UNIVERSITY OF SOUTH CAROLINA
College of Nursing FALL 2017
A RURAL OUTREACH College of Nursing initiatives make a big impact on S.C.’s rural health care.
plus A SMART START TO A NURSING CAREER WHAT ‘BIG DATA’ CAN DO FOR HEALTH CARE
Contents
pg. 7 In this issue 4
/ New crew Meet some of the College of Nursing’s new senior faculty members.
FALL 2017 College of Nursing Dean / Jeannette O. Andrews Associate Dean of Academic Affairs / Kristen Starnes-Ott Associate Dean of Faculty Affairs / Robin Dail Associate Dean of Practice and Health Policy / Stephanie Burgess Associate Dean of Research / Bernardine M. Pinto Director of Communications and Marketing / Jan Johnson Senior Director of Development / Monica Cromer Director of Alumni Engagement/ Annie Lambert CON Communications Office Williams-Brice Building Columbia, SC 29208 Phone: 803-777-3861 Email: nursingq@mailbox.sc.edu University Home Page: sc.edu College of Nursing Home Page: sc.edu/nursing University Writers Group / Integrated Communications Contributing writers / Ronda Hughes Designer / Brinnan Wimberly Photographer / Kim Truett The University of South Carolina does not discriminate in educational or employment opportunities or decisions for qualified persons on the basis of race, color, religion, sex, national origin, genetics, age, disability, sexual orientation, or veteran status. The University of South Carolina has designated as the ADA Title II, Section 504 and Title IX coordinator the Executive Assistant to the President for Equal Opportunity Programs. The Office of the Executive Assistant to the President for Equal Opportunity Programs is located at 1600 Hampton Street, Suite 805, Columbia, SC; telephone 803-777-3854. UCS 17-10274 9/17
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/ Breathe easier A research project aims to help lung cancer survivors better cope with common symptoms of the disease.
7/ A smart start to a nursing career A new honors program guarantees progression to the upper division for top students.
8/ A rural outreach College of Nursing faculty members and students are expanding their footprint across the rural health care landscape.
12/ Destined to help Nursing Alumni Award winner Kahlil Demonbreun has forged a successful path in a field with few male nurses.
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/ What ‘big data’ can do for health care Answers to some of health care’s most vexing problems lie in ferreting out useful information embedded in databases across the industry.
On the cover: College of Nursing clinical instructor Leigh Pate teaches USC Lancaster nursing students including junior Morgan Brown. Pate is also a family nurse practitioner at the Community Medical Clinic of Kershaw County.
Here at the University of South Carolina, momentum is growing in the College of Nursing. Our faculty, staff and strategic initiatives are expanding as we pursue an ambitious vision. Our commitment to quality, excellence and impact guides our actions. In response, our U.S. News & World Report rankings, NIH rankings and national and international recognition have soared rapidly in the past several years. The heightened impact in our local region and communities generates a higher sense of accomplishment for our team. In this issue, we highlight our influence on health care delivery and patient outcomes in rural communities in South Carolina and bordering regions through practice advances, research discoveries and educational programs. We are focused on improving access to quality health care, increasing engagement and inclusivity and deploying a higher educated
JEANNETTE ANDREWS
nursing workforce in the state’s rural communities. Also, check out our new Nursing Honors Program, our expanding global footprint and interprofessional collaboratives in the
DEAN OF THE COLLEGE OF NURSING
classroom and clinical settings. We’re excited to introduce an expanded mission in our Center for Nursing Leadership with a new consortium using big data to improve clinical decision making at the bedside and boardroom with health system partners across the state. We are inspired by our research faculty members in the Center for Cancer Survivorship as they continue innovative approaches to improve the quality of lives of cancer survivors in the Southeastern U.S. We are also thankful to our committed donors and alumni who are dedicated to our college. Finally, I must give a shoutout to a group of our youngest alumni, the May 2017 B.S.N. graduates. This talented cohort set a new college record with their 99.3% NCLEX first-time pass rate. These 152 graduates represent our Columbia, Salkehatchie and Lancaster campuses. Let’s continue to raise the bar for nursing and quality health care in South Carolina and beyond! You make us all proud.
