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TEXASNURSING M A G A Z I N E
MENTAL HEALTH
A CALL TO NURSING AWARENESS + ACTION TRANSITION TO PRACTICE POLARITY IN LEADERSHIP
T N A : E m p o w e r i n g Te x a s N u r s e s t o a d v a n c e t h e p r o f e s s i o n | S p r i n g 2 0 1 7
SPRING 2017 Volume 91, Number 2 EDITOR-IN-CHIEF: Cindy Zolnierek, PhD, RN MANAGING EDITOR: Kat Hinson 8501 North MoPac Expressway, Suite 400, Austin, TX 78759-1292 P: 800.TNA.2022 or 512.452.0645; F: 512.452.0648 tna@texasnurses.org | texasnurses.org
MISSION Empowering Texas Nurses to advance the profession
BOARD of DIRECTORS OFFICERS: Jeff Watson, DNP, RN-BC, NEA-BC, NE-BC, CRRN, President Kim Belcik, PhD, RN-BC, CNE, Vice President Terry Throckmorton, PhD, RN, Secretary Sarah Moody, DNP, RN, NEA-BC, Treasurer REGIONAL DIRECTORS: Rhonda Winegar, DNP, RN, FNP-BC, CCRN, CPN, Central Tamara “Tammy” Eades, DNP, MSN, RN, North Pam Greene, PhD, RN, South Patricia “Pat” Morrell, DNP, RN, NEA-BC, East Patty Esposito, MSN, RN, NEA-BC, West EXECUTIVE DIRECTOR: Cindy Zolnierek, PhD, RN
TNA DISTRICT AND PRESIDENT
VISION Nurses Transforming Health TEXAS NURSING (ISSN 0095-36X) is published quarterly – Winter, Spring, Summer, Fall – by the Texas Nurses Association, 8501 N. MoPac Expy., Ste 400, Austin, TX 78759-8396 Periodical Postage is paid in Austin, Texas. One-year subscriptions: $25 (nursing schools, libraries, hospitals, non-nurses, out-of-state nurses) foreign, $30; single copy, $2.50. Subscription is not available to non-member Texas nurses. Some back issues may be viewed online at texasnurses.org. PUBLISHING PARTNER Monarch Media & Consulting, Inc. P: 512.680.3989 or 512.293.9277; F: 866.328.7199 monarchmediainc.com | chellie@monarchmediainc.com Advertising inquiries call Chellie Thompson at 512.293.9277. TEXAS NURSING is indexed in The Cumulative Index to Nursing and Allied Health Literature and in the International Nursing Index. 16mm, 35mm microfilm, 105mm microfiche, article copies available from University Microfilms International: 1.800.521.3044 Statements of fact and opinion are made on the responsibility of the authors alone and do not imply an opinion on the part of the officers or the membership of TNA. POSTMASTER Send address changes to TEXAS NURSING, 8501 North MoPac Expy., Suite 400, Austin, TX 78759-8396 ARE YOU MOVING? Need to change your address? If so, provide it quickly and easily in the Members Only section of the TNA web site, texasnurses.org. Or mail us your new address — at least six weeks prior to your move — to Texas Nurses Association headquarters. We’ll make sure your TEXAS NURSING makes the move with you. FEEDBACK EMAIL OR LETTER GUIDELINES TEXAS NURSING will select emails/letters on the basis of readership interest and relevance to current nursing/health care events. TEXAS NURSING reserves the right to edit all letters. Guide: Limit to 200 words; focus on single issue; include writer’s name, mailing address, and daytime phone. Send to: editor@texasnurses.org.
Dist.1:
Paula Meagher, 915-831-4530, pmeagher@epcc.edu
Dist. 2: Sharon Brewer, 806-414-9336, sharon.brewer@ttuhsc.edu Dist. 3: Elaine Nelson, 682-518-0819, elainenelson@texashealth.org; District office: 817-249-5071, tna3@usapathway.com, tna3.org Dist. 4: Jeanie Zelanko, 972-270-4691, zelanko@sbcglobal.net; District office: Pat Pollock, P.O. Box 764468, Dallas, TX 75376; 972-435-2216; d4tna@flash.net; tnad4.org Dist. 5: Matthew Davis, 413-841-1319, MatthewDavisRN@gmail.com, tna5.org Dist. 7: Naomi Devers; District office: P.O. Box 132, Belton, TX 76513, tnadistrict7@gmail.com Dist. 8: Linda Juenke, 830-739-7028, ljsoaringeagle3@gmail.com Dist. 9: Cheryl Lindy, 281-883-8229, cmlindy@earthlink.net; District office: Melanie Truong, 7324 Southwest Freeway, Suite 2-1453, Houston, TX 77074; 713-523-3619; tna9@tnadistrict9.com; tnadistrict9.com Dist. 10: Anita Farrish, 254-421-9797, anitafarrish2001@yahoo.com Dist. 11: Daria Close, 940-867-1134, daria.close@mwsu.edu Kathleen Williamson, 940-397-4610, Kathleen.williamson@mwsu.edu Dist. 12: Heidi Wolf, 409-853-5900, HWolf@iasishealthcare.com Dist. 13: Nannette Kelley, nannettekelley@msn.com Dist. 14: Eloisa Tamez, 956-882-5079, eloisa.tamez@utrgv.edu Dist. 15: Andrea Kerley, 325-670-4230, akerley@hendrickhealth.org Dist. 16: Vacant Dist. 17: Cindy Keese, 361-332-1643, cakeese@aol.com Dist. 18: Pat Francis Johnson, 806-743-2730, ext. 237, patricia.francis@ttuhsc.edu Dist. 19: Karen Koerber-Timmons, 903-452-3004, ktimmons@uttyler.edu Dist. 20: Deborah Peña, 361-570-0356, debbie.pena@victoriacollege.edu Dist. 21: Jessica Tully, 432-254-1949, jessica.tully@midland-memorial.com Dist. 22: Toni McDonald, 936-544-8823, t.mcdonald323@yahoo.com Dist. 26: Elizabeth Adamson, 956-362-3015, e.adamson@dhr-rgv.com Dist. 28: Jessica Smallwood, 903-280-2071, jessicasmallwood@me.com Dist. 35: Chrystal Brown, 903-434-8302, cbrown@ntcc.edu Dist. 40: Contact TNA, 800-862-2022, ext. 129, brichey@texasnurses.org
Copyright 2017 © Texas Nurses Association
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TRANSITION TO PRACTICE
MENTAL HEALTH
12
POLARITY
A CALL TO NURSING AWARENESS + ACTION
8
COVER: photo courtesy iStock
Leadership & Managing Unsolvable Problems
15
5
6
16
18
24
PRESIDENT’S NOTES
TNA MEMBER NEWS
22
2017 HOUSE OF DELEGATES
TNA COMMITTEE ACCOMPLISHMENTS
The Cusp of Transformation
Kudos and Announcements
NURSES: STRENGTH IN NUMBERS
Starting Conversations that Matter
2017 House of Delegates Features TNA Committee Posters
2017 TEXAS NURSING LEADERSHIP CONFERENCE
TNA's 2017 Nurse Day
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President’s Notes Jeff Watson, DNP, RN-BC, NEA-BC, NE-BC, CRRN
