disorders have created a deficit in mental health nurse practitioners with the necessary psychotherapy skills education to meet the mental health care demands of these populations. In response, nurses marshalled resources and relationships to design a successful new master’s educational program in New York State to ensure all graduates are prepared to provide both medication management and valuable psychotherapy. Consistent lactation support and education for mothers in “Breastfeeding Bundles to Reduce Readmission, Risk for Late Preterm and Early Term Infants” is shown to be instrumental in reducing length of stay and infant readmissions due to hyperbilirubinemia in late preterm and early term infant populations. In the words of former President Bill Clinton and President-Elect Joe Biden, this issue of the Journal honors the work and educational services of all nurses “not by the example of our power, but by the power of our example.” Meredith King-Jensen, PhD, MSN, RN Dana Deravin-Carr, DrPH, MS, MPH, RN-BC, CCM Caroline Mosca, PhD, MSN, RN, ANP Coreen Simmons, PhD-c, DNP, MSN, MPH, RN Audrey Graham-O’Gilvie, DNP, ACNS-BC Anne Bové, MSN, RN-BC, CCRN, ANP

Journal of the New York State Nurses Association, Volume 47, Number 2

Variations in Healthcare Professionals’ “Ending the Epidemic” Training Needs and Experiences: Findings From a New York State Needs Assessment Tamala David, PhD, MPA, MS, FNP Kathleen Holt, PhD Scott McIntosh, PhD Monica Barbosu, MD, PhD, MSBA José G. Pérez-Ramos, MPH, PhD Timothy Dye, PhD

n A bstract

HIV/AIDS remains a leading health concern in New York State (NYS). In 2014, Governor Andrew Cuomo announced Ending the Epidemic (ETE), a plan to arrest HIV/AIDS by 2020 (NYS Department of Health, 2015). To assess training needs among NYS health professionals, the Department of Health AIDS Institute Clinical Education Initiative team deployed an online survey. Clinicians and non-clinicians responded. Analysis by provider type revealed no difference in knowledge about NYS HIV testing law or the ETE plan between clinicians and non-clinicians. Familiarity with pre- and post-exposure prophylactic therapies did not differ significantly, but there was a significant interaction between provider type and familiarity on preferences for additional training. Confidence for prescribing buprenorphine was low among all respondents, and lowest among non-physicians. NYS professionals need and want continuing education related to HIV risk reduction and treatment. Nurse education in risk reduction strategies is essential to reaching the ETE goal. The purpose of this paper is to discuss our survey methods and findings. Keywords: HIV/AIDS, New York, epidemic, clinician, training

Introduction New York State (NYS) is a “hot spot” for several of the nation’s leading health concerns, including HIV/AIDS. In 2014, the year-end prevalence of persons living with HIV in New York State was nearly 113,000 (NYS Department of Health [NYSDOH] AIDS Institute, 2015; 2016). That year, Governor Andrew Cuomo announced the three-point plan Ending the Epidemic (ETE) with the goal to arrest the HIV/AIDS epidemic by the end of 2020. New York was the first state in the country to have such a plan. The ETE plan includes a focus on HIV testing, treatment, and prevention strategies; however, attention to testing, treatment, and prevention of the

hepatitis C virus (HCV) and other sexually transmitted infections (STIs) are priorities as well. The NYSDOH AIDS Institute has principal responsibility for coordinating state programs, services, and activities relating to HIV/AIDS, HCV, and STIs (NYSDOH AIDS Institute, 2017). The NYSDOH AIDS Institute Clinical Education Initiative (CEI) is one pathway to meeting the training needs of New York State’s healthcare workforce. CEI has four centers of excellence throughout the state designed to enhance the capacity of a diverse healthcare workforce to deliver services that improve health outcomes related to HIV. (NYSDOH AIDS Institute, 2020). Through funding to the CEI

Tamala David1, 2, Kathleen Holt1, Scott McIntosh1, Monica Barbosu1, José G. Pérez-Ramos1, and Timothy Dye1 1 Clinical & Translational Science Institute, University of Rochester Medical Center; 2Department of Nursing, The College at Brockport, State University of New York Journal of the New York State Nurses Association, Volume 47, Number 2

Variations in Healthcare Professionals’ “Ending the Epidemic”

Resource Center of Excellence, our team (composed of a physician, a nurse practitioner, and public health researchers) conducted a needs assessment in order to obtain a better understanding of NYS clinicians’ training needs related to achieving ETE goals. The purpose of this paper is to describe and discuss our assessment methods and findings.

Background Attention to the number of people newly infected or living with HIV/ AIDS in New York has remained a public health priority. At the end of 2017, nearly 112,000 NYS residents were living with HIV (NYSDOH AIDS Institute, 2018), and at the end of 2018, there were 108,683 (NYSDOH AIDS Institute, 2019). The prevalence of New Yorkers living with HIV has gradually decreased since 2014 and the number of newly diagnosed persons has decreased 43% since 2009 (NYSDOH AIDS Institute, 2019). “Statewide, 21% of persons newly diagnosed with HIV were concurrently diagnosed with AIDS” (NYSDOH AIDS Institute, 2019, p. 5). This reflects a slight increase in concurrent diagnoses since 2017 (NYSDOH AIDS Institute, 2018). To reduce the prevalence of HIV/AIDS and achieve ETE goals effectively and efficiently, NYS health officials must continue to identify and address system-level barriers to the timely care and treatment of people infected with these health conditions and those at risk for infection (Center for Disease Control and Prevention, 2017). As the state organization with principal responsibility for coordinating state programs, services, and activities relating to HIV/AIDS, the NYSDOH AIDS Institute periodically identified and/or modified a list of priorities and proposed actions to address the state’s HIV/AIDS concerns and to achieve ETE goals (NYSDOH AIDS Institute, 2015; n.d.-a; n.d.-b). To accomplish the proposed actions for each of the NYSDOH AIDS Institute’s identified priorities, New York State must have a knowledgeable, skilled clinical workforce. To ensure that the state has the clinical workforce necessary, assessment of the skills and training needs of practicing clinicians throughout the state is essential. For more than 30 years, CEI has offered trainings and continuing medical education to NYS healthcare professionals (clinicians and other healthcare service providers) through its centers of excellence. Using several training platforms, CEI offers continuing medical education on topics related to HIV, HCV, STIs, and drug user health (DUH). In 2007, CEI launched its online education program alongside its live/ in-person trainings. The online program has evolved to encompass more than 300 multimedia learning modules/continuing education courses, 14 case simulation tools (via the Virtual Patient application), public service announcements, and other online resources. Healthcare professionals who participate in or use CEI’s live/in-person or online programs have the opportunity to complete a feedback form for each training, course, or module/tool used.

A 2015 evaluation of clinician feedback revealed that clinicians found CEI’s information to be useful, relevant, and easy to comprehend (Wang & Luque, 2016). Building on the history, strength, and potential of CEI, we created and deployed an online survey to improve our understanding of NYS clinicians’ training needs related to HIV/AIDS and the NYSDOH AIDS Institute priorities and actions toward achieving ETE goals.

Methods We developed an online Research Electronic Data Capture (REDCap) survey that respondents could access, complete, and submit anonymously. We did not use any formal theoretical framework to underpin the development of our survey or data collection methods. We did use previously developed items, extant literature, our collective public health knowledge, and clinical expertise to identify priority, practice-related topics and questions for inclusion in the survey. After pretesting iterative improvements of a survey adapted with survey items from our previous state-funded projects with the target population, the resultant survey contained 27 core questions. Items included respondents’ professional occupations, work environments, and recent experiences with and needs for training related to HIV/AIDS, HCV, and STIs. Most questions had a “select one” or “select all” response option; however, some had open-ended response options (see Appendix for survey). The survey was available via a web link circulated to people on the CEI Resource Center of Excellence’s distribution list via email and the CEI Newsletter published twice per month. The link was also available on the CEI website, www.ceitraining.org. The survey was accessible online May through August 2016, and our goal was to receive responses from as many clinicians practicing in New York State as possible. Respondents could complete the survey in about five minutes and they received no incentives for participation. The University of Rochester Medical Center Research Subjects Review Board determined our project was exempt from research review because it did not meet the federal definition of research.

Data Analysis and Management The survey received 310 healthcare respondents; 260 were healthcare professionals in New York State. We managed and analyzed all survey data using SAS version 9.4 (SAS Institute, Cary, NC). We used descriptive statistics to characterize the data and performed a series of analysis of variance (ANOVA) general linear models to examine the impact of healthcare provider type and familiarity with HIV pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) on training needs and experiences. Only the 260 NYS respondents were included in our analyses.

Independent Measures To accomplish the proposed actions for each of the NYSDOH AIDS Institute’s identified priorities, New York State must have a knowledgeable, skilled clinical workforce.

To discern the distinctions among providers for training preferences, we classified the respondents a priori as clinicians or non-clinicians (“provider type”) for the purposes of analysis. Clinicians included physicians (MDs), nurse practitioners (NPs), registered nurses (RNs), physician assistants (PAs), and pharmacists. Non-clinicians included social workers, case managers, and public health professionals. Respondents rated their familiarity with PrEP and PEP as “not at all,” “slightly,” “moderately,” “very,” or “extremely.” We classified respondents reporting being “very” or “extremely” familiar

Journal of the New York State Nurses Association, Volume 47, Number 2

Variations in Healthcare Professionals’ “Ending the Epidemic”

with both PrEP and PEP as “highly familiar.” We classified respondents reporting other levels as “less familiar.” To minimize the impact of multiple tests, we used provider type (clinicians vs. non-clinicians) and level of familiarity (highly familiar vs. less familiar) to predict dependent measures in ANOVA models assessing main effects and interactions.

Dependent Measures We summarized “training preferences” (1 = no preference, 3 = strong preference) as means for 13 specific topics covering screening, prevention, assessment and care, disease management/treatment, and state policy. Topics related to screening included HIV, HCV, and STIs. Topics related to prevention included PrEP and PEP. Topics related to assessment and care included sexual health history, smoking cessation, and behavioral counseling. Topics related to disease management/treatment included the latest developments in treatment options, linkage to care options, STI clinical management, and opioid overdose. The final topic, related to state policy, was the ETE blueprint.

Results

educators (n = 24), care managers (n = 5), and those describing themselves as ‘other’ (n = 33). Respondents reported working with a variety of populations, including high-risk groups for contracting or transmitting HIV, HCV, and STIs. Table 1 contains details related to the populations cared for by respondents. Eighty-three percent (n = 125) of clinicians reported they screen/test patients for HIV, HCV, or STIs, while 70% (n = 76) of non-clinicians reported the same. Eighty-two percent (n = 119) of clinicians reported that they treat patients with HIV, HCV, and STIs, while 43% (n = 46) of non-clinicians reported caring for these patients. Sixty percent (n = 90) of clinicians and 67% (n = 71) of non-clinicians reported that they address drug overdose issues with patients. Confidence for prescribing buprenorphine as a means of treating opioid addiction differed significantly among clinicians with prescribing privileges (MDs, NPs, PAs), clinicians without prescribing privileges (nurses and pharmacists), and non-clinicians, F(2, 106) = 5.58, p = 0.005. Confidence for prescribing buprenorphine to treat opioid addiction was low among all respondents: It was lowest among non-physicians.

Respondent Characteristics

Training Experiences and Preferences

The 260 respondents included 152 clinicians: MDs (n = 52), NPs (n = 52), RNs (n = 38), PAs (n = 8), and pharmacists (n = 2). Non-clinician respondents (N = 108) included social workers (n = 13), case managers (n = 13), public health professionals (n = 20), administrators/coordinators/

Analysis by provider type revealed no difference in knowledge about NYS HIV testing law between clinicians and non-clinicians, t(256) = 1.54, p = 0.13, or about Governor Cuomo’s ETE plan, t(250) = -0.85, p = 0.39. Regarding the ETE plan, non-clinicians reported a stronger preference for

Table 1 Populations in Care Reported by Provider Type

Populations in care

Percentage of providers (by type) who report populations in care Percentage of clinicians

Percentage of non-clinicians

Adolescents*

34.86

35.18

Inmates/parolees/probation/recently incarcerated

13.81

22.22

LGBTQ*

23.68

41.66

Men

34.21

34.25

Women

36.18

41.66

Men who have sex with men*

26.31

29.62

People who exchange sex for money/drugs*

18.42

27.77

People who use substances*

33.55

50.92

People with HIV/AIDS*

36.84

69.44

People with mental disorders*

22.36

40.74

Pregnant women*

11.18

27.77

Racial/ethnic minorities*

35.52

44.44

Note. * Denotes designation as a priority population according to NYSDOH AIDS Institute’s list of priorities and proposed actions (NYSDOH AIDS Institute, 2015; n.d.-a; n.d.-b).

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Variations in Healthcare Professionals’ “Ending the Epidemic”

training in regards to the state’s blueprint than clinicians, F(1, 221) = 13.03, p < 0.001; though all respondents expressed some preference for training in this area. Familiarity with PrEP and PEP did not differ significantly between clinicians and non-clinicians, t(252) = 1.82, p = 0.07 and t(255) = 1.80, p = 0.07, respectively. While clinician and non-clinician reports of familiarity with PrEP and PEP did not significantly differ, there was a significant interaction between provider type and familiarity on preferences for additional training on PrEP and PEP, F(1, 227) = 5.70, p = 0.018 and F(1, 227) = 5.58, p = 0.019, respectively. Non-clinicians who reported high familiarity with PrEP and PEP had the highest preference for additional training. Regarding topics related to disease management/treatment, clinicians and non-clinicians who reported high familiarity with PrEP and PEP reported a stronger preference for training related to the latest developments on HIV, HCV, and STI treatment options than those who reported lower familiarity, F(1, 234) = 6.22, p = 0.013. Non-clinicians reported a stronger preference for training on linkage to care options than clinicians, F(1, 227) = 23.15, p < 0.001; however, this main effect was qualified by an interaction with familiarity. The greatest desire for training on linkage to care options was among non-clinicians with high familiarity with PrEP and PEP, F(1, 227) = 8.97, p = 0.003. Clinicians and non-clinicians expressed some preference for training related to opioid overdose. Non-clinicians, however, reported the strongest preference for training on this topic, F(1, 230) = 11.25, p < 0.001.

Discussion A workforce of healthcare providers who lack the knowledge or skills to carry out actions related to prevention, testing, and treatment is a major system-level barrier to the timely care and treatment of people infected with HIV/AIDS and those at risk for infection. It is the responsibility of the NYSDOH AIDS Institute to assess and address the capacity of the NYS healthcare systems and healthcare workforce to deliver services that improve health outcomes related to HIV. The NYSDOH AIDS Institute’s periodically amended list of priorities and proposed actions reflect its ongoing efforts to assess and address the capacity of New York’s healthcare systems and healthcare workforce to improve health outcomes related to HIV among many diverse populations of residents living in New York State. Examples of the NYSDOH AIDS Institute’s proposed actions and priorities include:

All respondents reported completing training activities on topics related to HIV, HCV, and STIs within the past year (Table 2), but indicated that more training was preferred. Differences in preferences for additional training were found between clinicians and non-clinicians on the topics of screening/testing for HIV, F(1, 221) = 12.17, p < 0.001; HCV, F(1, 218) = 8.81, p = 0.003; and STIs F(1, 225) = 7.42, p = 0.007. Non-clinicians reported stronger preferences for training on these topics than did clinicians. In addition, differences in preference for additional training were found on topics related to assessment and care. Non-clinicians reported a stronger preference for training on taking sexual health history, F(1, 225) = 16.70, p < 0.001; smoking cessation, F(1, 228) = 6.24, p = 0.013; and behavioral counseling for STIs/HIV risk reduction, F(1, 232) = 13.48, p = 0.0003.

 Increase HIV testing and HIV status awareness through testing. Priority 1 is to “Improve HIV care outcomes, including timely HIV detection and higher rates of viral suppression” among persons living with HIV/ AIDS (NYSDOH AIDS Institute, n.d.-a, p. 1; NYSDOH AIDS Institute, n.d.-b, p. 1).  Develop comprehensive healthcare provider education that assures timely and appropriate prevention, screening, and treatment for STIs/ HIV in multiple healthcare settings. Priority 4 addresses sexual health awareness, education, and treatment and care options for STIs, with increased focus on youth and young adults (NYSDOH AIDS Institute, n.d.-a, p. 2).  Priority 5 seeks to “eliminate HCV” by developing an HCV elimination plan focused on at-risk populations, while expanding screening, improving access to care and new HCV drugs, and promoting awareness and education (NYSDOH AIDS Institute, n.d.-a, p. 3).

A workforce of healthcare providers who lack the knowledge or skills to carry out actions related to prevention, testing, and treatment is a major system-level barrier.

Table 2 Past Year Training Activities Reported by Provider Type

Training topics

Percentage of providers (by type) who report having had training Percentage of clinicians

Percentage of non-clinicians

HIV

74.34

86.11

PrEP

67.76

61.11

PEP

38.16

41.67

HCV

59.20

53.70

STIs

57.90

53.70

Smoking cessation

20.40

24.10

Opioid overdose

25.00

34.26

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Variations in Healthcare Professionals’ “Ending the Epidemic”

 Priority 7 is to “Promote interagency collaboration to improve drug user health, with a specific focus on expanding access to sterile syringes, increasing safe syringe disposal resources, and preventing overdose deaths including providing access points for buprenorphine” with action to “increase access to buprenorphine for opioid dependent individuals” (NYSDOH AIDS Institute, n.d.-a, p. 2; NYSDOH AIDS Institute, n.d.-b, p. 4).  Priorities 2 and 6 serve to increase awareness of and access to PEP through consumer materials, clinical provider education, PEP guidelines and 24/7 CEI line access for clinical providers, and a consumer hotline, while priority 2 seeks to “Increase access to PrEP and PEP” for individuals (NYSDOH AIDS Institute, n.d.-a, p. 3; NYSDOH AIDS Institute, n.d.-b, p. 2).  Increase the delivery of PrEP services in primary care (with emphasis on adolescents and obstetrics and gynecology providers), mobile medical units, STI clinics, family planning/reproductive health care settings (NYSDOH AIDS Institute, n.d.-a, p. 3; NYSDOH AIDS Institute, n.d.-b, p. 2). This list of examples does not reflect the NYSDOH AIDS Institute’s full range of proposed actions and priorities since the inception of the ETE blueprint. It does reveal the alignment between the institute’s proposed actions and priorities, CEI goals, and healthcare provider needs and preferences for training related to HIV/AIDS. Results from our needs assessment generally show that, compared to clinicians, non-clinicians report serving a greater proportion of priority populations, including, people with HIV/AIDS, pregnant women, people who are LGBTQ, people who exchange sex for money/drugs, people who use substances, and people with mental disorders. It is not surprising that this group has stronger preferences for additional training in nearly all topics related to HIV/AIDS prevention, screening/testing, and treatment and care. The list of priorities and proposed actions published periodically by the NYSDOH AIDS Institute clearly shows that interagency collaboration and interprofessional collaboration (i.e., collaboration between the clinician and non-clinician workforce) are essential to the success of ETE. Therefore, it is important for NYS clinicians, as well as CEI centers of excellence teams, to be made aware of our needs assessment results so that they may better understand the potentials gaps or threats that exist within the healthcare delivery chain as related to HIV/AIDS-related prevention, care, and treatment. Results from our needs assessment also show that clinicians and non-clinicians report similar levels of familiarity with PEP and PrEP, with both groups expressed a desire for additional training on these topics. However, our analyses show that the desire for additional training on these topics was highest among non-clinicians with already high familiarity. Our needs assessment does not give us a clear understanding about why this might be, so this stated desire warrants further investigation along with efforts to provide additional training to both clinician and non-clinician groups. Interestingly, results from our needs assessment show that clinicians and non-clinicians report similar levels of knowledge about New York State’s ETE initiative and HIV testing law. All respondents expressed some interest in additional training related to the ETE blueprint, with this interest observed more strongly among non-clinicians. As stated previously, interagency collaboration and interprofessional collaboration are essential to the success of ETE. Therefore, this finding is important and warrants urgent attention.

CEI’s response to this training need is critical to the success of the NYSDOH AIDS Institute’s identified actions and priorities related to improving drug user health as part of HIV/AIDS prevention and treatment.

To address this identified need, various CEI centers of excellence offer courses with or without continuing education accreditation (i.e., continuing medical education/continuing nursing education) online, live/in person, or by webinar per request. Regarding NYS HIV testing law, one of CEI’s most popular courses is the online HIV/AIDS Confidentiality Law Overview course (https://ceitraining.org/courses/course_detail.cfm?mediaID=811). Hence, New York State may well be on its way to meeting the training needs of its healthcare workforce in this area. In July 2016, President Barack Obama signed the Comprehensive Addiction and Recovery Act (CARA) into law. The law expands buprenorphine prescribing privileges to NPs and PAs for five years (American Society of Addiction Medicine, 2017). Since CARA became law, states have been moving quickly to train more clinicians in buprenorphine treatment for individuals with opioid dependency. While MDs have had access to acquiring buprenorphine prescribing privileges for many years, findings from our needs assessment and extant literature (Andrilla et al., 2017) suggest that their confidence for prescribing buprenorphine to treat opioid addiction remains low. We acknowledge the need for additional training in this area and advocate for buprenorphine prescribing education/training for MDs, NPs, and PAs, and buprenorphine treatment education/training for nonprescribing clinicians (e.g., RNs and pharmacists) who handle screening, care planning, and patient education. Following the results of our needs assessment and to meet the training needs of clinicians and non-clinicians related to topics on disease management/treatment, CEI teams developed new courses, among them opioid overdose and buprenorphine treatment. CEI’s response to this training need is critical to the success of the NYSDOH AIDS Institute’s identified actions and priorities related to improving DUH as part of HIV/AIDS prevention and treatment.

Conclusion Governor Andrew Cuomo’s 2014 ETE initiative is an ambitious plan to end the AIDS epidemic in New York State and to reduce the number of new HIV infections from 3,000 in 2013 to 750 by the end of 2020. As the first state to have a plan to address the HIV/AIDS epidemic, New York has taken the lead in the public health campaign against HIV/AIDS and must remain attentive to the capacity of its healthcare workforce to address issues inherent to the epidemic. Aligning ourselves with the governor’s commitment to ETE and building on the longstanding reputation of the CEI program, we assessed the training needs of NYS healthcare providers necessary to accomplish the NYSDOH AIDS Institute’s proposed actions in support of the ETE plan’s priorities. We learned that NYS providers have variation in their training wants and needs; therefore, our focus must be to update CEI training modules and create new courses, materials, and tools to address providers’ needs and preferences. Together, the ETE initiative, the NYSDOH AIDS

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Variations in Healthcare Professionals’ “Ending the Epidemic”

Institute’s priorities and proposed actions, and CEI’s training activities and opportunities support the CDC’s recommendation to identify and address system-level barriers to the timely care and treatment of people infected with HIV/AIDS, HCV, STIs, and those at risk for infection (Center for Disease Control and Prevention, 2017). CEI aims to offer accessible, interactive, and personalized trainings tailored to providers’ needs and preferred learning styles in an effort to enhance the capacity of New York’s diverse healthcare workforce to deliver clinical services and to improve patient health outcomes related to HIV, STIs, HCV, and DUH. Over the years, CEI has offered more than 440 live trainings, more than 300 online trainings, CE accredited courses, many multimedia modules, 14 interactive case simulation tools, and other materials in an ongoing effort to enhance its medical education expertise and offerings and meet the needs of NYS clinicians. Nurses comprise a significant percentage of the healthcare workforce in New York State and have indispensable roles and functions at various practice levels in a variety of healthcare environments alongside other clinicians and non-clinicians. As caregivers in clinical settings, the nursing

As caregivers in clinical settings, the nursing workforce has the power to influence the health outcomes of NYS residents directly, including outcomes related to ETE.

workforce has the power to influence the health outcomes of NYS residents directly, including outcomes related to ETE. In other types of settings, the workforce also has the power to influence outcomes indirectly as leaders, educators, policymakers, etc. As suggested by findings in our needs assessment, one way to address workforce training needs is to increase awareness of CEI’s free, live/in-person and online courses and topic-specific trainings related to HIV/AIDS, HCV, and STI prevention and treatment and the care of substance users among New York nurses. Addressing the training needs of the NYS nursing workforce will influence progress made toward ETE goals.

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n References American Society of Addiction Medicine. (2017). Summary of the Comprehensive Addiction and Recovery Act. https://www.asam.org/ advocacy/issues/opioids/summary-of-the-comprehensive-addictionand-recovery-act

New York State Department of Health AIDS Institute (2016). New York State HIV/AIDS Surveillance Annual Report for Cases Diagnosed Through December 2014. https://www.health.ny.gov/diseases/aids/ general/statistics/annual/2014/2014-12_annual_surveillance_report.pdf

Andrilla, C. H. A., Coulthard, C., & Larson, E. H. (2017). Barriers rural physicians face prescribing buprenorphine for opioid use disorder. Annals of Family Medicine, 15(4), 359–362. https://doi.org/10.1370/ afm.2099

New York State Department of Health AIDS Institute. (2017). AIDS Institute Homepage. https://www.health.ny.gov/diseases/aids/

Centers for Disease Control and Prevention. (2017). 2020 Topics and Objectives. https://www.healthypeople.gov/2020/topics-objectives New York State Department of Health. (2015). Ending the Epidemic in New York State. https://www.health.ny.gov/diseases/aids/ending_ the_epidemic/campaign/ New York State Department of Health AIDS Institute. (n.d.-a). AIDS Institute Priorities 2017–2018. https://www.health.ny.gov/diseases/ aids/general/about/docs/ai_priorities.pdf New York State Department of Health AIDS Institute. (n.d.-b). AIDS Institute Priorities 2019–2020. https://www.health.ny.gov/diseases/ aids/general/about/docs/ai_priorities.pdf New York State Department of Health AIDS Institute. (2015). AIDS Institute Priorities 2015–2016. https://www.health.ny.gov/diseases/aids/general/ about/docs/ai_priorities.pdf

New York State Department of Health AIDS Institute (2018). New York State HIV/AIDS Surveillance Annual Report for Persons Diagnosed Through December 2017. https://www.health.ny.gov/diseases/aids/ general/statistics/annual/2017/2017_annual_surveillance_report.pdf New York State Department of Health AIDS Institute (2019). New York State HIV/AIDS Surveillance Annual Report for Persons Diagnosed Through December 2018. https://www.health.ny.gov/diseases/aids/ general/statistics/annual/2018/2018_annual_surveillance_report.pdf New York State Department of Health AIDS Institute. (2020). About CEI. https://ceitraining.org/about/ Wang, D. & Luque, A. E. (2016). Evaluation of a statewide HIV-HCVSTD online clinical education program by healthcare providers—a comparison of nursing and other disciplines. Nursing Informatics, 225, 267–271. https://doi.org/10.3233/978-1-61499-658-3-267

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Variations in Healthcare Professionals’ “Ending the Epidemic”

Appendix

2016 CEI Needs Assessment Survey

Journal of the New York State Nurses Association, Volume 47, Number 2

Variations in Healthcare Professionals’ “Ending the Epidemic”

Journal of the New York State Nurses Association, Volume 47, Number 2

Variations in Healthcare Professionals’ “Ending the Epidemic”

Appendix

2016 CEI Needs Assessment Survey (con't)

Journal of the New York State Nurses Association, Volume 47, Number 2

Variations in Healthcare Professionals’ “Ending the Epidemic”

Journal of the New York State Nurses Association, Volume 47, Number 2

Variations in Healthcare Professionals’ “Ending the Epidemic”

Appendix

2016 CEI Needs Assessment Survey (con't)

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Variations in Healthcare Professionals’ “Ending the Epidemic”

Journal of the New York State Nurses Association, Volume 47, Number 2

Developing an Innovative Psychiatric-Mental Health Nurse Practitioner Program to Meet Current Mental Health Needs Marissa D. Abram, PhD, RN, PMHNP-BC Jane H. White, PhD, MSN, BSN William Jacobowitz, EdD, MPH, MSN, BSN

n A bstract

This article describes the development and implementation of a contemporary graduate program for psychiatric mental health nurse practitioners (PMHNPs). Factors impacting society such as substance use disorders, the need for integrated care, the increasing need for mental health services with a shortage of mental health providers have influenced the need for a different approach to preparing advanced practice psychiatric-mental nurses. Furthermore, when considering today’s mental health landscape, the need for expanding the numbers of PMHNPs and their role, this program addresses issues related to: teaching content across the lifespan, integrating psychopharmacology and psychotherapy treatment, the need to treat today’s significant growing substance use disorder population, and providing content and experiences on the various transitions that mental health populations face today in the community. Keywords: Graduate education, psychiatric nurse practitioner education, program development

Introduction This article describes the development and implementation of a contemporary graduate program for psychiatric-mental health nurse practitioners (PMHNPs) at Adelphi University in New York State (NYS). Significant societal changes have created the need for a different approach to preparing advanced practice psychiatric-mental nurses. These factors include the opioid epidemic (National Institute of Health [NIH], 2018); a population wherein at least 20% of people are diagnosed with a psychiatric disorder (NIH, 2017); the call for integrated models of care (Delaney et al., 2018); the decrease in the number of psychiatrists and the gap between providers and the treatment needs of the current population (Association of American Medical Colleges, 2012); and the emergence and success of the psychiatric-mental health nurse practitioner in filling some of these gaps (de Nesnera & Allen, 2016).

Noted in current literature as barriers to the ability of PMHNP graduate programs to meet this need for psychiatric-mental care are an overall shortage of licensed PMHNPs, a limited number of PMHNP graduate programs, and inadequate graduation rates. New York, in particular, suffers from an inadequate number of PMHNPs. There are approximately 1,752 licensed PMHNPs in New York State, as compared to 5,780 primary care nurse practitioners, and an additional 9,401 family nurse practitioners (NYS Office of the Professions, 2018). In a survey of 75 graduate programs, Vanderhoef et al. (2017) reported that the number of students in psychiatric-mental health programs increased over 2014–15 by 30% (3,909). However, graduation rates remained relatively low, averaging about 1,000 new PMHNPs in 2014 (Fang et al., 2015). Even within typical graduate programs, the PMHNP specialty has always had lower student enrollment. In addition to the Adelphi University program, two other

Marissa D. Abram, PhD, RN, PMHNP-BC; Jane H. White, PhD, MSN, BSN; and William Jacobowitz, EdD, MPH, MSN, BSN Adelphi University 18

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The focus on psychotherapy skills in graduate programs for advanced practice nurses (APRNs) has significantly declined.

PMHNP programs exist in our immediate area, but the number of graduates is still not enough to meet the present needs of our state. The more than 200 jobs currently posted for PMHNPs in New York State is further evidence of the continued shortage in psychiatric-mental services. Given today’s mental health landscape, the need for increasing the number of PMHNPs as well as expanding their roles is a common refrain on the blogs and social media of psychiatric-mental health advanced practice nurses (American Psychiatric Nurses Association, 2019). Many continue to call for psychotherapy skills, an important previous central competency for the preparation of PMHNP students, which is also currently included in the National Organization Nurse Practitioner Faculty (NONPF) competencies. With the retirement of the national certification for clinical nurse specialist in psychiatric-mental health, the focus on psychotherapy skills in graduate programs for advanced practice nurses (APRNs) has significantly declined. In reality, content in most PMHNP graduate programs center on assessment, diagnosis, and treatment primarily as psychopharmacology. According to a recent survey, most programs that offer some psychotherapy models have integrated the content into general clinical courses (Vanderhoef & Delaney, 2017). In the most recent survey on the roles of the advance practice in psychiatric-mental health nursing, Delaney et al. (2018) outlined the percentage of practicing PMHNP respondents who provide psychotherapy services and utilize cognitive behavioral therapy (CBT) and supportive models. Comparatively, in Delaney’s survey, when the percentages of types of service provision are review, 54.2% of PMHNPs provide only medication management versus 38.2% who provide medication management with psychotherapy and 15% who provide only psychotherapy. Given the urgent need for more comprehensive services and the current gaps in care, we developed a master’s program for which the focus was ensuring that 100% of our graduates be prepared to provide a combination of evidence-based treatment modalities, while using other types of brief models such as interpersonal psychodynamic therapy in addition to CBT and supportive models. Complicating the ability of programs to teach psychotherapy is the cost of qualified faculty for supervision (Weber at al., 2016; Wheeler & Delaney, 2008). While counseling models are included in some current programs in a didactic format, few programs provide the necessary supervision for more psychodynamic or interpersonal models, and many do not have the appropriate clinical placements to practice psychotherapy skills. Many of our colleagues liken the cancellation of supervised psychotherapy in graduate programs as “throwing the baby out with the bathwater.” Despite these challenges, the need to integrate psychotherapy skills remains a crucial cornerstone of effective treatment (APNA, 2019). To meet that need, specific courses on individual and family psychotherapy didactic are included in our curriculum. This was followed by both individual and family psychotherapy supervision by the psychiatric-mental health clinical nurse specialist (PMHCNS) faculty.