THE CUSP OF TRANSFORMATION A FEW YEARS AGO, I came across some historical information regarding the early work of a hospital engaged in AIDS care. We know that San Francisco and New York City were the two hardest-hit metropolitan areas in the country when the AIDS epidemic started in the early 1980s. Hospitals in those areas were overrun with cases. The nurses at San Francisco General Hospital found themselves in the middle of a crisis and on the cusp of transformation. All throughout the acute care units of the San Francisco General, Psychiatric Clinical Nurse Specialist Cliff Morrison, RN, saw the tangible outcroppings of AIDS-related fear: limited caregiver availability, delayed delivery of medications, nutrition, and hydration, reduced human contact, etc. Those images created urgency in Morrison and other like-minded caregivers — they knew they had to approach this evolving crisis differently. They began to have meaningful conversations about the disturbing care they were witnessing. They collaborated to design a holistic model of care for the population before them. As a result, Cliff Morrison, RN, became the first nurse leader of the first AIDS unit in the United States (Online Archive of California [OAC], 2017). Ward 5B was a 12-bed unit fully dedicated to the care of individuals who, at the time, were diagnosed with AIDS and in the final stages of life. It was not intended to be operated from the traditional medical hierarchy — the unit was nurse-led, and included an all-RN staff. Abandoning traditional restrictive hospital rules, they reached out to community volunteer services to help with the overwhelming routine of daily care. Together, they successfully returned
dignity to each individual with AIDS and, in turn, transformed care and health in their community and eventually, around the world1. The work of Morrison and his team helped create what is known as the San Francisco Model of care1. A plaque to honor the work of nurses, physicians, and the community crushed by the virus sits inside Zuckerberg San Francisco General Hospital:
THE FIRST AIDS WARD On July 25, 1983, here on Ward 5B, a group of caregivers gathered to confront a new epidemic: AIDS. They created a haven of acceptance and compassion at a time when others called for isolation and rejection. They saw fellow human beings where others saw only contagion and disease. With the volunteer participation of a generous, loving community, they developed an internationally-renowned center of excellence committed to quality care for the living and the dying. The words from the inscription above cause me to reflect often. “They created a haven of acceptance and compassion at a time when others called for isolation and rejection. They saw fellow human beings where others saw only contagion and disease.” We live in a much different world than Morrison and his team of nurses who started this unit in 1983. And, yet, no single generation holds the market on isolation, rejection, contagion, and disease. The work on Ward 5B is not insignificant to us today. As you look into your community of practice and around the
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communities in which you live — in the places where you eat, sleep, work, play, and pray — are there tangible signs of a population in need? What do you need to be empowered to step into this work? Is it time to revisit acceptance and compassion? Is it time to stop worrying about external drivers of nursing practice and focus on real, lasting human relationships in bringing transformation to the health of our cities and rural spaces? As professional Registered Nurses in Texas, each of us has the capacity to identify and bring resolution to the needs that present to us right where we live. I have great hope that the annals of history will record our willingness to step forward to honor our common humanity and respect for human dignity. Who knows? Decades from now, some freshfaced nurses may look back and say, “Wow! Look at how those RNs from the Texas Nurses Association transformed health all across the state!” Let’s begin with conversations that matter. — Jeff i
REFERENCE: 1. Online Archive of California (2017). Finding aid to the San Francisco general hospital AIDS ward 5B/5A archives, 1983-2003. Retrieved from www.oac.cdlib. org/findaid/ark:/13030/c8bc3x0q/
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TNA MEMBER NEWS SPOTLIGHT ON YOU
KUDOS Dr. Barbara Cherry, DNSC, MBA, RN, NEABC, professor and department chair for leadership studies at the Texas Tech Health Sciences Center, was the recipient of the 2016 Texas Organization of Nurse Executives Excellence in Leadership Award. Her research areas are workforce issues in long-term care facilities and the use of technology in the caregiver role with funding from the National Science Foundation to investigate how robots can be designed to serve in the caregiver role. Her proudest scholarly achievement is being co-author and editor of “Contemporary Nursing: Issues, Trends and Management,” with the 7th edition published in 2016.
Dr. Susan McBride, PhD, RN-BC, CPHIMS, (above left) and Dr. Mari Tietze, PhD, RN, (above right) of Texas Women’s University were given the distinction of having authored the American Journal of Nursing Book of the Year. The title of the book is “Nursing Informatics for the Advanced Practice Nurse: Patient Safety, Quality, Outcomes, and Interprofessionalism.” The authors have been notified that it is in use by MD Anderson Cancer Center, Mount Sinai Beth Israel
Hospital in New York City and Vanderbilt. Springer Publishing indicated that the book was their most widely adopted graduate nursing textbook last year.
among nine faculty members in the JoAnne Gay Dishman School of Nursing at Lamar University who were awarded the Texas Organization for Baccalaureate and Graduate Nursing Education (TOBGNE) Excellence in Research Award. They were honored for their research analyzing the effects of mindfulness meditation on anxiety levels in BSN students. The prestigious Teaching Innovation Award is presented annually by the Texas organization for innovations in teaching and excellence in research.