Anecdotally, practicing PMHNPs often share that they believe they could provide more comprehensive care given expanded skills such as counseling and psychotherapy. A key complaint is fragmentation of care. For example, a patient for which a psychopharmacology treatment is provided by a PMHNP, but for whom additional help is then reliant on social workers, or a patient who is referred out of the PMHNP’s practice site for necessary counseling. Conversely, those prepared as PMHCNSs in states without prescriptive privileges complain of the difficulty in finding providers when psychopharmacology assessment and treatment are needed for their clients. In addition, primary care and family nurse practitioners continue to express a need for PMHNP skills to better treat mental health issues in the population they care for. Aside from the program challenges to expanding psychotherapy skills already discussed, there exist other barriers to program development. Some outlined in the literature include “how to parse out clinical hours among the lifespan populations (child, adult geriatric); the breadth and depth of substance use disorder treatment in the curriculum; incorporating content around acute care psychiatric issues; and how to address the lack of experienced faculty to teach child and geriatric content” (Weber et al., 2016, p. 427). Considering these factors, we were committed to developing a program able to prepare students on how to manage contemporary mental health issues. Specific courses were developed for managing the care of children, adolescents, and families, as well as substance use disorders. Simulations were developed to standardize student experiences and to support practicum experiences. For example, students participated in a simulation for prescribing the medication-assisted treatment buprenorphine. Given the pressing needs for, and challenges to, an expanded PMHNP role to serve diverse populations in New York State, we attempted to develop a PMHNP program sufficient to meet those needs with an expanded focus on psychotherapy with supervision. While a blended role might have been more apt, New York State does not recognize or approve any such role. Therefore, the new content and skills for an expanded PMHNP role needed to be added to a typical state accredited PMHNP program.

Program Development The Adelphi University PMHNP graduate program was developed in five stages. Each stage had specific steps and tasks to complete in order to develop this unique program and ensure its approval by the college, the University Senate, and the state (see Appendix A for an outline of these tasks). The program’s development from conception to marketing took approximately one year. Implementation of the program began with the admission of the first cohort 18 months following the predevelopment stage.

Predevelopment Stage Administrative support and encouragement was the first critical step in obtaining the resources for developing and implementing the program. In

Considering these factors, we were committed to developing a program able to prepare students on how to manage contemporary mental health issues.

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particular, the assurance that additional PMHNP faculty would be approved was key. Following a review of the literature for challenges such as those noted above and the collection of data on provider trends and capacity issues to support the program’s needs, we proceeded to establish a team of PMHCNSs and PMHNPs for the planning stage.

a group. The cohort model was chosen because it is student centered, and also allowed for the flexibility needed to meet with students face-to-face for the program’s psychiatric-mental health content. When carefully designed, it allows for collaboration, enhances individual perspectives, and fosters team building and leadership development (Boud et al., 2014; Compton & Compton, 2017; Drago-Severson et al., 2001).

Faculty Team for Program Planning and Development

After completing the general core, courses following the AACN Masters Essentials, and the nurse practitioner core courses (Advanced Pathophysiology, Advanced Pharmacology, and Advanced Physical Assessment), students are required to take Psychopharmacology, followed by Differential Diagnoses and Treatment Planning, both in a didactic format. These courses provide the foundation for both the clinical environment and the more in-depth, specialized psychiatric-mental health content.

The current program faculty team consists of four practicing, doctorally prepared PMHCNSs and one doctorally prepared PMHNP. In the development stage, this team served as a committee, with three members volunteering to develop the program and all five to ultimately teach it. Importantly, our committee agreed that the expanded PMHNP role was essential to prepare students to meet current gaps in care provision. Our own experiences, and those of our colleagues, highlighted the limitations of purely CNS or NP roles, and influenced our model for the expanded PMHNP role. Of note, New York State does not license graduates or approve those programs usually identified as a blended role. Thus, we came to a consensus that the program would need to address and expand the NONPF psychotherapy competency to more adequately meet the needs of our psychiatric-mental health population.

Program and Curriculum Planning For stages II and III, we had the benefit of a program planning and curriculum development expert on our committee faculty, which ensured we had a team leader for the overall project. We also had experts in various subspecialties such as families and substance use disorders. All committee faculty members were also actively practicing, nationally certified, and had graduate level course development and teaching experience. Program development followed the typical format of first developing the program’s objectives and outcomes for students and selecting national and organizational competencies. The NONPF competencies and the American Association of Colleges of Nursing (AACN) Masters Essentials and Consensus Model for APRN Regulation served as a framework for the course content mapping and remapping upon course development completion (AACN, 2008; AACN, 2011; NONPF, 2017). Individual faculty members developed respective courses, which were then reviewed by peers on the planning committee and revised as indicated.

The Lengthy Program Approval Processes The approval process entailed five levels of examination. Following preapproval by the dean of the College of Nursing and Public Health (CNPH) and the Office of the Provost, the program was then submitted for review to the Master’s Curriculum Committee, the CNPH Curriculum Committee, the University Senate Committee, the Full Faculty Senate, and finally an application was sent to New York State for approval. At each stage, minor revisions and refinements were made to the program.

The Final Curriculum and Sequencing The program was designed to be offered on a part-time basis and developed as a cohort model where students are admitted and progress as 20

The program was structured so students complete the didactic component the semester before entering the clinical environment, which focuses on the specific content. This was to ensure students were knowledgeable and confident in the application of the content and their skills. This sequencing also allows for faculty evaluation and student remediation before actual application of content. The final courses, descriptions, and faculty roles and responsibilities are identified in Appendix B.

The Clinical Component and Student Evaluation The NONPF has delineated core competencies and population competencies for all nurse practitioners. The independent practice competency area states that the NP student will “function as an independent practitioner managing diagnoses while demonstrating the highest level of accountability for practice” (NONPF, 2017, pg. 14). The clinical evaluation instruments for the program were developed by utilizing the independent practice competency as the core and integrating each of the other areas of competency. Objectives for the clinical learning experience were based on each course’s objectives and the expanded PMHNP role to include prescribing and psychotherapy competencies.

Planned Program Evaluation The program evaluation plan aligned with plans used for all graduate programs at the CNPH, and included outcomes such as data on student retention and graduation rates, and licensing and certification. Course evaluations and student feedback are solicited for every course and clinical experience. Preceptors and agencies are evaluated each semester by faculty and students.

Challenges: Student Clinical Placements The most significant challenge to the program, and one we anticipated, remains the availability of clinical placements. Because of the specific focus of each course, the program development team took an active role in identifying prospective agencies for each clinical course to build a database of relevant agencies. This was time consuming because the program was new. After the list was compiled, the program coordinator sent out emails with information about the new program and its focus on the expanded PMHNP role to request meetings. Agencies in the community were welcoming. However, because of the general shortage in psychiatrist and PMHNP services in New York State, there were limited placement

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opportunities and preceptor availability. A dedicated part-time placement coordinator was hired to mitigate this challenge.

A critical consideration of the program is the significant

Discussion

substance use disorder prevalent

The Adelphi University PMHNP graduate program’s uniqueness as a program preparing today’s advanced practice nurses to meet current psychiatric-mental health needs, as well as the specific challenges in this educational undertaking outlined in the literature, warrants discussion (Delaney et al., 2018; Weber et al., 2016). These issues include teaching content across the lifespan, integrating psychopharmacology and psychotherapy treatment, the need to treat today’s significant growing substance use disorder population, and providing content and experiences on the various transitions that mental health populations face today in the community. We relied heavily on published works about not only what was needed, but also what might be problematic. Importantly, the need for APRNs to able to provide both intervention roles, such as therapy and psychopharmacology, as outlined by Delaney et al. (2018), Weber et al. (2016), and Wheeler et al. (2008) was addressed through utilizing the combined skills of faculty prepared in each of these roles for program development and teaching. Differential Diagnosis and Treatment Planning involved integrating psychopharmacology and therapy/counseling as strategies. In the classroom, utilizing case studies was a technique used throughout coursework. We developed two required role courses so that students could learn the many aspects of the therapist role in addition to their typical course on the NP role and regulatory and legal issues. Psychotherapy courses (Individual, Family/Adolescent and Children) had an on-campus supervision component. A critical consideration of the program is the significant substance use disorder prevalent in the United States today. Offering course content and clinical experience in substance use disorders is paramount to preparing today’s PMHNPs. Fortunately, we had a PMHNP with this expertise on our faculty to develop the course content and engage her colleagues as potential preceptors. A further concern noted in the literature and addressed by our program was the need to prepare clinicians with expertise across the lifespan. Therefore, courses needed to include child/adolescent and geriatric mental health content. These populations have their own specific needs regarding mental health and psychiatric disorders, so each was viewed as important and separate content. Family content also needed to be incorporated into courses because of the need for more than individual modes of treatment, especially given that most children are treated within a family system. Combining course content on families, children, and adolescents into one course afforded the opportunity to address these populations and treatment modes. We also knew that the expanded PMHNP might be called on to work in a diversity of community settings. As this might entail program planning and evaluation, the Community Mental Health course included content on program planning and evaluation, and a related hands-on program development project. We also wanted to prepare graduates who would be capable of providing care for clients across the many transitions clients experience in the community, including crisis situations. Therefore, we incorporated some practicum hours in the Community Mental Health Clinical course in an emergency department.

in the United States today.

In sequencing program courses, Differential Diagnosis and Psychopharmacology was a prerequisite, while the other three clinical courses (Individual Mental Health, Substance Use Disorders, and Families, Children and Adolescents) could follow in any order. Sequencing was developed this was to allow for flexibility in student progression. However, the cohort model has superseded students’ moving out of their initially assigned cohort.

Further Challenges, Lessons Learned, and Future Plans Our challenges are not unique, and our preparatory research of the literature alerted us to potential problems. First of all, finding qualified preceptors, especially PMHNPs, proved to be difficult. Child and adolescent placements were also a challenge to find, given the limited number of agencies who work with these populations. We have admitted three cohorts of students to date, with 12 to 15 enrollees in each; approximately 20% are in the post-MS certificate program. Applications are abundant and admissions recently had to be capped (Fall and Spring admits) at 10 to 12 students due to the challenge of finding clinical placements. We anticipate that this will be temporary as the program’s first graduates in May of 2020 will serve as preceptors for future students. Looking ahead, future plans are to establish a supervision group for faculty who are overseeing students engaged in psychotherapy to provide support and peer learning. The plan is to survey students enrolled in order to track important data on their backgrounds, needs, and plans for future placements/employment in order to guide marketing of the program and placing students clinically. Preparing the students with a practice doctorate (DNP) in the specialty will also be an important consideration; our college only recently embarked on its first DNP program (in adult geriatric primary care), although a master’s level track has been in existence at our college for more than 30 years.

Conclusions This exciting PMHNP program is unique in that it has been built on the challenges and needs of today’s mental health systems and populations. The collaboration of faculty prepared as CNSs and NPs was paramount to designing an expanded PMHNP role that best meets the need for integrating competencies. Courses that address children, adolescents, families, and those with substance use disorders also serve to fill gaps in today’s psychiatric-mental care, given the dearth of PMHNPs and other mental health professionals working with these populations. The challenges we face, especially related to clinical placements, are those outlined by many of our colleagues.

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n References APRN Consensus Work Group and the National Council of State Boards of Nursing, APRN Advisory Committee. (2008). Consensus model for APRN regulation: Licensure, accreditation, certification & education. American Colleges of Nursing. http://www.aacnnursing. org/Portals/42/AcademicNursing/pdf/APRNReport.pdf American Colleges of Nursing. (2011). The essentials of master’s education in nursing. https://www.aacnnursing.org/Portals/42/Publications/ MastersEssentials11.pdf American Psychiatric Nurses Association. (2019). Expanding mental care services in America: the pivotal role of psychiatric-mental health nurses. https://www.apna.org/files/public/Resources/Workforce_ Development_Report_Final_Draft_6_25.pdf Boud, D., Cohen, R., & Sampson, J. (2014). Peer learning in higher education: Learning from and with each other. Routledge. Center for Workforce Studies. (2012). Physician specialty databook. Association of American Medical Colleges. https://www.aamc.org/ download/313228/data/2012physicianspecialtydatabook.pdf Compton, D. A., & Compton, C. M. (2017). Progression of cohort learning style during an intensive education program. Adult Learning, 28(1), 27–34. https://doi.org/10.1177/1045159516634044 Delaney, K., Drew, B., & Rushton, A. (2018). Report on the APNA national psychiatric mental health advanced practice registered nurse survey. Journal of the American Psychiatric Nurses’ Association. https://doi. org/10.1177/1078390318777873 de Nesnera, A., & Allen, D. E. (2016). Expanding the role of psychiatric mental health nurse practitioners in a state psychiatric system: the New Hampshire experience. Psychiatric Services, 67(5), 482–484. https://doi.org/10.1176/appi.ps.201500486 Drago-Severson, E., Helsing, D., Kegan, R., Popp, N., Broderick, M., & Portnow, K. (2001). The power of a cohort and of collaborative groups. Focus on Basics, 5(2), 15–22.

Fang, D., Li, Y., Arietti, R., Trautman, D. E., & American Association of Colleges of Nursing. (2015). Enrollment and graduations in baccalaureate and graduate programs in nursing 2014–2015. American Association of College of Nursing. National Institute of Health. (2017). Mental health information. https:// www.nimh.nih.gov/health/statistics/mental-illness.shtml National Institute of Health, HEAL Initiative. (2018). Improve treatments for opioid misuse and addiction. https://www.nih.gov/research-training/ medical-research-initiatives/heal-initiative/improve-treatments-opioidmisuse-addiction New York State Office of the Professions. (2018). License statistics. http:// www.op.nysed.gov/prof/nurse/nursecounts.htm Nurse Practitioner Core Competencies Content Work Group. (2017). Nurse practitioner core competencies with curriculum content. National Organization of Nurse Practitioner Faculties. https://cdn. ymaws.com/www.nonpf.org/resource/resmgr/competencies/2017_ NPCoreComps_with_Curric.pdf Wheeler, K., & Delaney, K. (2008). Challenges and realities of teaching psychotherapy: A survey of psychiatric-mental health nursing graduate programs. Perspectives in Psychiatric Care, 44(2), 72–80. https://doi.org/10.1111/j.1744-6163.2008.00156.x Weber, M. T., Delaney, K. R., & Snow, D. (2016). Integrating the 2013 psychiatric mental health NP competencies into educational programs: Where are we now?” Archives of Psychiatric Nursing, 30(3), 425–431. https://doi.org/10.1016/j.apnu.2015.12.004 Vanderhoef, D., & Delaney, K. (2017). National organization of nurse practitioner faculties: 2016 survey of psychiatric mental health nurse practitioner programs. Journal of the American Psychiatric Nurses Association, 32(2), 159–165. https://doi.org/10.1177/1078390316685154

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Appendix A

Program Development and Implementation by Stages With Specific Tasks Stage I Pre-Development Phase 1. Collect data on mental health services and providers 2. Review of existing PMHNP programs and data 3. Delineate challenges reported in the literature for developing PMHNP programs 4. Obtain administrative support for the addition of an NP Program 5. Review approval guidelines and steps for a new program (University and State) 6. Assemble a team of faculty with PMHN expertise 7. Come to a consensus regarding the program’s focus and or overall philosophy 8. Develop a timeline for completion for first approval in the College 9. Submit a required pre-approval plan to the Dean and Provost with proposed budget including resource allocation or need, and marketing data such as competing programs in the area

Stage II Program Objectives, Required Student Competencies 1. Use data collected such as regional stats and determine program objectives /outcomes 2. Review NONPF competencies as the overall framework for course content 3. Review the AACN Essentials for master’s Programs 4. Review existing MS core courses and NP core (3 Ps) for feasibility for new program’s competencies 5. Decide on credits required given our other graduate program requirements and sequencing of content influenced by how populations would be addressed (by course?), 6. how to incorporate psychotherapy, acute and emergency care, and substance use disorders. 7. Develop program evaluation plans and criteria

Stage III Course Development 1. Assign courses for development matched to faculty member’s experience and expertise and using NONPF competencies and the Essentials Document. Syllabus Templates Used 2. Have other team members review and recommend course content developed by colleagues; courses are revised 3. Add assignments to match course objectives; add readings and weekly topics 4. Develop Clinical Guidelines and Evaluation Instruments 5. Prepare and present Program Outline, Objectives, and Course for first review by the Department of Graduate Studies members in the College of Nursing and Public Health (CNPH) 6. Develop Post MS Certificate Program for NPs prepared in another specialty

Stage IV Approval Processes 1. Submit Program Description with Objectives, Competencies Used for Course Development to the CNPH Curriculum Committee; Revise courses if appropriate with recommendation 2. Submit Program and all courses for approval to University Senate Committee on Academic Affairs 3. Present Program to Faculty Senate for its vote and approval 4. Prepare State Forms for approval of a new program

Stage V Marketing and Admission of Students 1. Following State approval, develop marketing materials for Open Houses, mail distribution and internet advertising 2. Review all applicants and meet with them individually 3. Admit first cohort in Spring 2018

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Appendix B

Brief Description of Courses and Sequencing of Specialty Course Content Course title/credits

Description

Teaching modalities

Psychopharmacology Across the Lifespan (2 credits)

Focus on learning the principles of psychopharmacology with clinical application. Legal and ethical aspects of prescribing also discussed.

Case study, high fidelity simulations on adverse medication reactions

PMHNP Role I (1 credit)

Focus on learning the process of integrating psychopharmacology with brief therapies and analyze the role of the psychotherapist in a healthcare reform framework.

PMHCNS faculty led

PMHNP: Differential Diagnosis and Treatment Planning Didactic (2 credits)

Focus on learning to differentiate diagnoses and their psychopathology integrating therapy and psychopharmacology into the plan of care.

Case study, high fidelity simulations, analysis, and critique of the literature

PMHNP Role II (1 credit)

Focus on learning the advance practice role through collaborative, interprofessional lens. Legal and ethical aspects of the role also covered.

PMHNP faculty led

PMHNP: Differential Diagnosis and Treatment Planning Clinical (1 credit)

Application through the psychiatric evaluation process, students will determine diagnosis, differential diagnoses and formulate integrated treatment plan.

100 hours in specialized clinical setting with additional 20 hours on campus supervision hours (PMHNP in the field and on campus)

PMHNP: Individuals Mental Health Treatment Didactic (2 credits)

Focus on analysis of brief therapy models for adult and geriatric clients to formulate integrated treatment plan.

Case study, comparing and contrasting brief models of therapy appropriate application to specific disorders

PMHNP: Individuals Mental Health Treatment Clinical (1 credit)

Application of brief therapeutic models to develop psychotherapeutic competence with psychopharmacological integration to adult and geriatric clients.

100 hours in specialized clinical setting with PMHNP preceptor oversight by a PMHCNS with an additional 20 hours on campus therapy supervision hours

PMHNP: Substance Use Disorders Across the Lifespan Didactic (2 credits)

Focus on learning theory and evidence-based approaches to diagnose and manage the treatment of substance use disorders across the lifespan.

Case study, high fidelity simulations-interprofessional, treatment planning focusing on psychopharmacological interventions and counseling techniques specific to the treatment of SUD

PMHNP: Substance Use Disorders Across the Lifespan Clinical (1 credit)

Application of evidenced based approaches to manage SUD across the lifespan in the SUD clinical setting.

100 hours in specialized clinical setting with PMHNP preceptor and PMHNP faculty oversight with additional 20 hours on campus supervision hours for therapy

PMHNP: Families, Adolescents, Children Mental Health Treatment Across the Lifespan Didactic (2 credits)

Focus on learning health or dysfunction of family units and utilizing evidenced based models of treatment for families, adolescents, and children.

Case study, treatment planning focusing on psychopharmacological interventions and counseling techniques specific to the treatment of the family, adolescent, and child

PMHNP: Families, Adolescents, Children Mental Health Treatment Across the Lifespan: Clinical (1 credit)

Application of evidenced based approaches to manage the care of the family and its units in the clinical setting.

100 hours in specialized clinical setting with PMHNP preceptor and additional 20 hours on campus supervision hours for therapy with a PMHCNS

PMHNP: Community Mental Health Crisis Intervention Didactic (2 credits)

Focus on learning mental health promotion, the process of recovery, care transitions, crisis intervention with client centered focus and importance of interprofessional collaboration.

Explore theory that guides community mental health interventions while analyzing levels of community care based on client need and for their effectiveness and outcomes.

PMHNP: Community Mental Health & Crisis Intervention Clinical (1 credit)

Application of evidenced based approaches to manage care of the client across the lifespan in various levels of community settings including Eds.

100 hours in specialized clinical setting with PMHNP preceptor and PMHNP faculty oversight with additional 20 hours on campus supervision hours for therapy

Journal of the New York State Nurses Association, Volume 47, Number 2

Breastfeeding Bundles to Reduce Readmission Risk for Late Preterm and Early Term Infants Lynne Ponto, BSN, RNC Christopher Kowal, DNP, RN, CCRN-K

n A bstract

This quality improvement project decreased hyperbilirubinemia readmissions in late preterm infants (LPIs) from 34 0/7 to 36 1/7 weeks gestation, and early term infants (ETIs) from 37 0/7 to 38 2/7 weeks gestation, by implementing breastfeeding and lactation support care bundles in one urban Northeastern United States Level-1, 20-bed mother-baby unit and one Level-1 birthplace with three postpartum beds. Infant participants were neonates between 36 0/7 to 38 6/7 weeks gestation, readmitted to acute care over the period of January 2015 through November 2018. Gestational age ranges drove bundle diversity. LPI and ETI breastfeeding bundles included parental education on infant feeding cues and frequencies; promotion of early, frequent postpartum maternal breast pumping-feedings; and early access to hospital lactation support. Retrospective data analyses established readmission baselines and descriptive post-intervention outcomes. Between August 2017 to November 2018, LPI readmissions decreased 80% (n = 1) and ETIs decreased 50% (n = 4), for a combined readmission reduction of 55%. Keywords: Infant, newborn, infant, premature, breastfeeding, gestational age, breast milk expression, infant care, lactation, hyperbilirubinemia

Introduction

for Quality Improvement Reporting Excellence 2.0 (Ogrinc et al., 2016) guidelines, a quality improvement (QI) project was initiated.

Problem Description Implementation of a 2015 operational rounding initiative to improve patient outcomes and length of stay (LOS) led staff in the women’s and children’s service line of one Northeastern United States hospital to recognize an opportunity to reduce infant readmissions. The initiative demonstrated that 0.6% of 2015 infant readmissions (11 of 1,928 total annual births) were due to hyperbilirubinemia in the late preterm infant (LPI) and early term infant (ETI) populations. This occurred despite following the World Health Organization (2018) Baby Friendly Hospital Initiative Guidelines in conjunction with our inpatient/outpatient lactation support services. Staff established a direct association between these readmissions to inefficient or absent infant-mother breastfeeding practices, as well as lack of established, consistent lactation support for mothers while in the hospital setting. A clinical team was assembled, and following the Standards

Available Knowledge LPIs are defined as infants born 34 0/7 weeks through 36 6/7 weeks gestation (Association of Women’s Health, Obstetric and Neonatal Nurses [AWHONN], 2015). ETIs are defined as 37 0/7 weeks gestation through 38 Staff established a direct association between these readmissions to inefficient or absent infant-mother breastfeeding practices, as well as lack of established, consistent lactation support.

Lynne Ponto, BSN, RNC, and Christopher Kowal, DNP, RN, CCRN-K St. Joseph’s Health & College of Nursing Journal of the New York State Nurses Association, Volume 47, Number 2

Breastfeeding Bundles to Reduce Readmission Risk for Late Preterm and Early Term Infants

6/7 weeks gestation (Bingham & Spong, shift from practices used with full-term infants where an effective latch, suck, and 2014; Noble et al., 2019). In 2005, the ETI hospital readmission within the first swallow are the foundation for successful National Institute of Child Health and 7–10 days following discharge is primarily maternal lactation and infant nutrition Human Development designated infants due to feeding-related problems such as (Boies et al., 2016). born between 34 0/7 and 36 6/7 weeks low weight, [and] hyperbilirubinemia. of gestation as LPIs in order to establish While evaluating the available a standard terminology and to emphasize literature for creating our LPI/ETI breastfeeding bundles, we discovered a the fact that these infants are really “preterm” and not “almost” or “near” term (Boies et al., 2016). Sengupta, greater volume of evidence describing and supporting LPI care than ETI care. et al. (2013) suggested ETI births outnumber LPI births by three to one. Noble et al. (2019) reported there is limited literature regarding the effects of Nonetheless, both populations of infants have associated risks for higher ETI birth on exclusive breastfeeding, and no studies describing breastfeeding intensity in the ETI population were discovered by our team. Presently, there neonatal morbidity (Ruth et al., 2014). LPIs are now recognized as a unique group of infants who need focused is a paucity in literature for hospital LOS and focused treatment and care of postpartum hospital monitoring, tailored feeding plans, and close follow-up ETIs as compared to term infants (Hwang et al., 2013). after discharge (Baker, 2015). LPIs may appear and behave like full-term infants. However, they have many of the same physiologic vulnerabilities as younger preterm infants, such as altered sleep-wake states (AWHONN, 2015). Due to physiologic immaturity, LPIs are less alert, have reduced stamina, and have greater difficulty than full-term infants with regard to latch, suck, and swallow (Boies et al., 2016). Underdeveloped buccal pads create an ineffective latch in this population, and LPIs are also at increased risk of respiratory distress, poor thermoregulation, and ineffective milk transfer (Lucas, et al., 2014). All of these LPI characteristics can increase an infant’s risk for breastfeeding failure, hypoglycemia, hyperbilirubinemia, weight loss, delay of discharge, and the potential for hospital readmission (Mannel & Peck, 2018). An additional danger with manifesting these symptoms is that they cause fatigue in the LPI. This often leads to a mistaken conclusion that the infant is satiated with feeding, when they are really falling asleep (Briere et al., 2015). Compared with term infants born between 39 0/7 and 41 6/7 weeks gestation, it is now recognized that ETIs, born between 37 0/7 and 38 6/7 weeks gestation have an increased risk for health complications similar to LPIs, including hyperbilirubinemia, hypoglycemia, and respiratory problems (Boies et al., 2016; Hwang, et al., 2013). Neurologic immaturity of ETIs also extends to their potential for acquiring breastfeeding difficulties (Noble et al., 2019). Noble and colleagues (2019) found that more mothers of ETIs reported breastfeeding difficulties related to infants not waking up enough to breastfeed. Similarly, ETIs were also at risk for increased hospital readmissions when displaying fewer episodes of successful postpartum breastfeeding initiations and frequency duration (Boies et al., 2016). Muelbert et al. (2019) found that LPIs and ETIs are less likely to be initially breastfed; and if they are breastfed, it is done for 10 weeks or longer, compared to full-term infants. Nevertheless, the overall evidence suggests ETI breastfeeding is not the same practice as that defined for term infants. ETI hospital readmission within the first 7–10 days following discharge is primarily due to feeding-related problems such as low weight, hyperbilirubinemia, failure to thrive, hypernatremia, and/or dehydration (Boies et al., 2016). According to Baker (2015), although the elimination and breakdown of bilirubin is the same in the LPI as in the term newborn, bilirubin levels increase in the LPI due to poor suck and swallow abilities, dehydration, suboptimal elimination, and underdeveloped liver enzymes. Similarly, other studies have also suggested LPIs and ETIs are at a greater risk for readmission due to poor feedings and hyperbilirubinemia (Rajan et al., 2017). Breastfeeding management of LPIs and ETIs requires a paradigm 26

LPIs and ETIs can be considered the “great dissemblers.” They resemble healthy, full-term infants in appearance, but their physiologic immaturity places them at increased risk of poor short- and long-term physical outcomes (Muelbert et al., 2019). Today, more clinicians and professional communities recognize that ETIs cannot be treated like term infants because their inherent health risks as a population are closer to those of LPIs. Limiting factors such as lack of social support or parental barriers to accessing outpatient resources contribute to LPI and ETI readmissions (American Academy of Pediatrics [AAP], 2010). Kair et al. (2015) noted many LPI’s struggle to latch and feed exclusively at the breast, and they tend to go home with their mothers feeding them pumped breastmilk. Some of these dyads are discharged prior to the production of mature maternal milk, and many are discharged with the infant not taking full feeds from the breast. These mothers rely on outpatient providers to offer ongoing infant feeding guidance (Kair et al., 2015). Seagraves et al. (2013) concluded a lack of breastfeeding support increases the rate of poor infant breastfeeding episodes, putting them at risk for hyperbilirubinemia and readmission.

Rationale Nurses and clinical colleagues in our mother-baby setting followed the revised, Iowa Model of Evidence-Based Practice to Promote Excellence in Health Care (Buckwalter et al., 2017) to collaborate interprofessionally on this QI project. Despite finding less information on care and readmission of ETIs, the team decided sufficient guiding evidence within the current literature would support the creation of breastfeeding bundles for both populations. LPI and ETI readmissions triggered the project’s onset, and our team began to build an evidence-based practice (EBP) breastfeeding bundle to reduce readmissions in both populations. It was hypothesized that greater episodes of successful LPI/ETI breastfeeding (including successful maternal lactogenesis) would yield fewer acute care infant readmissions for hyperbilirubinemia.

Specific Aims This QI project aimed to create and implement an EBP bundle to improve breastfeeding episodes and successful episodes of lactation support among mothers of LPIs and ETIs in our acute care setting. The anticipated outcome was a reduction of LPI and ETI hospital readmissions.

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Breastfeeding Bundles to Reduce Readmission Risk for Late Preterm and Early Term Infants

Methods Context Our birthplace is a three bed, low-risk unit, admitting mothers who are at least 37 weeks gestation. Infants are typically discharged after 24 hours, but they can stay for up to 48 hours as medically necessary. These couplets received a discharge follow-up phone call at the 24-hour, at-home mark and one home visit by a birthplace nurse at 48 hours post-discharge. Infants in our 20-bed unit traditionally average a 48-hour LOS, and if breastfeeding, receive a lactation consultation phone call 24–72 hours post-discharge. Historically, once discharged, this infant population never received a home visit from a birthplace nurse. Infants born under 36 weeks gestation are admitted to our neonatal intensive care unit and do not follow breastfeeding standards of care, because many are not medically stable for conventional feedings. The average annual birth rates for our infant populations from January 2013 through the end of December 2015 were 29 preterm infants, 95 LPIs, and 409 ETIs. Full-term infant births during the same time period were found to average 1,427 annually.

Staffing Our clinical staff are shared among the mother-baby and birthplace units. This includes 13 obstetricians and five midwives; 47 primary, registered nurses (inclusive of five lactation consultants), and an additional 36 nurses to assist with general newborn and dyad care duties across the service line; 30 neonatal intensive care unit nurses; seven neonatal nurse practitioners; three neonatologists; and 16 family medicine physician-learners who assist with all deliveries and comprehensive newborn care. One director of nursing provides oversight and leadership.

Interventions QI Project Team

set, which includes AAP recommendations for infant care along with our LPI bundle guidelines (AAP, 2010; 2012; Engle et al., 2007). LPIs require more frequent vital signs, a car seat evaluation prior to discharge, and a post-discharge follow up within 24 to 48 hours. LPI mothers are educated to breast pump after every feeding until milk production is adequate enough to feed their infant every 2 to 4 hours around the clock with sufficient milk transfer. ETI mothers are educated to pump: (a) only if their baby does not feed at all, (b) only feeds from one breast per episode, or (c) feeds without good milk transfer and/or has a weak suck/swallow (AWHONN, 2015; Flaherman et al., 2017). LPI and ETI parents are educated to ensure at least 8–12 infant feedings occur within a 24-hour period, and they are taught to combine electric pump expression with synchronous manual (hands-on) technique (Romero et al., 2018). Supplemental parental and clinician education consists of the identification of infant feeding cues and awareness of successful latchand-suck infant behaviors (Boies et al., 2016). Mother-baby nurses proficient in breastfeeding education, teachback method, and lactation consultation are assigned to each dyad to confirm quality infant feedings. They coach and offer additional awareness to mothers in need. As Thulier (2017) suggested, it is the quality not the quantity of newborn feedings that supports adequate infant weight gain. ETIs also require more frequent assessments than term infants (Boise et al., 2016). This confirmed the team’s hypothesis that ETIs should be cared for in the hospital setting more closely to that of LPIs. Rajan et al. (2017) discovered ETI hyperbilirubinemia requiring phototherapy treatment was significantly higher when compared to term infants, suggesting the need for additional hyperbilirubinemia and weight loss at-risk assessments (with appropriate follow-up as needed) prior to infant discharge.

Operational Workflow Adjustments

Our interprofessional team consisted of one clinical bedside nurse, two clinical nurse leaders, two certified lactation consultants, one pediatric clinical nurse specialist, the director for Women’s and Children’s Services, and our medical director of Nurseries. Additionally, frontline nurses, as members of the service line’s shared governance council, were involved in the vetting of the bundles.