ANNOUNCEMENTS
TNA members Eileen Deges Curl, PhD, RN, CNS; Iva Hall, MSN; Cindy Pipkins, MSN; Cindy Stinson, MSN, CNS, RNC; and Kelli White MSN, RN-BC were
"Are you receiving Check-up? If not, email us at TNA@texasnurses.org. Don't miss an issue!"
If you are a Texas Nurses Association member and you’ve changed employers, been promoted, received an award, or been elected or appointed to a board or community organization, we’d like to hear from you. Notices printed in the TNA News section are limited to members of the Texas Nurses Association and are printed at no cost. Information must be submitted in writing, is subject to editing, and will be printed as space is available. The TNA News section does not include information on papers, speeches (unless they are of national stature), CNE presentations, or political announcements. Announcements for TNA News should include all pertinent information including employer name, email, and contact numbers. Photos are welcome, but must be 300 dpi (high resolution) at a size of at least 3” x 4”. Send submissions to editor@texasnurses.org.
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MAY IS MENTAL HEALTH MONTH: A CALL TO NURSING AWARENESS AND ACTION By Carson Easley, MS, RN, Director of Nursing, The Harris Center for Mental Health and IDD, Chair, TNA Mental Health Workgroup
RECOGNIZED IN THE UNITED STATES SINCE 1949, Mental Health Month (May) was initiated by Mental Health America (MHA) and is promoted by MHA and its affiliate associations across the country. MHA remains a recognized resource for mental health awareness education, programs, and tools geared toward community education. At the time of the initiation of Mental Health Month, psychiatric/mental health (PMH) nursing practice was considered
a specialty whereby nurses received training post licensure. In the mid-1950s, PMH concepts became a requirement for all nursing education programs. However, nursing education has not been consistent in the availability of either clinical learning opportunities or experienced PMH faculty. For the purpose of this article, the impact of unrecognized/untreated depression will be explored. Depression is often comorbid with chronic disease states,
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meaning that patients experiencing mental illness also have medical diagnoses such as heart disease, hypertension, diabetes, obesity, cancer, etc. Those experiencing mental illness in conjunction with another diagnosis die at an earlier rate than the general population with these diagnoses, and this is especially true for those diagnosed with schizophrenia. Many times patients do not recognize that the feelings of sadness, loss, and/ or hopelessness may be stemming from
Missed opportunities occur when members of the healthcare team fail to actively engage and identify patients presenting with depression or who may be at risk for suicide. (See sidebar discussion of a practice innovation implemented by Parkland Hospital to screen patients for suicide risk at multiple entry points into the healthcare system with the goal of suicide prevention.) An alarming nationwide trend is the increased rates of suicide, a public health issue that impacts society for all ages, races, and ethnicities. Statistics show that annual suicide rates are more than two times the rate of homicides. Many of the persons who die by suicide have come in contact with a healthcare professional in the year preceding death. Depression is often undiagnosed, untreated, or unreferred for consultation in acute healthcare settings. Rarely does the discharge plan include recommendations for follow-up with a mental health professional. When untreated, depression has a high correlation with suicide — both attempts and deaths. For those who unsuccessfully attempt suicide, an opportunity arises in hospitalizations that may result in life-changing outcomes that impact individuals, families, and communities. The Healthy People 2020 project re-
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The American Psychiatric Nurses Association (APNA), the organization that represents PMH nursing, has published a position statement, “Whole health begins with mental health” (2017). The statement declares that health is more than an absence of illness and that mental health is foundational to overall health and well-being. This aligns with the Robert Wood Johnson Foundation's pioneering efforts to advance a culture of health. The action framework for this work is based on the World Health Organization's (WHO) definition of health as “a complete state of physical, mental, and social well-being, and not merely the absence of disease or infirmity” (WHO, 1948). Mental health is an essential element of whole and complete health.
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depression. More often than not, persons with chronic medical conditions, who may also have symptoms of depression, are not assessed for depression. It is safe to say, if it is not assessed, it is not addressed.
THE PARKLAND EXPERIENCE DEATH BY SUICIDE in the US is on the rise, increasing 24 percent between 1999 and 2014. Now the 10th leading cause of death in the US, outnumbering traffic fatalities, data shows that 77 percent of people who die by suicide had an encounter with a primary care provider in the year prior to death, and 40 percent saw an emergency department provider in the year before their death. These data indicate there is an important opportunity to identify persons at risk for death by suicide and taking appropriate preventive action. Celeste Johnson, DNP, APRN, and vice president of nursing, behavioral health at Parkland Hospital and Healthcare System, recently updated the TNA Mental Health Work Group on an initiative to use every patient encounter as an opportunity to identify persons at risk for suicide. Parkland implemented the universal suicide risk assessment program in 2015, first in the emergency department and then in other areas of the hospital. As of December 2016, Parkland Hospital staff completed over 1 million screenings for suicide risk. Working with their electronic health record vendor, staff incorporated two valid and reliable screening tools into patient documentation: the Columbia-Suicide Severity Rating Scale for adults
leased by the U.S. Department of Health and Human Services outlines health issues that are high risk to the public’s health. It is noteworthy that suicides and adolescent depression are listed as two
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and the Ask Suicide-Screening Questions to identify at-risk youth. In the first year of this program, six percent of patients were found to be at high risk or moderate risk. High-risk patients are placed under suicide precautions including one-on-one supervision and are evaluated by a behavioral health clinician. Patients identified at moderate risk are automatically referred to a psychiatric social worker and are usually seen during the same visit. If the patient prefers not to speak with a social worker during the hospital stay, the patient receives a follow-up phone call for support and resources. Although it is too soon to estimate the number of lives saved with this program so far, quick math reveals compelling numbers: the two percent of persons at highest risk equates to 20,000 people. That means the Parkland staff are identifying a person at high risk on average every 30 minutes, or 54 people per day. Because this screening assessment has been built into the workflow, Johnson notes that this initiative has not resulted in care delays. In addition to saving lives, this important program provides patients with the support and counseling they need but may not have received without the screening assessment.