Bundle Components and Implementation Following literature review and critique, the team assembled each bundle by professional consensus. The goal was to change clinical staff and newborn parent behaviors to feed infants sooner and more frequently, while encouraging immediate breast pumping and lactation support from the moment of birth. Each bundle specifically addressed these three objectives within their respective population: (a) standardization of early breastfeeding practices; (b) use of evidence-based, gestational age clinical care guidelines; and (c) early, standard, and consistent discharge follow-up practices.

Prior to the implementation of our project, there was never an air of urgency for infants to effectively breastfeed during each episode in their first 24 hours of life, especially our ETIs. Interventions to stimulate maternal milk production would begin only if the infant was still not effectively breastfeeding after the 24th hour postpartum. We discovered such delay in practice puts LPI/ETI intake and maternal milk production over a day behind all other newborn dyads who consistently and effectively feed (Flaherman et al., 2017). This type of delay further places the infant at risk for lower caloric intake, which can lead to increased enterohepatic circulation and the development of hyperbilirubinemia (Flaherman et al., 2017).

Lactation Consultation and Follow-Up Today, all our newborn dyads, regardless of gestational age, receive a post-discharge follow-up phone call from a lactation consultant, as well as a pediatric provider appointment scheduled any time after 48–72 hours of

The goal was to change clinical staff and

Clinical Guidelines and Parent Education LPI and ETI bundle guidelines included colored crib cards, respective to population, applied to the crib upon admission to postpartum care, to easily identify the infant’s population-group. LPIs have an exclusive order

newborn parent behaviors to feed infants sooner and more frequently.

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Breastfeeding Bundles to Reduce Readmission Risk for Late Preterm and Early Term Infants

life. Historically, our follow-up lactation consultation process was reserved only for infants with > 10% weight loss. Given the literature findings, the team hypothesized this prior and outdated practice was a predominant indicator contributing to infant readmissions for hyperbilirubinemia, as the lower an infant’s gestational age, the greater the risk (Maisels et al., 2009). Per both bundles, if the infant has >/= 7% weight loss at the time of discharge, lactation consultants now follow-up by telephone with all mothers within 24 hours of discharge. If feeding effectiveness is a concern, our dyads are encouraged to come back to the hospital for an outpatient visit with the lactation consultant (AAP, 2012; AWHONN, 2015; Boise et al., 2016; Flaherman et al., 2018; Thulier, 2017). Multiple professional organizations, including the AAP (2012) and the Academy of Breastfeeding Medicine (ABM) suggest that exclusively breastfed newborns who exceed 7% weight loss should be evaluated for poor breastfeeding management (Boise et al., 2016).

Staff Education Our team came together with all our lactation consultants to formalize a didactic approach to educate all mother-baby and birthplace unit staff, providers, and parents of LPIs and ETIs. Prior to bundle implementation, educational content was provided to 100% of our colleagues. New bundle education and reinforcement was consistently reviewed in daily operations huddles, and the bundle interventions for each population were posted at all nursing workstations. Education was deployed by service line nurses and certified lactation consultants. Handouts with face-to-face reviews were used for teach-back sessions (Rajan et al., 2017).

Study of the Interventions The primary objective of this QI project was to reduce the percentage of LPI/ETI hospital readmissions resulting from hyperbilirubinemia. Data from pre- and post-intervention LPI/ETI readmissions were collected and tracked. As the aforementioned changes were the only variables altered in this QI project, it was assumed that alterations in staff or maternal behaviors impacting earlier infant feeding and more successful maternal lactation were direct results.

Measures The daily census was monitored for LPI/ETI readmissions. Chart reviews were completed by lactation consultants and project team members for compliance with bundle implementation. Immediate staff and family education, with teach-back, were performed for all episodes of bundle drift and non-compliance (Spatz et al., 2015). Infant readmission tracking was designed to gather pre- and post-bundle implementation data including: (a) infant medical record number; (b) date of birth; (c) gestational age; (d) type of delivery; (e) birth LOS; (f) feedings: breastfed, formula fed, or combination of breast and formula feedings; (g) feeding pattern and difficulties: number of breastfeeding episodes, frequency, and volume of intake (infant latch and number of sucks/swallows); (h) transcutaneous serum bilirubin levels at discharge; (i) date of readmission; (j) readmission diagnosis; (k) transcutaneous serum bilirubin levels on readmission; (l) readmission LOS; and (m) any additional comments or descriptors from the clinical staff (infant weight loss tracking, documentation of lactation support, etc.). Staff education began June–July 2017, with project implementation

commencing in August 2017. Project outcomes were recorded from August 2017–November 2018. Pre-bundle data collected January 2016–May 2017 served as our baseline comparison.

Analysis This project measured findings using quantitative data analysis. Descriptive and inferential analyses were performed on readmission data for all LPIs and ETIs. These secondary readmission data were separated into groups and compared to each other. We used MYSTAT 12, version 12.02.00 for statistical analysis. Our intent was to characterize the basic, descriptive nature of the samples and use t-testing to evaluate the difference between the LPI/ETI readmission means by month.

Ethical Considerations This QI project proposal obtained organizational institutional review board approval. No member of our team claimed any personal, professional, or financial conflict of interest. Readmission-tracking forms were kept securely. De-identified monthly LPI/ETI readmission counts were collected, analyzed, and reported for this QI project.

Results Pre-Intervention Findings In 2015, it was reported that 11 infants (4 LPIs and 7 ETIs) of 1,928 total live births were readmitted to our hospital (a 0.6% readmission rate). Prior to the launch of our project (January 2016 to May 2017), 12 LPI/ETI readmissions (5 LPIs and 7 ETIs) of 2,054 live births (0.6%) occurred. The one commonality surfacing among all 12 recent infant readmissions was that they were exclusively breastfed.

Pre-Intervention LPI Readmission Characteristics Of the five readmitted LPIs, two were twins, three were born by Caesarian section, and two were vaginal deliveries. Four infants were readmitted for hyperbilirubinemia, and one was readmitted for hypothermia. All five had documented breastfeeding issues in their electronic medical records (EMRs), and lactation support (if provided) was not well documented. All families received a post-discharge lactation support follow-up telephone call.

Pre-Intervention ETI Readmission Characteristics Two of the seven readmitted ETIs were born by Caesarian section and five were vaginal deliveries, six were readmitted for hyperbilirubinemia, and one was readmitted for rule-out sepsis. Two EMRs documented appropriate inpatient breastfeeding sessions and the remaining five documented difficulties with breastfeeding.

Post-intervention Findings Following the August 2017 bundle implementation, five infants (1 LPI and 4 ETIs) of 2,703 total live births (.2%) were readmitted exclusively with hyperbilirubinemia. All five infants were vaginal deliveries with two of them being exclusively breastfed (the other three were supplemented with formula

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Breastfeeding Bundles to Reduce Readmission Risk for Late Preterm and Early Term Infants at discharge). Lactation consultations with documented feeding plans were present in each infant’s EMR prior to discharge and each family received a post-discharge lactation follow-up telephone call.

Our bundle interventions were evidence-based and more prescriptive than

Comparisons Reduced Readmission Rates for Hyperbilirubinemia

past institutional behaviors,

Overall, staff decreased the number of hyperbilirubinemia LPI/ETI readmissions to our hospital. The impact on LPI/ETI readmissions was a rate reduction of 80% and 50%, respectively (Pre-Post TLPI Deliveries = 130, 133, respectively; Pre-Post TETI Deliveries = 557, 515, respectively). Combined infant (LPI + ETI) readmission reduction was 55%.

Missing Data The only missing data were readmission data excluded from June– July 2017, when all service line staff received bundle education for proper care of each dyad population. Our hesitance to collect data during this transition period was fueled by concern that as new practice in early transition, traditional (older) care behaviors could have been occurring concurrently.

Discussion Summary We meaningfully reduced the numbers of hyperbilirubinemia LPI/ETI hospital readmissions by bundling care practices for each of these respective newborn dyad populations. Specific, individualized breastfeeding and breast pumping instructions, coupled with lactation support and discharge follow-up for all dyads, markedly aided in increasing infant feeding episodes and quality, leading to fewer incidents of hyperbilirubinemia in the home setting. Continuous performance improvement standardization, monitoring, staff coaching, and family awareness led to consistent compliance and the overall success of this QI project. If real time audits revealed a mother did not start pumping timely enough or did not pump at all following any unsuccessful feeding, the responsible nurse was coached and reeducated on the value of effective bundle implementation, and our lactation consultants worked more closely with the parents.

Interpretation Our team observed three direct outcomes resulting from this project: (a) an increase in successful LPI/ETI feeding episodes, (b) consistent early lactation support offered to all mothers, and (c) increased clinician awareness of signs of infant feeding difficulties and premature infant weight loss. Many involved mothers also expressed feeling well-prepared to care for their infant at home as a result of receiving early education on infant feeding technique, infant feeding cues, breast pumping skills, and awareness of infant medical risks resulting from substandard feedings. Other positive, operational outcomes were also experienced. For every avoided infant readmission, the hospital saved a daily average of $3,900. Parents verbalized increased visit satisfaction following participation in the new education content. Earlier breastfeeding offerings to LPI/ETI mothers resulted in fewer episodes of infant weight loss and/or

especially for the care of the LPI population.

hypoglycemia, and thus a decreased need for use of feeding supplementation with formula.

Bundle Drift One LPI and one ETI were born in our birthplace, and each drifted from following their bundled standards of care. The LPI did not have standing LPI-newborn orders entered into the EMR. As a result, maternal pumping after each feeding was not initiated prior to the infant’s discharge. Similarly, the mother of an ETI was discharged without being taught to pump after each breastfeeding, because documentation noted “fair” infant feedings throughout the record. Following these discoveries, LPI/ETI bundle reeducation was reinforced with all staff in each clinical area, and no further episodes of bundle deviation have occurred for those dyads discharged from our service.

Limitations Sample Size Small sample size was the first limitation affecting this project. The number of pre- and post-intervention infant readmissions was not large enough, and therefore, power and generalizability could not be ascertained. Descriptively, it was apparent that this project decreased infant readmissions in these populations; however, each small sample size precluded us from inferring anything more, as the normality of each distribution could not be tested. Our team is committed to address the impact of this project over a longer period of time (a five-year, retrospective secondary data review), in order to calculate appropriate sample distributions of normality and apply fitting inferential analyses.

Human Factors Human factor variability cannot be discounted when discussing additional limitations to this project. Certainly, the demeanor, behavior, and readiness for mothers to learn new methods of care with their newborns was a complementary limitation when cooperation came down to them regularly breast pumping throughout their hospital stay. While no mothers refused to participate in their appropriate bundled program, at times, there were challenging episodes of frequency and pumping compliance noted between mom and caregiver. This type of situation did not often arise in our clinical units, but the risk of mothers potentially deviating from this recommended in-home best practice could negatively impact the success of ongoing lactogenesis, newborn adherence to feedings, and overall infant health (e.g., increased risk for weight loss) (Boise et al., 2017).

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Breastfeeding Bundles to Reduce Readmission Risk for Late Preterm and Early Term Infants

Conclusion Our QI project demonstrated a sustainable reduction in LPI/ETI readmission rates. Bundle implementation, staff and parent education, and breastfeeding support, coupled with lactation consultant interventions for these breastfeeding dyads, helped our infant populations better thrive by having more optimal feeding intakes. At the same time, readmission rates for hyperbilirubinemia were markedly decreased. Our bundle interventions were evidence-based and more prescriptive than past institutional behaviors, especially for the care of the LPI population. Our hospital and our nurses continue to champion supporting mothers choosing to breastfeed their infant, even when barriers seem insurmountable. As healthcare clinicians, our responsibility lies in equipping parents of infants with the tools they need to care for their vulnerable newborn in their home setting. No parent wants to have their infant readmitted to a hospital to be placed under phototherapy lights. The emotional stress alone can be very overwhelming.

We encourage other hospitals and clinical practices to consider bundling care practices for these infant populations, assisting with infant latch or maternal breast pumping, and assessing milk transfer within the first hour of life and continuing every 2 to 3 hours around the clock in the first few days of life. Similarly, we recommend emphasizing the importance of early, all-inclusive lactation support for these dyad populations and other mother-infant dyads who may be struggling with successful breastfeeding. Lastly, we recommend more research be conducted in this area of LPI/ETI improvements in care practices and infant outcomes. If infants do not effectively feed early on and often in life, they risk quickly acquiring downstream adverse health outcomes. This QI project is one opportunity for other institutions to replicate better practices to promote the health of our infants and reduce the risk of readmissions back into the acute care setting for suboptimal feeding, increased weight loss, and/ or hyperbilirubinemia.

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Breastfeeding Bundles to Reduce Readmission Risk for Late Preterm and Early Term Infants

n References American Academy of Pediatrics. (2010). Policy statement—Hospital stay for healthy term newborns. Pediatrics, 125(2), 405–408. https://doi. American Academy of Pediatrics. American Academy of Pediatrics. (2012). Policy Statement—Breastfeeding and the use of human milk. Pediatrics, 129(3), e827-e841. https://doi. org/10.1542/peds.2011-3552 Association of Women’s Health, Obstetric and Neonatal Nurses. (2015). Breastfeeding [AWHONN position statement]. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 44(1), 145–150. https://doi. org/10.1111/1552-6909.12530 Association of Women’s Health, Obstetric, and Neonatal Nurses. (2015). Breastfeeding support: Preconception care through the first year. Baker, B. (2015). Evidence-based practice to improve outcomes for late preterm infants. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 44(1), 127–134. https://doi.org/10.1111/1552-6909.12533 Bingham, D. & Spong, C. Y. (2014). The redefinition of term pregnancy. https://www.medscape.org/viewarticle/827957_2 Boies, E. G., Vaucher, Y. E., & the Academy of Breastfeeding Medicine. (2016). ABM clinical protocol #10: Breastfeeding the late preterm (34–36 6/7 weeks of gestation) and early term infants (37–38 6/7 weeks of gestation), second revision 2016. Breastfeeding Medicine, 11(10), 494–500. https://doi.org/10.1089/bfm.2016.29031.egb Briere, C. E., Lucas, R., McGrath, J. M., Lussier, M., & Brownell, E. (2015). Establishing breastfeeding with the late preterm infant in the NICU. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 44(1), 102–113. https://doi.org/10.1111/1552-6909.12536 Engle, W. A., Tomashek, K. M., Wallman, C., & Committee on Fetus and Newborn. (2007). “Late-preterm” infants: A population at risk. Pediatrics, 120(6), 1390–1401. https://doi.org/10.1542/peds.2007-2952 Flaherman, V. J., Maisels, J., & Academy of Breastfeeding Medicine. (2017). ABM clinical protocol #22: Guidelines for management of jaundice in the breastfeeding infant 35 weeks or more of gestation (revised 2017). Breastfeeding Medicine, 12(5), 250–257. https://doi.org/10.1089/ bfm.2017.29042.vjf Flaherman, V., Schaefer, E. W., Kuzniewicz, M. W., Li, S. X., Walsh, E. M., & Paul, A. I. (2018). Health care utilization in the first month after birth and its relationship to newborn weight loss and method of feeding. Academic Pediatrics, 18(6), 677–684. https://doi. org/10.1016/j.acap.2017.11.005 Hwang, S. S., Barfield, W. D., & Smith R. A. (2013). Discharge timing, follow-up and home care of late-preterm and early term infants. Pediatrics, 132(101), 101–108. https://doi.org/10.1542/peds.2012-3892 Kair, L. R., Flaherman, V. J., Newby, K. A., & Colaizy, T. T. (2015). The experience of breastfeeding the late preterm infant: A qualitative study. Breastfeeding Medicine, 10(2), 102–106. https://doi.org/10.1089/ bfm.2014.0121 Lucas, R., Gupton, S., Holditch-Davis, D., & Brandon, D. (2014). A case study of a late preterm infant’s transition to full at-breast feedings at 4 months of age. Journal of Human Lactation, 30(1), 28–30. https:// doi.org/10.1177/0890334413495973

Maisels, M. J., Bhutani, V. K., Bogen, D., Newman, T. B., Stark, A. R., & Watchko, J. F. (2009). Hyperbilirubinemia in the newborn infant ≥ 35 weeks’ gestation: An update with clarifications. Pediatrics, 124(4), 1193–1198. https://doi.org/10.1542/peds.2009-0329 Mannel, R., & Peck, J. D. (2018). Outcomes associated with type of milk supplementation among late preterm infants. Journal of Obstetric, Gynecologic, and Neonatal Nursing: JOGNN, 47(4), 571–582. https:// doi.org/10.1016/j.jogn.2017.11.005 Muelbert, M., Harding, J. E., & Bloomfield, F. (2019). Nutritional polices for late preterm and early term infants-can we do better? Seminars in Fetal and Neonatal Medicine, 24(1), 43–47. https://doi.org/10.1016/j. siny.2018.10.005 Noble, A., Eventov-Friedman, S., Hand, I., Meerkin, D., Gorodetsky, O., & Noble, L. (2019, April 16). Breastfeeding intensity and exclusivity of early term infants at birth and 1 month. Breastfeeding Medicine. https://doi.org/10.1089/bfm.2018.0260 Ogrinc, G., Davies, L., Goodman, D., Batalden, P., Davidoff, F., & Stevens, D. (2016). SQUIRE 2.0 (standards for quality improvement reporting excellence): Revised publication guidelines from a detailed consensus process. BMJ Quality & Safety, 25(12), 986–992. https:// doi.org/10.1136/bmjqs-2015-004411 Rajan, N., Kumar Kommu, P. P., Krishman, L., & Mani, M. (2017). Significant hyperbilirubinemia in near-term and term newborns: A case-control study. Journal of Clinical Neonatology, 6(4), 220–224. https://doi.org/10.4103/jcn.JCN_35_17 Romero, H. M., Ringer, C., Leu, M. G., Beardsley, E., Kelly, K., Fesinmeyer, M. D.,…Migita, A. D. (2018). Neonatal jaundice: Improved quality and cost savings after implementation of a standard pathway. Pediatrics, 141(3), 1–9. https://doi.org/10.1542/peds.2016-1472 Ruth, C. A., Roos, N. P., Hildes-Ripstein, E., & Brownell, M. D. (2014). Early term infants, length of birth stay and neonatal readmission for jaundice. Pediatrics & Child Health, 19(7), 353–354. https://doi. org/10.1093/pch/19.7.353 Seagraves, K., Brulte, A., McNeely, K., & Pritham, U. (2013). Supporting breastfeeding to reduce newborn readmissions for hyperbilirubinemia. Nursing for Women’s Health, 17(6), 500–507. https://doi. org/10.1111/1751-486X.12078 Sengupta, S., Carrion, V., & Shelton, J. (2013). Adverse neonatal outcomes associated with early-term birth. JAMA Pediatrics, 167(11), 1053– 1059. https://doi.org/10.1001/ jamapediatrics.2013.2581 Spatz, D. L., Froh, E. B., Schwartz, J., Houng, K., Brewster, I., Myers, C., …Olkkola, M. (2015). Pump early, pump often: A continuous quality improvement project. The Journal of Perinatal Education, 24(3), 160170. https://doi.org/10.1891/1058-1243.24.3.160 Thulier, D. (2017). Challenging expected patterns of weight loss in fullterm breastfeeding neonates born by Cesarean. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 46(1), 18–28. http://dx.doi. org/10.1016/j.jogn.2016.11.006 World Health Organization. (2018). Ten steps to successful breastfeeding (revised 2018). https://www.who.int/nutrition/bfhi/ten-steps/en/

Journal of the New York State Nurses Association, Volume 47, Number 2

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue, Part 2: NYSNA 2020 Staffing and Job Stress Survey Results Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD Lucille Contreras Sollazzo, MSN, RN-BC, NPD Christina DeGaray, MPH, RN-BC

n Abstract Objective: The purpose of this study was to establish a baseline measure of characteristics of the work environment, sources of stress and impact on health (physical, mental, sleep) among staff nurses prior to implementation of contractually mandated nurse-to-patient ratios. Aims were to determine the top three stressors nurses face on a daily basis on the job and to broadly evaluate trends among workload, stress, and health as they relate to burnout, depression, and compassion fatigue. Design: A quantitative descriptive survey design was conducted to evaluate trends among work environment characteristics, staffing, stress, and nurse health. Population: Surveys were sent to 1,237 registered nurses working in seven unionized acute care hospitals in New York State. Respondents numbered 279 nurses. The analyzed population was a convenience sample comprised of 181 nurses working on medical-surgical units. Measurements: The NYSNA 2020 Staffing and Job Stress Survey contained 38 items. The survey captured factors among five categories: demographics, organizational characteristics, practice environment with regard to staff mix and workload, impact on nurse health, and nurse stress reduction/action. Results: Inadequate staffing, lack of adequate supplies and/or equipment, and pressure to carry out duties out of scope of practice were the three most significant sources of stress for the majority of nurses. Of respondents, 82.8% believed work-related stress negatively affected their health. Respondents reported an average of 7.9 and 10 days in the past 30 with poor physical and/or mental health, respectively. The most commonly reported adverse health effects experienced due to job stress included headaches and/or other body aches (81%), sleep disruption (65%), and extreme or chronic fatigue (59.2%). Conclusion: Institutional practices such as lapses in upholding agreed upon staffing grid or ratios, delays in filling vacancies, and floating practices contribute to work stress for nurses. This study will serve as a baseline for future evaluation of whether contractually mandated nurse-to-patient ratios reduce stress, burnout, compassion fatigue, and depression of the working nurse, and to determine whether contractually mandated nurse-to-patient ratios increase the work satisfaction of the working nurse. Keywords: Stress, nurse-to-patient staff ratio, work stress impact on nurse health, contractual agreement

Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD1; Lucille Contreras Sollazzo, MSN, RN-BC, NPD1; Christina DeGaray, MPH, RN-BC2 1 Nursing Education and Practice at the NYSNA; 2Doctoral student in New Jersey at Rutgers University 32

Journal of the New York State Nurses Association, Volume 47, Number 2

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue

Introduction Nurses’ associations and unions are situated to improve nurses’ stress from the hospital level to the unit level to the individual member level. This report is the second part in a series describing a current effort to help reduce stress, burnout, depression, and compassion fatigue among nurses represented by NYSNA in acute care hospitals (Contreras Sollazzo & Esposito, 2020). Job stress is defined as, “the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker” (Sauter et al., 1999). Working conditions and worker characteristics contribute to workplace stress (Sauter et al., 1999). Prolonged exposure to stress may lead to depression, compassion fatigue, and burnout. Extrinsic factors contributing to nurses’ stress, such as the nurse practice environment, can be modified through contract negotiations. Contractual language can address major extrinsic factors. Requiring an employer to fill all vacant positions reduces shortages and maintains operational continuity on units. Contractual modification of nurse-to-patient levels in existing units and determination of appropriate nurse-to-patient ratios in new units and/or in units where there is a clinical programmatic change that fundamentally alters the character of the unit can strengthen the work environment and the delivery of safe care. Modification of nurse-to-patient ratios based on predetermined plans, allows units to flexibly respond to increases in patient census and/or patient acuity. These potentially stress-reducing, extrinsic factors were successfully negotiated in more than ten hospitals throughout New York State by the New York State Nurses Association in its capacity as a collective bargaining agent. A second approach to stress reduction addresses intrinsic factors such as self-care and resilience. This is being done by educating nurses on self-care modalities, aromatherapy, meditation, and resilience-enhancing techniques such as breathwork, qigong, and others (Contreras Sollazzo & Esposito, 2020). To measure the impact of contractually negotiated nurse-to-patient staffing ratios and grids, a survey was conducted in January 2020, prior to contract implementation. The survey will be repeated within one year, once staffing is expected to improve following contract implementation. This article reports the results of the NYSNA 2020 Staffing and Job Stress Survey, prior to contract implementation.

Background and Significance Nurses have an ethical obligation and personal commitment to provide quality, compassionate care to patients and their families (American Nurses Association [ANA], 2015). Moreover, they want to do their job well and provide caring support to those in need. Institutionalized sources of workplace stress, primarily due to inadequate staffing, are insidious Extrinsic factors contributing to nurses’ stress, such as the nurse practice environment, can be modified through contract negotiations.

operators in healthcare facilities worldwide. Occupational stress, more than individual, family, or cultural-socioeconomic was the greatest source of stress for nurses, with heavy workload, salary, and prejudice at work contributing most to occupational stress (Salehi et al., 2014). The literature is replete with examples of extrinsic factors that correlate to the increasing stress of nurses. Overwhelming workloads, inadequate care team skills mix, lack of access to supplies, and working in unsupportive environments can, over time, lead to burnout; compassion fatigue; empathy fatigue; moral distress; adverse mental, physical, and psychosocial changes to the nurse; turnover (Halter et al., 2017), turnover intention (Chegini et al., 2019; Sasso et al., 2019); and leaving the nursing profession (Lo et al., 2018). Among medical-surgical nurses, occupational stressors were found to be significant predictors for perceived stress regardless of age (Wakim, 2014). Adverse working conditions may intensify stress, leading to emotional exhaustion and depersonalization (Organopoulou et al., 2014). Job satisfaction among hospital-based nurses has been found to be mediated or moderated by various complex factors, including work environment, job stress, and nurse-to-patient ratios (Lu et al., 2019). Each additional increase in the number of patients per nurse was associated with reduced job satisfaction and increased exhaustion (Nantsupawat et al., 2015). “Burnout is a psychological syndrome emerging as a prolonged response to chronic interpersonal stressors on the job. The three key dimensions of this response are an overwhelming exhaustion, feelings of cynicism and detachment from the job, and a sense of ineffectiveness and lack of accomplishment” (Maslach & Leiter, 2016, p. 103). In this context, there are several key determinants of burnout in nursing. Burnout has been predicted by practice environment (Van Bogaert et al., 2017), is associated with high nurse-to-patient ratios, turnover, poor job performance, and decreases in patient safety (Bakhamis et al., 2019). Hospitals with quality work environments tend to have staff with less burnout. Studies have shown that when institutions prioritize nursing work environments, well-being (Casalicchio et al., 2017), and health of its nursing workforce, they have less burnout and lower turnover rates, while nurses report fewer intentions to leave and more job satisfaction (Zhang et al., 2013). By offering on-the-job stress reduction activities, they benefit from cost savings, fewer nosocomial infections, better quality of care, improved patient outcomes, and enhanced nurse life (Contreras Sollazzo & Esposito, 2020). “Economic analysis has found that when the cost savings from lower length of stay, reduced adverse outcomes, reduced admissions, and other benefits of adequate staffing are considered, adequate staffing is affordable” (Needleman, 2016, p. 26). It is in the best interest of healthcare organizations, nurses’ associations, nurses, and patients to have work environments that minimize stress and optimize job satisfaction.

Study Aims The purpose of this study was to establish a baseline measure of the characteristics in the current nursing work environment, sources of stress, and the impact stress has on nurses’ health (physical, mental, sleep) prior to implementation of contractually mandated nurse-to-patient ratios. Overarching objectives were to determine the top three self-declared stressors nurses face on a daily basis on the job, and to broadly evaluate trends amongst workload, stress, and consequences to health.

Journal of the New York State Nurses Association, Volume 47, Number 2

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue

Methods Participants and Design of Study

stress, referred to as Exhibit 3 of Part 1 of this study (Contreras Sollazzo & Esposito, 2020, pp. 34–42).

The New York State Nurses Association created the 2020 Staffing and Job Stress Survey used in this study and referred to as Exhibit 1 in Part 1 of this study (Contreras Sollazzo & Esposito, 2020, pp. 30–32). This quantitative descriptive survey was used to evaluate trends in nurse demographics, organizational characteristics, staff mix, workload, and practice environment. The survey contained 38 items, derived from survey items used in the NIOSH Quality of Work Life Survey (NIOSH, 2013), the Practice Environment Scale of the Nursing Work Index (Lake, 2002), and a survey item from a primary study on nurse workloads (Aiken et al., 2010). It also included the 2017 NYSNA Survey referred to as Tables 3–6, and Table 8 of Part 1 of this study (Contreras Sollazzo & Esposito, 2020, pp. 25–28). In addition, there were three qualitative, written response items soliciting information on: (a) how members reduced their own stress; and (b) what techniques were utilized to reduce

A non-experimental quantitative descriptive survey design was used to broadly evaluate trends among work environment characteristics, staffing, stress, and health. Experimental quantitative descriptive designs establish causality and, therefore, measures participant responses before and after a change (Lauer & Asher, 1988). Before and after contract implementation with concomitant improved staffing after contract implementation is the change variable being studied. The survey will be repeated within the year, following contract implementation.

The 2020 Staffing and Job Stress Survey was sent via SurveyMonkey® to 1,237 registered nurses working on the medical-surgical units in seven unionized acute care hospitals in New York State. Responses included 279 nurses, yielding a response rate of 22.6%. The analyzed population was a convenience sample comprised of 181 nurses working on medical-surgical units. Consent was obtained and implied through voluntary participation in the survey.

Table 1 Description of Study Participants

Demographics N = 180

% (n)

Mean (SD), range

Female

89.1 (156)

Male

10.3 (18)

Other

0.6 (1)

Gender

Age, y

36.5 (10.5), 22-63

Length at present job, y

6.1 (7.3), <1-36

Educational degree

789

Associate

14.0 (25)

Bachelor

69.7 (124)

Master

10.1 (18)

Other

6.2 (11)

Shift worked Day

59.7 (108)

Evening

2.2 (4)

Night

37.6 (68)

8 hours

7.2 (13)

12 hours

91.7 (165)

1.1 (2)

Shift length

Other Extra hours beyond usual schedule per week

147.0

Journal of the New York State Nurses Association, Volume 47, Number 2

2.6 (3.9), 0-24

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue

Results The percentage of participants who

Demographics are reported in Table 1. The majority of participants were female (89.1%) with a mean age of 36.5 years old, and with 69.7% reporting having earned a bachelor’s degree. Of participants, 59.5% worked the day shift, 37.6% worked the night shift, 2.2% worked the evening shift, and 91.7% worked 12-hour shifts. Participants averaged 2.6 hours per week of work beyond their scheduled shifts. Organizational characteristics are reported in Table 2. Prior to contract implementation, 64.6% of respondents reported having previously identified a staffing ratio or grid on their units, which denoted a nurse-to-patient ratio of 1:5–6. However, results of the survey indicated that this established ratio was upheld only 22.1% of the time. Of respondents, 54.4% reported that their hospitals do not fill vacancies promptly. Results of survey questions for items pertaining to staff mix, workload, and the practice environment are reported in Table 3. Participating nurses routinely had six to 17 patients assigned to them. Having too many patients assigned to them in order to do everything well and having inadequate numbers of ancillary staff assigned to help were reported by 90% of nurses. Having a workload that sometimes caused them to miss changes in patients’ conditions was reported by 71.5% of nurses. Survey results also indicated time for communication with other nurses and physicians was generally lacking. Not having a full complement of staff was reported as a source of stress by 96.7% of participants. The percentage of nurses who often or always found their work stressful was 82.2%. Floating onto another unit was another common cause of stress, with 40.6% reporting this as often and 33.9% as sometimes. Conversely, having staff float onto their unit was also identified as a source of stress by 40.6% of nurses. The three greatest

believed that work-related stress had negatively affected their health was 82.8%.

causes of stress on participants’ units (Figure 1) were inadequate staffing (94.6%), lack of adequate supplies and/or equipment (71.5%), and pressure to carry out duties legally out of scope of practice (28.4%). Impacts of stress on nurses’ health were reported in Table 4. The percentage of participants who believed that work-related stress had negatively affected their health was 82.8%. Many reported difficulties falling or staying asleep. Out of the past 30 days, participants reported suffering an average of 7.9 days from poor physical health and 10 days from poor mental health. The most commonly reported adverse health effects experienced due to job stress (Figure 2) included headaches and/or other body aches (81%), sleep disruption (65%), and extreme or chronic fatigue (59.2%). In Table 5, results of the survey show the majority of nurses (69.9%) reported that their facility did not offer a nurse stress reduction program. And of those who reported their facility as having one, only 7% of nurses participated. The survey also reported that many nurses engaged in self-help union activity, such as filing a protest of assignment (98.3%), participating in contract negotiations (32%), or participating in another concerted action (Figure 3) to protest inadequate staffing (31.4%).

Table 2 Organizational Characteristics

Variable Do you have a staffing grid or nurse/patient ratio on your unit?

Response

% (n)

Yes

64.6 (113)

35.4 (62)

If there is a staffing grid or ratio on your unit, what is it?

95.0

Is the ratio or staffing grid upheld? Is there a process for modifying agreed upon staffing grids or nurse/patient ratios to account for census and acuity changes?

The hospital fills all vacancies promptly.

Is there a process to adequately orient newly hired staff?