of the 26 Leading Health Indicators (LHIs) that pinpoint determinants of health promotion, quality of life, and healthy continued on page 10
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behaviors. This falls under mental health, which is one of the 12 topics identified as high-priority health issues. For many healthcare systems, it is assumed that once physical medical symptoms are under control, the patient’s affect will improve. Healthcare literature regarding patients with heart disease finds there is a strong correlation between cardiac heart disease and depression. Patients with chronic health conditions are discharged from acute care settings and often have not been asked during or at the end of their stay any questions reflective of their mental health status or their feelings regarding their condition, feelings of sadness, or if they are hopeful for the future. Reports in the medical literature reveal that these patients often return to the acute care setting with their medical condition symptoms worse than at discharge. Someone experiencing depression may have challenges adhering to a medical regimen such as taking medications as prescribed, exercising, making and keeping follow-up medical appointments, and following an eating plan that supports an improved state of health. Maintaining a healthy lifestyle is not an easy task even with the best of intentions, but becomes more difficult when dealing with symptoms of depression. Hospitals are recognizing the financial impact of recidivism for patients who fall into this category. The situation above is a prime example of the impact of a mental health condition on symptom management and quality of life for a person experiencing a physical medical condition. The concept of mental health as foundational to all health as stated by APNA requires nurses in all practice settings to have the skills, knowledge, and abilities that enable them to gain competency and become comfortable with integrating PMH concepts and content as part of their assessment and intervention tool kits. New nursing graduates rarely identify PMH as a practice choice within the first two years post-graduation. In Texas, less than 8,000 of the approximate 280,000 registered nurses self-identity their primary practice setting as PMH. Advanced
Practice Registered Nurses whose primary focus is PMH number less than 600. The numbers are daunting in terms of the quantity of nurses with a primary practice focus in PMH, but this can also be seen as a call to action for every nurse in practice to improve their literacy regarding PMH in the areas of assessment, interventions, and knowledge of community resources for patients in any settings.
WHAT CAN NURSES DO? Become advocates for treating/engaging the whole person. Here are some suggested actions: Become informed and knowledgeable regarding the presence and types of mental illnesses prevalent in your community.
Research suicide rates locally and nationally and the populations most at risk — in other words, know the stats for your community and the population served.
Review current screening tools and comprehensive nursing assessments in use to ascertain if the data collected provides the necessary information to determine if there are underlying symptoms of depression with a risk for suicide.
Become knowledgeable regarding standardized rating scales for depression that are populationspecific and can be employed in a variety of healthcare settings. Such tools can be found for child/adolescent, adult, and geriatric patients.
Establish an information database for resources and PMH tools.
Engage nursing leadership to develop a plan of action.
Initiate training programs to increase awareness and knowledge of mental health issues and methods for practice integration.
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Establish an organizational cultural norm for all patients to be screened and assessed for depression and suicide ideation. When it is the norm, just like taking blood pressures, stigma is reduced. Gain knowledge regarding what
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other healthcare entities are doing, such as the Parkland Algorithm for Suicide Screening (PASS) initiative.
Develop community partners who can collaborate and support the initiative and may be employed for consultations in-hospital and post discharge.
Engage members of the healthcare team and stakeholders at all levels of the healthcare system. Inform them of the public health issue and community impact of deaths by suicide as well as the role the system can take in prevention.
Nurses have the training, but like with any skill, if not used, the knowledge becomes stored away. A few of the many attributes for which the profession is recognized are communication skills, patient education abilities, and most importantly, patient advocacy. So you are more than halfway there in taking the lead in your practice setting to support equity for mental health as a driver for treating the whole person so that overall health and wellness can be fostered. i
MENTAL HEALTH MONTH RESOURCES Department of State Health Services Texas Suicide Prevention Information on suicide prevention for youth and adults. Mental Health America Advocacy group for mental health focused on early treatment. National Council for Behavioral Health Information on mental health first aid. Suicide Prevention Resource Center Comprehensive prevention resources, including the Zero Suicide initiative to prevent deaths by suicide in health care and behavioral health care systems. American Foundation for Suicide Prevention The American Foundation for Suicide Prevention funds research, provides resources, and raises awareness of suicide prevention. American Psychiatric Nurses Association Information and resources for psychiatric mental health nurses and nurses in any practice setting who encounter persons with mental health conditions.