Yes

22.1 (32)

77.9 (113)

Yes

6.9 (12)

28.2 (49)

Don’t know

64.9 (113)

Yes

16.7 (30)

54.4 (98)

Don’t know

28.9 (52)

Yes

79.8 (142)

10.7 (19)

Mean (SD), range

5.6 (0.75), 4-8

Journal of the New York State Nurses Association, Volume 47, Number 2

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue

Table 3 Staff Mix / Workload / Practice Environment

Variable

Response

How many patients are routinely assigned to you?

I have too many patients to do everything well.

How often are there not enough RNs to get all work done?

How often are there not enough ancillary staff to get all work done?

How often are there not enough MDs to get all work done?

I usually receive enough help to get job done

Adequate ancillary staff allows me to spend enough time with my patients.

172.0 Often

53.6 (97)

Sometimes

37.0 (67)

Rarely

2.2 (4)

Never

1.7 (3)

Often

55.6 (100)

Sometimes

37.2 (67)

Rarely

6.7 (12)

Never

0.6 (1)

Often

90.6 (163)

Sometimes

7.8 (14)

Rarely

1.1 (2)

Never

0.6 (1)

Often

27.8 (49)

Sometimes

41.5 (73)

Rarely

24.4 (43)

Never

6.3 (11)

Strongly agree

1.7 (3)

Agree

32.2 (58)

Disagree

49.4 (89)

Strongly disagree

16.7 (30)

Strongly agree

45.3 (81)

Agree

21.8 (39)

Disagree

14.5 (26)

Strongly disagree

18.4 (33)

Strongly agree I have enough time and opportunity to discuss patient care problems with other nurses and physicians.

Not having a full complement of staff is a source of stress for me

There are enough RNs on my unit for quality patient care.

% (n)

1.7 (3)

Agree

26.7 (48)

Disagree

55.6 (100)

Strongly disagree

16.1 (29)

Strongly agree

71.1 (128)

Agree

25.6 (46)

Disagree

2.2 (4)

Strongly disagree

1.1 (2)

Strongly agree

4.4 (8)

Agree

29.1 (52)

Disagree

43.6 (78)

Strongly disagree

22.9 (41)

Journal of the New York State Nurses Association, Volume 47, Number 2

Mean (SD), range 6.1 (1.5), 0-17.5

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue

Table 3 Staff Mix / Workload / Practice Environment (con't)

Variable

My workload sometimes causes me to miss changes in patients’ conditions.

Is being floated off your unit a cause of stress?

Is having staff floated onto your unit a cause of stress?

How often do you find your work stressful?

Response

% (n)

Strongly agree

15.1 (27)

Agree

56.4 (101)

Disagree

27.9 (50)

Strongly disagree

0.6 (1)

Often

40.6 (73)

Sometimes

33.9 (61)

Rarely

16.7 (30)

Never

8.9 (16)

Often

11.1 (20)

Sometimes

40.6 (73)

Rarely

33.9 (61)

Never

14.4 (26)

Always

29.4 (53)

Often

52.8 (95)

Sometimes

17.2 (31)

Never

0.6 (1)

Mean (SD), range

What are the three greatest causes of stress on your unit? Please check 3: Inadequate staffing

94.6 (176)

Lack of adequate supplies and/or equipment

71.5 (133)

Pressure to carry out duties out of scope of practice

28.4 (53)

Conflict between coworkers

19.8 (37)

Conflict with managers

18.2 (34)

Inadequate policies

16.6 (31)

Conflict with doctors

16.1 (30)

Inadequate training

12.9 (24)

Excessive number of hours worked

10.2 (19)

Harassment due to race, gender, sexual orientation or identity, age, country of origin

In the first qualitative write-in item, participants were asked to describe activities they engaged in to decrease their stress level. A variety of responses were listed, including exercise; deep breathing; enjoying quality time away from work; leaving work at work; leaving the unit or hospital while on break; socialization; discussion and debriefing with colleagues about stressors; listening to music, prayer, religious, and spiritual activities; meditation; getting restful sleep; and watching television. Techniques participants found helpful in reducing their stress

2.7 (5)

level included deep breathing, exercise, doing one work task at a time, avoiding conflict with coworkers, time management, task delegation, mindfulness, prayer, sleep, meditation, and enjoying time off. Lastly, participants were asked to suggest things that could be done to reduce stress experienced at work. The most frequently requested items were improved nurse and ancillary staffing, lower nurse-to-patient ratios, reduced reliance on floating, more equipment, and increased availability and access to supplies.

Journal of the New York State Nurses Association, Volume 47, Number 2

Figure 2 What, If Any, Adverse Health Effects Have You Experienced Due to Job Stress?

Check all that apply:

100% Responses

80%

60%

40%

20%

0% Other (please specify)

Inadequate training

Inadequate policies

Lack of adequate supplies

Excessive number of hours worked

Harassment due to race, gender, sexual orientation

Pressure to carry out duties out of scope

Conflict between coworkers

Conflict with doctors

Conflict with managers

Inadequate staffing

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Other (please specify)

Tachycardia

Depression and/ or anxiety

Extreme or chronic fatigue

Appetite suppression or overeating

Gastrointestinal distress

Sleep disruption

Hypertension

Headaches and/or other body aches

n Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue

Figure 1 What Are the Three Greatest Causes of Stress on Your Unit?

Please check three

Responses

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue

Table 4 Impact on Health (Physical, Mental, Sleep)

Variable

My stress level at work has negatively affected health.

During the past 12 months, how often have you had trouble falling asleep or staying asleep?

Response

% (n)

Strongly agree Agree

250.0 (45) 57.8 (104)

Disagree

16.0 (29)

Strongly disagree

1.1 (2)

Often

43.1 (78)

Sometimes

41.4 (75)

Rarely

8.8 (16)

Never

6.1 (11)

Mean (SD), range

Thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 was your physical health not good?

160.0

7.9 (8.7), 0-30

Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 was your physical health not good?

158.0

10.0 (8.4), 0-30

What, if any, adverse health effects have you experienced due to job stress? Check all that apply. Headaches and/or other body aches

81.0 (145)

Sleep disruption

65.4 (117)

Extreme or chronic fatigue

59.2 (106)

Depression and/or anxiety

51.4 (92)

Appetite suppression or overeating

48.6 (87)

Gastrointestinal distress

38.6 (69)

Tachycardia

24.6 (44)

Hypertension

17.3 (31)

Other (please specify)

10.6 (19)

Discussion The results of this study suggest that extrinsic factors contributing to workplace stress are rooted in role conflict, inadequate staffing, higher workloads, and pressure to carry out duties out of legally defined scope of practice, environmental incongruence, and inadequate supplies. Additionally, these factors negatively influence the physical and mental health of nurses. The percentage of participants who responded that they found their work to be stressful most of the time was 82.2%. Inadequate staffing was identified as the greatest cause of stress among participants, with 96% of nurse participants agreeing that inadequate staffing was a significant source of stress for them. This is consistent with previous NYSNA findings (Contreras Sollazzo & Esposito, 2020) and aligned with findings by Davey et al. (2019) where 89% of hospital-based staff nurses rated their work stress as moderate to high.

In the present study, 71.5% of nurses indicated that their workload was so high that they sometimes missed changes in patients’ conditions. Reported in 90.6% of the cases, not enough ancillary staff was available to complete care on time. Stress as a consequence of short-staffing (Simpson et al., 2016; Chegini et al., 2019) leads to missed care and potential for failure to rescue (Simpson et al., 2016). In a study on missed care (Winters & Neville, 2012), when nurses failed to complete patient care on time, all surveyed nurses identified physical care, such as hygiene, grooming, mobility, and checking skin integrity as the most frequent nursing intervention that could not be accomplished by shift end. Here, nurses expressed their belief that the emotional well-being of their patients suffered as a consequence. Nurses in the Winters and Neville (2012) study also reported that those tasks that are often delegated to ancillary staff, such as patient vital signs and assessments, were delayed or missed as a consequence as well. One nurse reported leaving work thinking, “I haven’t done my job properly;

Journal of the New York State Nurses Association, Volume 47, Number 2

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue

Table 5 Stress Reduction, Actions Taken

Variable

Response

Is there a nurse stress reduction program at your workplace? If there is a stress reduction program, do you participate?

% (n)

Yes

30.10 (53)

69.90 (123)

Yes

7.00 (8)

930.00 (107)

Have you ever taken any of the following actions to protest inadequate staffing? Check all that apply: Filed a protest of assignment form (POA)

98.30 (178)

Participated in contract negotiations to fight for improved staffing levels

32.00 (58)

Participated in a union action to protest inadequate staffing

31.40 (57)

Signed a letter or petition protesting inadequate staffing

30.30 (55)

Other (please specify)

2.21 (4)

I feel sorry for the patients because they were not getting the care they could be getting,” (Winters & Neville, 2012, p. 24). Aspects of nurse occupational stress such as role stress (including workload, shiftwork, and hours worked) and interpersonal relations stressors contributed significantly to clinical errors (Kakeman et al., 2019). Consistent adequate nurse staffing is repeatedly linked to better patient safety, outcomes and reduced mortality (Twigg et al., 2010) and is cost-effective for patients, insurers, and government (Kim et al., 2016). These types of “missed” nursing interventions are crucial to patient safety and satisfaction (Bal et al., 2018) and increase feelings of moral distress. According to philosopher and ethicist, Andrew Jameton, moral distress is “when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action” (Jameton, 1984, p. 6). When left unaddressed by the employer and due to working conditions can never be met, the unique kind of work-related stress experienced by nurses, who are bound by their professional and ethical obligations toward patients, result in moral distress. Indeed, any perceived form of avoidable harm to a patient as a consequence of nurse action or inaction that is due to a lack of foreseeable organizational support and that resulted in patient suffering, can be both immoral and, at times, illegal. Along a gradient, the patient’s state of suffering perceived by the nurse may be transferred to the nurse’s emotional queue, moderating the nurse’s internal experience of suffering and generating their physical and psychological experiences of distress. This may be an internal psychologic process that transforms moral distress to a nurse’s perceived reality, compounding the emotional and physical response to preventable, perceived patient suffering. The dynamic operation among nurse perception, role, empathy, and degree of suffering by the nurse-patient dyad may contribute to nurse stress under short-staffed conditions. Floating nurses between units is a function of inadequate staffing in a hospital. In this study, floating off of the nurses’ primary unit was identified as stressful to the nurses on both the home unit and the receiving unit. This study’s findings are aligned with the finding in a recent study of non-ICU 40

The three most common adverse health effects experienced by nurses in the present study were headaches and/or other body aches, sleep disruption, and extreme or chronic fatigue.

nurses who were floated frequently. Nurses experienced a chaotic workflow process, lack of familiarity with unit-specific tasks on the unit they floated to, unfamiliarity with patient care supplies and necessary documentation, perception of unfair patient care assignment, unfriendly or unwelcoming receiving staff, and difficulty getting breaks for meals (Lafontanant, 2019). Characteristics including disrupted workflow, sudden assignment changes, and poor communication, may also explain why receiving a nurse from another unit may be stressful. Inadequate supplies have been identified in the present study as the second leading cause of stress among the nurses surveyed. Searching for short supplies of equipment, medications, wound care products, linens, or food occupied much of the RNs time and led to missed or delayed care on the unit (Winters & Neville, 2012). Functional congruence is a characteristic of a physical work environment to facilitate the execution of work by the worker (Dendaas, 2011). The physical work environment of the medicalsurgical unit, such as configuration of the nurses’ stations, and adequacy of space for routinely used patient care supplies, has been demonstrated in the literature to moderately contribute to work-related stress (Dendaas, 2011) and nurse fatigue (Wingler & Keys, 2019). The third leading cause of stress identified by 28.5% of the present study’s participants was pressure to carry out duties out of the legally defined scope of practice. There are few research articles that can be found in the literature that report on the correlation between stress

Journal of the New York State Nurses Association, Volume 47, Number 2

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue

Figure 3 Have You Ever Taken Any of the Following Actions to Protest Inadequate Staffing? Check all that apply:

100% Responses 80%

60%

40%

20%

Filed a protest of assignment form (POA)

Signed a letter or petition protesting inadequate staffing

Participated in a union action to protest inadequate staffing

and the prevalence of medical-surgical nurses working outside their scope of practice. However, one similarly situated study reported on rural emergency department nurses’ anxiety and concerns about their licensure when the participants indicated that in order to save the lives of patients, they needed to work outside their scope of practice (Dekeserdy et al., 2019). The three most common adverse health effects experienced by nurses in the present study were headaches and/or other body aches, sleep disruption, and extreme or chronic fatigue. A plethora of research studies report on the negative consequences occupational stress places on the physical and mental health of nurses, which align with the results of the present study. Exposure to chronic work stress has been documented in the literature to cause anxiety, depression, and somatic symptoms (Davey et al., 2019); and to negatively impact nurses’ caring behaviors and quality of life (Sarafis et al., 2015). Job stress contributed to anxiety, depression, poor sleep health, fatigue, and poor lifestyle and coping habits among nurses (Jordan et al., 2016). There is growing evidence of work-related post-traumatic stress disorder among nurses (Schuster et al., 2020). Psychological job stress has been found to affect allostatic load and immunological biomarkers among nurses and has been significantly

Participated in contract negotiations to fight for improved staffing levels

Other (please specify)

associated with lower white blood cell levels and higher total salivary IgA levels among female nurses (Lee et al., 2010). Long-term work stressors have been shown to be associated with higher allostatic load index, indicating that cumulative work stress may adversely affect chronic physiologic stress processes (Coronado et al., 2018). Furthermore, specific aspects of nurse job stressors at work such as control and influence, resources, role ambiguity, role conflict, intercollegial clashes, skill underutilization, and task control were all found to have significant relationships to cortisol levels (Yoon et al., 2014). General stress, work stress, and strenuous work activity were found to be strong risk factors for musculoskeletal disorders, while sleep disorders were found to be associated significantly with general and work-related stress (Hämmig, 2020). Hämmig (2020) also found prevalence rates for musculoskeletal and sleep disorders to be higher among nurses than other hospital-based healthcare workers. Stress has been associated with headaches among nursing staff (Lin et al., 2007). The third adverse health effect attributed to job stress most often reported by 59.2% of participating nurses in the present study was extreme or chronic fatigue. Studies noted in the literature that also align with the findings in the present study have been reported by LeGal et al., 2019. In that

Journal of the New York State Nurses Association, Volume 47, Number 2

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue

Implementation of contractually agreed upon staffing improvements will facilitate a self-reported reduction in workplace stress, burnout, depression, and compassion fatigue.

study, high psychological demands correlated with long-term, moderately high chronic fatigue scores among nurses working in Canada over a oneyear period. In another study, hospital-based nurses working in China with diagnosed chronic fatigue syndrome had higher occupational stress, higher incidences of workplace violence, and less organizational support than nurses without chronic fatigue syndrome (Li et al., 2020). Given the low prevalence of resilience training and stress reduction in nursing schools across the United States, (Cochran et al., 2020), employers and nurses’ unions and professional associations have an important role in reducing nurses’ stress. Once nurses are cognizant of their stress, they are likely to develop coping behaviors (Wakim, 2014). It is important for nurses to recognize stress in themselves and their colleagues, in order to enable them to engage in early intervention activities, which supports concomitant efficacious and positive results. Only 30.1% of the facilities surveyed offered stress reduction programs. Moreover, utilization of on-site nurse stress reduction programs, when available, was reportedly low in our study (7%). The low employersponsored program utilization rate for this study’s participants may be a function of participants’ younger age, which was a mean of 36 years old. There is evidence that participation may be higher among nurses over 40 years of age (Kurnat-Thoma et al., 2017), suggesting that employers consider age-targeted wellness programs and activities. Significant improvements in health and well-being and reductions in stress and burnout among healthcare workers was achieved following a workplace stress-reduction program (Sallon et al., 2017). Periodic unit quiet time (Riemer et al.,

2015), building humor competency among staff (Fang et al., 2019), and mindfulness practices (De Cieri et al., 2019) have all been shown to reduce nurse workplace stress. Availability of such stress-reducing programs was reported to be low in our study. In the case that workplace stress reduction programs are unavailable, there are other effective ways for nurses to facilitate their own well-being, such as a web-based stress reduction programs (Hersch et al., 2016), (Lamke Jin Shin Jyutsu et al., 2014), building positive nurse-colleague relationships to improve compassions satisfaction (Balinbin et al., 2019), and other suggestions made by the participants in this study and in the literature (Contreras Sollazzo & Esposito, 2020).