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TRANSITION TO PRACTICE By Crystal Wilkinson, DNP, RN, CNS-CH, CPHQ Associate Professor of Nursing, Texas Tech University Health Sciences Center
PREPARING NURSES WHO ARE READY for practice is a key concern for nursing faculty, hospitals, and society. Historically there has been a gap between nursing faculty and hospital partners regarding how well new nurses are prepared for practice. In a survey of 400 nursing school deans and 5,700 nurse leaders, 90 percent of the deans thought their students were fully prepared for practice with only 10 percent of nurse leaders in agreement. I recently conducted a focus group as part of a Nursing Innovation Grant Award from the Texas Higher Education Coordinating Board entitled Bridging the Gap: Developing a Competency Assessment Tool to Address Key Issues in Graduate Nurse Transition to Practice. Faculty and hospital leaders agreed that the gap still exists and that nursing students are still not adequately prepared to meet the challenges of the current fast-paced, rapidly changing practice environment. The looming shortage and aging of the current nursing workforce has intensified the concern over practice readiness. The anticipated massive retirement of experi-
enced nurses may soon create a workforce with fewer seasoned nurses than novice nurses. All these factors make the transition from nursing student to a fully responsible professional nurse incredibly daunting. Nursing schools and healthcare employers have a vested interest in ensuring new graduates have a successful launch into the real world of nursing knowing that every graduating student is needed and we cannot afford to lose even one during their critical transition year. So how do we ensure a successful transition? We know that for a graduate nurse, the first year will likely be the toughest. Graduates leave school with the ability to apply nursing knowledge, to think critically, and to reflect upon their practice. But, within weeks, their confidence in their knowledge and skills may be undermined by the overwhelming “real world” demands of a fast-paced work environment. The stressors of the transition year are well documented. In her book, From Surviving to Thriving: Navigating the First Year of Nursing Practice, Judy Duchscher (2012) provides guidance on how new graduates can recog-
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nize and deal with the well-documented “transition shock” and all the physical and emotional responses they may have during this critical time. She stresses selfcare and having a good support system at work and outside of work. An understanding of this first-year phenomenon can help graduates view their transition differently and be better prepared to be successful in the first year and beyond. Decades of research emphasize the importance of residency programs for the successful transition of new nurses. With recent estimates of onboarding costs ranging from $35,000 to $75,000, hospitals recognize the need for a significant return on investment from their residency program in terms of loyalty and retention. Most hospitals have invested in establishing residency programs that continually evolve to meet the needs of the organization and to strengthen their incoming staff. One of the strongest predictors of success for a resident is a structured preceptorship. Many hospitals have strengthened their training programs to provide residents with knowledgeable preceptors who have extensive formal
One of the strongest predictors of success for a resident is a structured preceptorship. Many hospitals have strengthened their training programs to provide residents with knowledgeable preceptors who have extensive formal training and are highly effective in this critical role. training and are highly effective in this critical role. Loyalty and retention has improved with the customization of residency programs that help residents find their ideal position within the organization and continue their education in their chosen specialty. The final predictor of a successful residency is one that allows adequate time for the new graduate to learn, apply knowledge, obtain feedback, and reflect on their development in professional practice. Evidence also exists pointing to workplace environment as a significant factor impacting new graduate transition. Graduates working in a healthy or very healthy work environment experienced less transition shock than those working in less healthy environments. The American Association of Critical Care Nurses (AACN) Standards for Creating and Maintaining a Healthy Work Environment (2016) describes critical features of a healthy work environment: authentic leadership, meaningful recognition, appropriate staffing, effective decision-making, true collaboration, and skilled communication. Implementation of these standards demonstrates an organizational commitment to develop systems, structures, and cultures to create and sustain a healthy work environment to achieve clinical excellence and improve patient outcomes. New graduates can look for clues in the organizational mission and vision statements to identify organizations that create and sustain healthy work environments. These guiding statements should reflect a culture of safety and commitment to high-quality care. Magnet Recognition ® or Pathway to Excellence ® status indicates the organization has formal systems and processes to continually strive for excellence. This includes ensuring nurses are part of decisions that affect nursing practice. Recognized programs continually work on strategies that have a positive influence on the quality and safety of patient care and the satisfaction of both patients
and nurses. Most importantly, new nurses must feel comfortable in their chosen work environment. After all, there is no way to be happy in a work environment, regardless of how well it checks out, unless the environment suits the employee. To help address transition-to-practice issues, the National Council of State Boards of Nursing (NCSBN) embarked on
a project to develop a comprehensive program to assist nurses as they transition from the classroom to the practice setting. They convened a committee that developed an evidence-based transition-to-practice model along with training and a toolkit. Testing of the transition-to-practice model and program elements has demonstrated improved safety and quality outcomes for patients. In addition, improved outcomes — including higher retention rates — were observed during the first year of practice. The study also found new graduates who had a preceptor in their residency felt more confident, had less stress, and were more satisfied with continued on page 14
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their jobs. This standardized program has added to the body of evidence on transition to practice. Nurse graduates can also do much to help themselves transition to their new role. Having a positive attitude and handling themselves with confidence when needed and humility when called for can go a long way to establishing positive working relationships. Holding on to passion for the profession, being willing to learn and accepting feedback can also help new graduates fit in. Remembering that all nurses start as a novice and understanding that there is a steep learning curve can help keep things in perspective. New graduates need to rec-
ognize they are a valuable resource and every graduate is needed in the profession. A shared understanding of the stressors graduate nurses face and the impact of support and a healthy work environment can help strengthen the relationships between those invested in a graduates’ successful transition to practice. We can all harken back to our new graduate experience and remember those who were kind to us and pay that kindness forward. From the perspective of a nursing educator, we are always trying to improve learning opportunities to prepare students for their transition. We are invested in interacting more with our practice partners to better
prepare our students for the work world. We all need to look ahead to a new vision of healthcare that is focused on wellness rather than illness and take advantage of technologies that will make our work more efficient with better outcomes. I always tell my students, “I am training you to take care of me someday, so I want you to be the best you can be!” i
REFERENCES: American Association of Critical-Care Nurses (AACN) (2016). AACN Standards for establishing and sustaining healthy work environments: A journey to excellence (2nd ed). Aliso Viejo, CA: American Association of Critical-Care Nurses. American Nurses Credentialing Center (2014). Magnet Recognition Program ® overview. Retrieved from www.nursecredentialing.org/Magnet/ ProgramOverview/New-Magnet-Model Spector, N., Blegen, M.A., Silvestre, J. Barnsteiner, J., Lynn, M.R., Ulrich, B., Fogg, L. & Alexander, M. (2015). Transition to practice study in hospital settings. Journal of Nursing Regulation, 5(4), 24-38.
Swarwout, E. (n.d.). The benefits of Pathway to Excellence® Designation: How implementing the practice standards can improve nursing care, satisfaction and retention. Retrieved from www. nursecredentialing.org/Pathway/PathwayResources/PathwayBenefitsPDF.pdf Berkow, S., Virkstis, K., Stewart, J., Aronson, S., & Conway, L. (2008). Assessing new graduate nurse performance. Journal of Nursing Administration, 38(1), 468-474. Duchscher, J.E. (2012). From Surviving to Thriving: Navigating the First Year of Professional Nursing Practice. Saskatoon, Canada: Nursing the Future. Moore, L.W., Leahy, C., Sublett, C. & Lanig, H. (2013). Understanding nurse-tonurse relationships and their impact on work environments. Medsurg Nursing, 22(3), 172-179. National Council of State Boards of Nursing (NCSBN)(2013). Transition to practice. Retrieved from https://www. ncsbn.org/2013_TransitiontoPractice_ Modules.pdf Rush, K.L., Adamack, M., Gordon, J., Lilly,, M. & Janke, R. (2013). Best practices of formal new graduate nurse transition programs: An integrative review. International Journal of Nursing Studies, 50, 345-356. Wilkinson, C. & Boyd, E. (2015). Nursing Innovation Grant Award from the Texas Higher Education Coordinating Board. Bridging the Gap: Developing a Competency Assessment Tool to Address Key Issues in Graduate Nurse Transition to Practice. Unpublished raw data.
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PROBLEM TO SOLVE OR A POLARITY TO MANAGE? By Ellen Martin, PhD, RN, CPHQ, TNA Director of Practice
POLARITY MANAGEMENT is a model and set of principles to move beyond problem solving toward innovative thinking about complex, dynamic issues. Polarities were first described by Barry Johnson, PhD, in 1992 as an organizational development model to improve leader effectiveness in identifying and managing unsolvable problems. Polarities represent natural dynamic tensions and are opposite interdependent sides of the same coin. Johnson uses breathing as a classic polarity management process. A person doesn’t solve this polarity by choosing to inhale or exhale; it is a process that requires the benefits and limits of each. The shift from “either/ or” thinking to a “both/and” perspective allows leaders to consider possibilities in a new way.
CONTEXT MATTERS Problems to solve have one right answer if the issue is simple (such as a math problem). More complicated problems may have several right answers that are independent (such as more than one right option for action). In contrast, polarities are ongoing, sometimes chronic situations that don’t have a right answer. Since a polarity is not a problem, it is unsolvable in the traditional way, and attempts to solve it ultimately fail. In polarity thinking, context matters. For example, consider the polarity of activity and rest. While hiking or training for a marathon, it would be appropriate to focus on activity. Similarly, it would be important to focus on rest while recuperating from surgery.
Polarities represent natural dynamic tensions and are opposite interdependent sides of the same coin. THE GENIUS OF “AND” Johnson applied these polarities to the many issues organizations face in times of rapid transformation. The stability and chaos polarity has been evident in numerous industries such as photography and desktop publishing and applies to healthcare organizations today. In this polarity, stability is valued by the “tradition bearers” in the organizations while the “crusaders” fight for change. In many organizations, each of these camps can hinder progress in their own way and many hours in meetings have been spent defending tradition and innovation. These circular arguments are different in every organization but sound something like, “We can’t survive if we don’t change with the times!” and “Well, we don’t want to destroy what we’ve built by going off the deep end!” This is not a problem to solve because there is no right answer. It is a polarity to manage. Well-managed polarities occur when organizations avoid over-focusing on one pole. In “Built to Last,” authors Jim Collins and Jerry Porras looked at the habits of successful companies and described effectively managing organizational dilemmas as “The Genius of the ‘AND’.” Transformational results are possible when leadership shifts from looking for the right answer through either/or thinking and move towards polarity thinking. The concept of polarity management has been applied to transformational change in nursing informatics. The
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Technology Informatics Guiding Education Reform (TIGER) initiative featured a polarity map to describe how leadership can leverage technology to enhance nursing practice. This polarity describes the dynamic tension between “high tech” and “high touch.” Polarity management is useful in numerous contexts relevant to nurses and nursing practice. From work-and-life balance needed for healthy nurses to accountability for individual and team performance, learning to manage polarities can enhance positive relationships and improve outcomes. If you want to learn more about polarities, don’t miss the Leadership Conference on Sept. 28 – 29, 2017, to learn from the expert, Bonnie Wesorick, MSN, RN, DPNAP, FAAN, author of “Polarity Thinking in Healthcare: The Missing Logic to Achieve Transformation.” See the back cover for conference details. i
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NURSES: STRENGTH IN NUMBERS “Nurse Day at the Capitol is an exciting opportunity to absorb the beauty of the Capitol building, mingle with the power-elite, and share experiences with nurse colleagues. The assembled numbers reflects the strength of nurses and disseminates an aura of power.” — Ruth Stewart, MSN, RN, FAAN
THE 85TH SESSION of the Texas Legislature has been an exciting one for nurses. The energy surrounding nursing bills has been palpable. Because of the advocacy efforts of nurses throughout the state, for the first time in history, legislation supporting full practice authority for Advanced Practice Registered Nurses (APRN) was given a hearing.
In one day, nurses met with 120 House and Senate offices to educate staff and legislators on a variety of nursing issues.
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Numerous legislative events were held by TNA, both alone and in conjunction with other organizations. One of the first was in late February when close to 300 Texas nurses gathered for the Texas Nurse Association’s 2017 Nurse Day at the Capitol. A two-day event, attendees first received a briefing on the various nursing issues and bills as well as the basics of how the legislature operates.
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1 During TNA's Nurse Day, nurses received recognition in the form of official resolutions in both the House and Senate. 2 Fun was center stage as nurses played games and assembled a giant puzzle to raise money for Texas Nurse PAC. 3 Government Affairs Committee member Jennifer Cook and TNA Membership Manager Belinda Richey welcomed attendees to the Capitol. 4 Hundreds of nurses visited with lawmakers during Nurse Day at the Capitol. 5 Nurse Day attendees were briefed on nurse-related legislation and capitol protocol prior to visiting with legislators.
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“The enthusiasm from nurses was inspiring,” said Director of Government Affairs Andrew Cates. “During the briefings, nurses were attentive and eager to learn details. That transformed into an energetic band of advocates who could speak competently about the issues affecting their profession.” On the second day, nurses visited with legislators, attended committee hearings, and delivered nursing’s message. An early morning hearing on HB 280 and HB 279 — both authored by Rep. Donna Howard — boasted standing room only! Nurses filled the room and spilled into the hallway. Close to 120 people registered in support of HB 280, and 91 in support of HB 279. In one day, nurses met with 120 House and Senate offices to educate staff and legislators on a variety of nursing issues.