Conclusion The overarching purpose of this study was to assess the stress level among nurses on medical-surgical units prior to contract implementation of better nurse-to-patient ratios for comparison post implementation in ten NYSNA represented facilities. Aspects of staffing and the work environment as sources of stress were identified and stratified. Poor physical, mental and sleep health were frequently reported by this sample of nurses who generally experienced elevated levels of work stress and inadequate staffing conditions. It is anticipated that implementation of contractually agreed upon staffing improvements will facilitate a self-reported reduction in workplace stress, burnout, depression, and compassion fatigue. Safe staffing is about providing the right amount of care at the right time and for the right reasons. Measures of various kinds of nursing stress, burnout, depression, and compassion fatigue serve as litmus tests to the technical, ethical, civil, and compassionate nature of healthcare delivery. Nurses’ unions are in the position to recognize worker needs and improve staffing, while reducing stress, burnout, depression, and compassion fatigue, and thereby supporting improvements in patient outcomes and the success of health systems.

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Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue

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Journal of the New York State Nurses Association, Volume 47, Number 2

THE

JOURNAL of the New York State Nurses Association

Call for Papers

Call for Editorial Board Members

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

Help Promote Nursing Research

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.

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.

Journal of the New York State Nurses Association, Volume 47, Number 2

n WHAT’S NEW

IN HEALTHCARE LITERATURE n The CURES Act n U.S. Department Health & Human Services. (2020, October). HHS extends compliance dates for information blocking and health IT certification requirements in 21st Century Cures Act final rule. https:// www.hhs.gov/about/news/2020/10/29/hhs-extends-compliancedates-information-blocking-health-it-certification-requirements-21stcentury-cures-act-final-rule.html

6. pathology report narratives

One aspect of the 21st Century CURES Act passed in 2016 requires that patients be provided access to all the health information in their electronic medical records without charge by their healthcare provider. Clinical notes must be shared by health systems with patients by April 5, 2021, and shared with a patient’s third-party application (e.g., a smart phone download) by October 6, 2022.

1. Psychotherapy notes recorded (in any medium) by a healthcare provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual’s medical record (Note: Clinicians and organizations are required to share medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date.)

The eight (8) types of clinical notes that must be shared are outlined in the United States Core Data for Interoperability (USCDI), and include: 1. consultation notes 2. discharge summary notes 3. history & physical

7. procedure notes 8. progress notes Clinical notes to which the rules do not apply include:

2. Information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding

4. imaging narratives 5. laboratory report narratives

n Remdesivir Effective, Well-Tolerated in Final Trial Report n Bosworth, T. (2020, October). Remdesivir effective, well-tolerated in Final trial report. Medscape Medical News. https://www.medscape. com/viewarticle/938940 A large multinational clinical trial has confirmed results from a previous study, showing that Remdesivir is a safe and effective antiviral drug that shortens the recovery time from COVID-19 infection. The mechanism of action for this intravenously available drug is to bind to the viral RNA polymerase (the enzyme responsible for transcribing an RNA sequence), thereby blocking viral replication. Findings from the placebo-controlled ACTT-1 trial are published in the New England Journal of Medicine. Remdesivir shortened average recovery time by a third, from 15 days to 10 days. It increased the chances of a providing significant clinical improvement by 50% by day 15, adjusting for factors such as baseline severity, initial length of stay, and fewer days on supplemental oxygen for the subgroup of patients who required oxygen at enrollment.

Participants from North America, Europe, and Asia included hospitalized patients with severe disease. While Remdesivir appeared to lower mortality, that effect did not yet achieve statistical significance. Adverse effect rates were comparable between the placebo and Remdesivirtreated groups of patients. Scientists agree that Remdesivir’s significant advantage over placebo supports the FDA’s current indication for use in treatment for all hospitalized COVID-19 patients. The article describes how benefits of Remdesivir treatment extend beyond the patient allowing resource conservation. Shorter, less severe hospital courses reduce exposure to the healthcare workers treating the patient, reduce the demand for PPE, increase availability of ICU beds, and reduce medical costs. Source: Beigel, J.H., et al. (2020). Remdesivir for the treatment of COVID-19—final report. New England Journal of Medicine, 383,1813–1826 https://doi.org/10.1056/NEJMoa2007764

Journal of the New York State Nurses Association, Volume 47, Number 2

n Convalescent Blood Plasma Safe, Effective for Covid-19 n Lynch, P. (2020, October). Convalescent blood plasma safe, effective for COVID-19. Medscape Medical News. https://www.medscape. com/viewarticle/938794

Convalescent plasma composition may vary from person to person. The kind considered effective for treatment contains sufficient antibody level and antibodies specific to the SARS-CoV-2 antigen.

At the time of this writing, convalescent blood plasma has been in use as a relatively safe, low-tech, cost-effective, and readily deployable treatment for COVID-19. The article holds that it should be more widely used because it has advantages over other kinds of treatment as an antiviral, by reducing inflammation. It was the first therapy demonstrated to very significantly lower mortality prior to ICU admission if given early enough to patients with COVID-19.

Professor Arturo Casadevall, a researcher from Molecular Microbiology and Immunology at the Johns Hopkins Bloomberg School of Public Health, advocates for bringing attention to and expanding the use of convalescent plasma. Recently working on two large clinical trials studying convalescent blood plasma for COVID-19 treatment and prophylaxis, he points out that current challenges are to determine when and how to use this kind of treatment effectively.

n Don’t Use N95 Masks for More Than 2 Days, Research Suggests n Hein, I. (2020, November). Don’t use N95 masks for more than 2 days, research suggests. Medscape Medical News. https://www.medscape. com/viewarticle/940168 A small study on N95 respirator reuse by healthcare workers in a trauma unit was conducted by a physician at St. Luke’s University Hospital in Bethlehem, Pennsylvania. Study participants had been fit tested and assigned a mask for use at work. Using the Occupational Safety and Health Administration qualitative fit-test guidelines, fitness was checked at intervals throughout workers’ shifts over five days.

Investigators initially found that more than half of the masks failed by their third day of use, with 9% failing in day 1. When they repeated the study using a larger number of participants and a total of 115 masks, results were similar. After two days of use, the odds ratio for failure was 7.1 (95% CI [2.5-20], p < .0001). The worldwide shortage of N95 masks prompted the CDC to create a protocol for reuse. This study demonstrates that safe reuse cannot be relied upon and calls for hospitals to increase their supply of N95s and the use of reusable respirators such as elastomerics.

Journal of the New York State Nurses Association, Volume 47, Number 2

n CE Activity: Variations in Healthcare Professionals’ “Ending the

Epidemic” Training Needs and Experiences: Findings From a New York State Needs Assessment

Thank you for your participation in “Variations in Healthcare Professionals’ ‘Ending the Epidemic’ Training Needs and Experiences: Findings From a New York State Needs Assessment,” a new 1.0 contact hour 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.

workforce to assess their knowledge of the ETE plan, HIV testing law, and preferences for additional training. Following this, they developed education materials to prepare a knowledgeable and skilled healthcare workforce for ETE success. Their assessment methods and findings are shared, encouraging all healthcare workers, particularly nurses, to participate in their free courses and trainings related to HIV/AIDS, HCV, STI, and care of substance users

INSTRUCTIONS In order to receive contact hours 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 out to NYSNA or credit card. The completed answer sheet and evaluation form may be mailed or faxed back to NYSNA; see the evaluation form directions 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 Contact Hour through the New York State Nurses Association Accredited Provider Unit. The New York State Nurses Association is accredited by the International Association for Continuing Education and Training “IACET” and is authorized to issue the IACET CEU. The New York State Nurses Association is authorized by IACET to offer 0.1 CEUs for this program. In order to receive CHs/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 was received for this educational activity. All planners/authors involved with the development of this independent study have declared that they have no vested interest. NYSNA Program Planners and Authors declare that they have no conflict of interest in this program. INTRODUCTION In 2014, New York State (NYS) Governor Andrew Cuomo commenced the plan Ending the Epidemic (ETE) to halt the HIV/AIDS epidemic in New York State and prioritize testing, prevention, and treatment strategies for hepatitis C virus (HCV) and other sexually transmitted infections (STIs). This bold national plan was the first of its kind. At the time, New York had been identified as a "hot spot" for the HIV/AIDS epidemic. The NYS Department of Health AIDS Institute Clinical Education Initiative (NYS CEI) surveyed clinicians and non-clinicians within the healthcare

Learning Outcome Participants will identify 2 barriers to the timely care and treatments of people infected with HIV/AIDS, and how the New York States Needs Assessment evaluated the capacity of the workforce to deliver services to improve health outcomes related to HIV. OBJECTIVES By completion of the article, the reader should be able to: 1. Identify the significance of the HIV/AIDS epidemic in New York State. 2. Identify goals and support for HIV/AIDS, HCV, and STIs risk reduction. 3. Identify the role and resources of the NYSDOH AIDS Institute to address barriers to timely care and treatment of patients with HIV/AIDS. 4. Identify findings of the Needs Assessment Survey (REDCap). 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 contact hours for this program will be offered until December 30, 2023. 1) Familiarity with pre- and post-exposure prophylactic therapies differed significantly between NYS clinician and non-clinicians. a. True b. False 2) In 2014, nearly 113,000 people were living with HIV/AIDS, in New York State, making it a national “hot spot” for the disease. a. True b. False 3) The goal of the New York State Ending the Epidemic (ETE) plan is to keep the epidemic of HIV/AIDS and STIs stable through 2020. a. True b. False

Journal of the New York State Nurses Association, Volume 47, Number 2

4) According to the REDCap survey performed by the Department of Health AIDS Institute Clinical Education Initiative team, non-clinicians, such as administrators and social workers, reported having similar levels of knowledge about New York State’s HIV testing law and the governor’s ETE plan to those of clinicians, such as physicians, nurse practitioners, and nurses. a. True b. False 5) Having a workforce of healthcare providers who lack knowledge or skills to prevent, test, and treat HIV/AIDS is not a barrier to care and treatment of those with or at risk of infection.

8) The NYSDOH AIDS Institute’s proposed actions and priorities include early HIV detection and viral suppression, prevention, screening, and treatment for STIs, HIV, and HCV, along with interagency collaboration to improve drug user health. a. True b. False 9) Most REDCap survey respondents did not report having training on topics related to HIV, HCV, and STIs within the past year. a. True b. False

a. True b. False 6) Non-clinicians work with a larger proportion of priority populations compared to clinicians and have strong preference for training in almost all topics related to HIV/AIDS.

10) A greater percentage of clinicians reported they screen/test patients for HIV, HCV, or STIs, than non-clinicians. a. True b. False

a. True b. False 7) The Clinical Education Initiative (CEI) is a NYS Depart of Health Aids institute program that provides training for the healthcare workforce to support patient’s health outcomes. CEI supported the ETE program by analyzing workforce education needs and tailoring various educational material accordingly. a. True b. False

Journal of the New York State Nurses Association, Volume 47, Number 2

The Journal of the New York State Nurses Association, Vol. 47, No. 2

Answer Sheet Variations in Healthcare Professionals’ “Ending the Epidemic” Training Needs and Experiences: Findings From a New York State Needs Assessment Note: The contact hour for this program will be offered until December 30, 2023. 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: NYSNA Member # (if applicable):

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

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: Name:

Expiration Date:

Signature:

CVV# Date:

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

1._________ 2._________ 3._________ 4._________ 5. _________

6._________ 7._________ 8._________ 9._________ 10._________

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

Journal of the New York State Nurses Association, Volume 47, Number 2

Learning Activity Evaluation

Variations in Healthcare Professionals’ “Ending the Epidemic” Training Needs and Experiences: Findings From a New York State Needs Assessment 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?

Journal of the New York State Nurses Association, Volume 47, Number 2

n CE Activity: Developing an Innovative Psychiatric-Mental Health

Nurse Practitioner Program to Meet Current Mental Health Needs

Thank you for your participation in “Developing an Innovative Psychiatric-Mental Health Nurse Practitioner Program to Meet Current Mental Health Needs,” a new 1.0 contact hour continuing education (CE) activity offered by NYSNA. NYSNA members and non-members 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 contact hours 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.

numbers of sufficiently trained mental health providers in the United States and in New York State may be improved through innovative curriculum development tailored to societal and professional needs. Mental health conditions among child, adolescent, and geriatric populations, the high prevalence and special needs of those suffering from substance use disorder, and the fact that nearly 20% of the United States population exceeds the capacity for adequate treatment are all impetuses to action. To address the need for mental health services, as well as the need for comprehensive training, one university took on many challenges and successfully developed a new master’s degree curriculum, Learning Outcome

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

Participants will be able to identify two significant changes in societal needs that can be addressed through the development and implementation of an innovative psychiatric-mental nurse practitioner graduate program.

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.

OBJECTIVES

This program has been awarded 1 Contact Hour through the New York State Nurses Association Accredited Provider Unit. The New York State Nurses Association is accredited by the International Association for Continuing Education and Training “IACET” and is authorized to issue the IACET CEU. The New York State Nurses Association is authorized by IACET to offer 0.1 CEUs for this program. In order to receive CHs/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 was received for this educational activity. All planners/authors involved with the development of this independent study have declared that they have no vested interest. NYSNA Program Planners and Authors declare that they have no conflict of interest in this program. INTRODUCTION Given increases in substance use disorders, and geriatric, child, and adolescent mental health demands, there is a critical need to expand access to mental health care throughout the United States and especially in New York State. One pathway to sufficient mental health care is through master’s degree curriculum development for advanced practice registered nurses (APRNs). Nurses working in academia require knowledge of how they may develop or modify APRN curriculum. Potential mental health nurse practitioner students would be empowered to decide upon a school that would prepare them to meet the current needs of society. The deficit in

By completion of the article, the reader should be able to: 1. Identify societal changes calling for a different training for advanced practice psychiatric-mental health nurse practitioners (PMHNPs). 2. Identify the challenges to developing an innovative PMHNP graduate program. 3. Differentiate the stages of the development of an innovative PMHNP program. 4. Identify what challenges were faced in the development of an innovative PMHNP program. 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 contact hours for this program will be offered until December 30, 2023. 1) Societal changes influencing the demand for specially trained psychiatricmental health nurse practitioners (PMHNPs) include the opioid epidemic and a plethora of available mental health providers. a. True b. False 2) The number of students enrolled in psychiatric-mental health programs decreased while graduation rates increased between 2014–15. a. True b. False

Journal of the New York State Nurses Association, Volume 47, Number 2

3) The literature suggests that a blended approach to many psychiatric ailments includes medication, psychotherapy, and other treatment modalities, but that PMHNPs often do not provide such comprehensive care. A master’s program curriculum can ensure these competencies are developed in participating students. a. True b. False 4) A challenge faced by the nursing department was in finding clinical placements where students practice psychotherapy skills and learn to treat patients across the lifespan (child, adolescent, geriatric). In time, graduates will help to sustain the program as they serve as preceptors. a. True b. False 5) Competencies and models recommended by the American Psychiatric Nurses Association (APNA) and National Organization of Nurse Practitioner Faculties (NONPF) served as the guiding framework of the designed graduate program. a. True b. False 6) State limitation of prescriptive privilege for advanced practice nurses contributes to fragmentation of care. a. True

7) Analysis of information on mental health services and providers, collaboration among expert faculty in psychiatric mental health nursing, building consensus on program priorities, and administrative support were critical to program development. a. True b. False 8) The program prepares nurses to work in a variety of community settings and professional roles, and provides clinical and psychotherapy training to prepare PMHNPs to care for patients in both routine and acute crises situations. a. True b. False 9) Students are admitted and progress through the program as a cohort. This model fosters team building and leadership development. a. True b. False 10) The APNA advocates for expanding the role and numbers of PMHNPs as a way to better serve national mental health needs. a. True b. False

b. False

Journal of the New York State Nurses Association, Volume 47, Number 2

The Journal of the New York State Nurses Association, Vol. 47, No. 2

Answer Sheet Developing an Innovative Psychiatric-Mental Health Nurse Practitioner Program to Meet Current Mental Health Needs Note: The contact hour for this program will be offered until December 30, 2023. 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: NYSNA Member # (if applicable):

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

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: Name:

Expiration Date:

Signature:

CVV# Date:

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

1._________ 2._________ 3._________ 4._________ 5. _________

6._________ 7._________ 8._________ 9._________ 10._________

Journal of the New York State Nurses Association, Volume 47, Number 2

Learning Activity Evaluation

Developing an Innovative Psychiatric-Mental Health Nurse Practitioner Program to Meet Current Mental Health Needs Please use the following scale to rate statements 1-7 below:

Poor

Fair Good

Very Good Excellent

____ 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?

Journal of the New York State Nurses Association, Volume 47, Number 2

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