TNA tracked almost 900 bills during the session. These ranged from bills specifically impacting nursing and patient care to those that might inadvertently affect those groups. I actually know what they are talking about regarding committees, house bills, senate bills, etc.” TNA tracked almost 900 bills during the session. These ranged from bills specifi-
cally impacting nursing and patient care to those that might inadvertently affect those groups. Watch future issues of Check-up and Texas Nursing to read the final wrap up. i
Legislative meetings allow nurses the chance to not only educate legislators and their staff on nursing issues, but more importantly, gives them the opportunity to answer questions and clarify misconceptions. “I was pleased to have the schedule and the time with the legislative aides,” said Tonya Taylor, RN. “Nurses have a voice, and we are respected for our voice. I will continue to be a part of this important day!” As many times as nurses read about legislative activities, nothing compares to being at the capitol observing committees and the House and Senate. Dropping a card at a committee hearing to support or oppose a bill is a small effort but can make a big difference. Several nurses who attended the event admitted that their views and understanding had changed after seeing the process up-close. “I see that the regulations that protect and define our practice are the result of hard work by nurses before,” said Samuel Wong, RN, BSN. “It was exciting to advocate, and I hope to do more advocacy in the future.”
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“It was fun and very educational,” said Joyce Heggins, RN. “I had no idea what went on. Now when I read the paper,
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STARTING CONVERSATIONS THAT MATTER IN A RECENT TEXAS NURSES ASSOCIATION SURVEY, 50 percent of participants responded that they rarely or never discussed TNA with other nurses. Why not?
Do nurses discuss legislation, but not who is promoting it?
Do nurses know about TNA initiatives?
Do TNA members have the tools to effectively conduct such conversations with both members and nonmembers?
With these questions in mind, TNA leadership crafted the House of Delegates theme “Starting Conversations that Matter.” More than 120 delegates attended the two-day conference in Georgetown to learn about building connection and excitement around recruitment.
More than 120 delegates attended the two-day conference in Georgetown to learn about building connection and excitement around recruitment.
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TNA currently boasts more than 11,000 members and is pursuing strategic goals to reach 20,000 members by 2020. “What better place than House of Delegates to train TNA activists on how to expand membership?” said Executive Director Cindy Zolnierek, PhD, RN. “We want to empower our members by illustrating how to overcome objections, how to connect the heart of the customer with the heart of TNA, and how to invite nurses to join. We want nurses to be engaged in our vibrant organization and to enjoy the superior value and op-
6 1 Current TNA Board of Directors: (back row from left) Pat Morrell, Tammy Eades, Treasurer Sarah Moody, Pam Greene, Rhonda Winegar, Secretary Terry Throckmorton; (front row from left) President Jeff Watson, Vice President Kim Belcik, Executive Director Cindy Zolnierek. 2 ANA Enterprise CEO Marla Weston provided insight into ANA's work. 3 District 4 Delegates Carol Hardin (left) and Natalie Garry 4 Rebecca Carrasco and Jeff Watson. 5 Kim Belcik and Jennifer Cook. 6 2017-2018 Board of Directors: (from left) Rhonda Winegar, Tammy Eades, Kim Belcik, Director-Elect Shakyryn Napier, Small District Director-Elect Patricia Feier, Secretary-Elect Kleanthe Caruso, Treasurer-Elect Gayle Dasher, Pam Greene, Jeff Watson.
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LE NE AD W #1 1 RA ERS EXE IN 20 HI CU NK 18 PD T U. S. NE ED NP IVE GR W AD S & D N TR SC W HO OR P P OL LD RO ACK RA REP G NK OR IN T N R GS UR AM SIN G
portunities available to them through membership.” Following Dr. Zolnierek’s uplifting presentation, Chuck Anderson of Mission Advancement introduced TNA’s Board of Directors, delegates, and observers to techniques for recruiting and retaining members focused on the value of membership.
“There is strength in numbers. If we work together to recruit and retain members, our influence will grow.” Attendees closed this portion of the event with a role-playing activity that helped them create their personal recruitment strategies. It also gave them the opportunity to voice what TNA leadership can do to support individuals and districts as they further the association’s goals. “TNA is a member-driven organization, and it was inspiring to see nurses from around the state participate in the House of Delegates,” said TNA Director of Practice Ellen Martin, PhD, RN, CPHQ. “There is strength in numbers. If we work together to recruit and retain members, our influence will grow.” ANA Enterprise CEO Marla Weston PhD, RN, FAAN, talked about the million-dollar question: How do we improve quality of care while simultaneously reducing costs? She explored disruptive trends in health care, such as the repeal of the Affordable Care Act, and discussed how continued on page 20
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nurses must be flexible as its replacement is rolled out. Weston also touched on how the empowered healthcare consumer is impacting the delivery of care. Many organizations are not only giving consumers access to their medical records but are allowing them to add their own notes and participate in their care. She ended by saying that ANA is preparing nurses and leading the way to the future of health care, noting that ANA’s mission has not changed: Nurses ADVANCING OUR PROFESSION to improve health FOR ALL.
2017-2018 Candidates: (from left) Irene Rosales, Andrea Kerley, Gayle Dasher, Clarissa Silva, Pat Morrell, Karen Koeber-Timmons, and Kleanthe Caruso.
TNA CANDIDATE FORUM A few years ago, TNA changed the process for electing board members and nominating committee members. Members of the House of Delegates, who are representative of the entire membership, now vote at the annual gathering. This year, a candidate forum was held the night before the House of Delegates, giving attendees the opportunity to ask questions of candidates. After, a reception was held where candidates handed out campaign materials and spoke one-on-one with attendees. Thank you to all candidates and delegates who made this year’s forum a success! Voting was held Saturday morning during the House of Delegates. Congratulations to this year's nominating committee winners Irene Rosales and Orlando Chapa and to the following new board members: Kleanthe Caruso, Secretary-elect Gayle Dasher, Treasurer-elect Patricia Freier, Board member-elect, Director-at-large Shakyryn Napier, Board member-elect, Director-at-large
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The remainder of the day was spent addressing the business of TNA. President Jeff Watson, MSN, RN-C, NEA-BC, CRRN, gave his annual address, and delegates reviewed the association’s finances with Treasurer Sarah Moody, DNP, RN, NEABC. Delegates also passed a bylaws amendment that changes who serves as an alternate to the ANA Membership Assembly. Andrew Cates, TNA general counsel and director of government affairs, gave an update on advocacy efforts in the 85th Legislative Session, including the push for support of HB 1415. The bill, authored by Rep. Stephanie Klick, would remove remaining barriers to full practice by registered nurses with advanced degrees. Advocates made historic progress this session when HB 1415 became the first full practice APRN bill to have ever been given a legislative hearing. i
TPAPN SEEKING CASE MANAGER The Texas Peer Assistance Program for Nurses (TPAPN) is seeking a Case Manager to support nurse participants in its program. TPAPN provides a non-disciplinary option for nurses experiencing substance use and/or mental health issues and assists program participants through recovery and integration back into practice. For the complete job description, please visit texasnurses.org. To apply, send resume to recruiting@texasnurses.org.
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TNA COMMITTEE ACCOMPLISHMENTS House Features TNA Committee Posters EACH YEAR, the reports to the Texas Nurses Association House of Delegates are delivered verbally, with a written version included in the program book. For the 2017 House of Delegates, the Texas Nurses Association transitioned from the traditional format to a poster. Each of the posters — which were displayed around the foyer — included the activities and accomplishments of a committee. Because this is a legislative year, the Government Affairs Committee (GAC) has been particularly busy.
TNA Director of Government Affairs Andrew Cates gave the report at House of Delegates, so it is not included in the information below. Easy to absorb, the posters gave attendees the chance to quickly find out what the TNA committees have been working on for the past year. In addition, each poster contained TNA’s mission, vision, strategic objective, and strategic goals. Throughout their activities, the committees further advance TNA’s strategic plan. i
APRN Committee Informed development of the APRN Full Practice Bill and legislative strategy Provided subject matter expertise to Rice University researchers evaluating the economic impact of APRN full practice Beginning development of a “Welcome to Texas” toolkit for APRNs moving to Texas Considered APRN issues in states after passage of full practice legislation
Workplace Advocacy
TEXAS NURSES ASSOCIATION
Informed policy positions related to workplace advocacy
Mission
Fatigue awareness campaign initiated with article in Winter issue of Texas Nursing
Empowering Texas Nurses to advance the profession
Reviewed TNA Safe Staffing Toolkit (update in progress)
Vision Nurses transforming health
Surveyed nurses on staffing committee education needs (part of TNA Survey)
Strategic Objective To position TNA as a vibrant, growing membership organization that provides superior value to its members. 1.
Align district strategy and efforts with member value through engagement.
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Aggressively grow membership by acquiring, engaging, and retaining members.
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Advance the quality and safety of patient care through policy initiatives that optimize professional nursing practice, advance positive nursing practice environments, and promote full use of the knowledge and skills of nurses.
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Become financially self-sustaining by 2020.
Reviewed results of Texas Center for Nursing Workforce Studies workplace violence survey (slide deck in development) Workplace violence prevention pocket guide (in development)
Mental Health Work Group
TNA BOARD OF DIRECTORS Policy Council
TNA Committees
APRN Committee
Workplace Advocacy
Audit/ Finance
Mental Health
Education
Continuing Nursing Education
Regulation Committee
Informed the development of mental health policy positions
Bylaws
Nominating
TNA/TONE Health Information Technology (HIT)
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Identified two priorities for committee work: Suicide prevention and care of persons with mental health conditions in acute care settings Article in May issue of Texas Nursing emphasizing that whole health begins with mental health Developing suicide prevention guide to increase nurse awareness of resources
Education Committee
Bylaws Committee
Informed policy positions related to nursing education
At the request of the TNA Board, the Bylaws Committee proposed a bylaws amendment to update the alternate representatives to ANA’s annual Membership Assembly
Developed resource guide “Pathway to Academia” for nurses interested in becoming an educator (pending publication) Education Data Dashboard on key statistics related to nursing education in Texas including graduation rates, program capacity, and faculty shortage (in development)
Regulation Committee Informed policy positions related to the regulation of nursing practice in Texas Reviewed Sunset Commission report on the Board of Nursing and made recommendations to Policy Council
TNA / TONE Health Information Technology (HIT) Committee HIT resource toolkit DNP-student-developed brochure for staff nurses on Meaningful Use Focus group with 20 nurse executives to identify best practices and needed interventions for electronic health records
Continuing Nursing Education Committee A task force out of the CNE Committee was assigned to develop a process to electronically submit CNE-related applications to TNA
Electronic Clinical Quality Measures webinar December 2016 HIT Webinar Series (three presentations) Spring 2017
A task force out of the CNE Committee was assigned to review and propose new language to address issues with Texas Board of Nursing (BON) rule 216.6(5) Approved 46 Approved Provider Units between July 2016 to June 2017
Guide for nurses facing BON discipline (in development)
Successfully completed the transition to the 2015 ANCC standards
Guide for nurses on practice considerations in caring for persons at the end-of-life (in development)
Clocked 847.83 volunteer hours in 2016
Nominating Committee Audit/Finance Committee
Established a timeline for the slating of the 2017 TNA Ballot
Review TNA’s 2015-2016 audit report and make recommendation to the Board of Directors
Slated 14 qualified candidates for five positions
Review TNA’s 2015-2016 990 and 900T tax returns and make recommendations to the Board of Directors Review of budget and review of financial statements Will review the 2017-2018 budget and make recommendation to the Board of Directors
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THE TEXAS NURSES ASSOCIATION is excited to announce that registration is open for the 2017 Texas Nursing Leadership Conference! Join the Texas Nurses Association for the 2017 Leadership Conference as we explore relational competence by analyzing creative work, featuring Bonnie Wesorick, RN, MSN, FAAN, and Margaret J. Wheatley, EdD. Wesorick is a healthcare visionary who works to change the dynamics of healthcare institutions. She is the author of “Polarity Thinking in Healthcare: The Missing Logic to Achieve Transformation.”
Wheatley is author of nine books, from the classic Leadership and the New Science to her newest book (June 2017) Who Do We Choose To Be? Facing Reality, Claiming Leadership, Restoring Sanity.
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