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From left: Kristen Starnes-Ott, Cindy Corbett, Robin Dail, Alicia Ribar and Rachel Onello
NEW CREW The College of Nursing has appointed key senior faculty members, including new associate deans for academics, faculty affairs and practice, as well as a new director of the Clinical Simulation Laboratory. Kristen Starnes-Ott, associate dean of academics, earned a bachelor’s degree in biology from East Carolina University, a B.S.N. from Auburn University, an M.S.N. in nurse anesthesia from the University of Southern California and a doctoral degree in nursing from the University of Texas Health Science Center at Houston. During her doctoral work, she was named the AANA Foundation New York Life Doctoral Fellow and received the Outstanding Doctoral Award from the Zeta Pi Chapter of Sigma Theta Tau. Her research interest focuses on using simulation technology to improve provider communication and impact patient safety outcomes in perioperative care systems. She co-authored and produced the video “21st Century Simulation Innovation in Education & Research,” which received the Award of Merit-Best Shorts Competition in 2012. She has served on numerous state and national professional organizations, committees and taskforces, including the American Association of Nurse Anesthetists Education and Continuing Education committees. Robin Dail, associate dean of faculty affairs and practice, earned an associate degree in nursing from the University of Nevada, Las Vegas, an M.S.N. as a neonatal nurse practitioner from East Carolina University and a doctoral degree in nursing from the University of North Carolina, Chapel Hill. Dail comes to USC’s College of Nursing from Duke University’s School of Nursing and School of Medicine.
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Inducted into the American Academy of Nursing in 2014, Dail practiced as a neonatal nurse and neonatal nurse practitioner for 30 years before beginning her academic career. She studies thermal stability in premature infants to reduce morbidity and mortality related to hypothermia in this vulnerable population. Rachel Onello, director of the Clinical Simulation Lab, has more than nine years of experience in clinical simulation education with formal education from the Peter M. Winter Institute for Simulation, Education and Research at the University of Pittsburgh and the Center for Medical Simulation at Harvard University. She comes to Carolina from the University of Maryland, where she was the assistant director of the simulation lab and taught clinical and simulation courses to undergraduate and graduate students. Onello’s main area of interest is in faculty development, particularly around simulation design integration and debriefing, in simulation-based encounters and also in facilitating debriefing style feedback conversations in clinical learning environments. Alicia Ribar, associate dean of practice, has practiced professional nursing for 25 years and has more than 19 years of advanced practice nursing experience. She earned a B.S.N. degree from the University of Toledo, Medical College of Ohio, and subsequently worked in several clinical settings. In 1998, she completed an M.S.N. at Wright State University, becoming a family nurse practitioner.
Ribar is certified as a family nurse practitioner by the American Nurses Credentialing Center and is recognized as an advance practice nurse by the Ohio and South Carolina Boards of Nursing. In 2012, she completed her doctoral degree in nursing at Duquesne University, concentrating in epidemiology and transcultural health disparities. She has had active clinical practices in both acute care and primary care pediatric/family practice settings and currently maintains a clinical practice delivering health care for the Division of Inpatient Services at the Department of Mental Health of South Carolina. Cindy Corbett, formerly associate dean of research and interim chancellor for research at Washington State University Spokane, has joined USC as a nursing research professor. Corbett focuses on strategies to improve chronic illness self-management and patient safety and has received funding from the American Society of Health-System Pharmacists’ Research and Education Foundation, the Robert Wood Johnson Foundation, the Agency for Healthcare Research and Quality, the National Institutes of Health and the Patient Centered Outcomes Research Institute. “I look forward to working with faculty, students, staff and community partners to design and implement research to improve health care for South Carolina and beyond,” says Corbett, a fellow in the American Academy of Nursing and a member of the Western Institute of Nursing.
STICK WITH THE PROGRAM Tisha Felder was a social worker in Washington, D.C., when her best friend’s mother died of breast cancer. Felder knew the statistics that showed African-American women were less likely to be diagnosed with breast cancer but more likely to die from it. Having lived through it with her friend, she could not shake the sadness. She talked with her father, telling him how bad she felt. “All he said was ‘What are you going to do about it?’” Felder says. At that moment, Felder says, she began her quest to improve the outcomes. “I felt a calling to do something about these disparities,” says Felder, a native of Easley, S.C., and a researcher with a joint appointment in USC’s College of Nursing and the Cancer Prevention and Control Program in the Arnold School of Public Health. She recently received funding from the National Cancer Institute to identify and test intervention strategies to improve adherence to hormonal therapy among disadvantaged breast cancer
Eventually, Felder says, the side effects lessen. So getting women through that first year is key. Her research began with interviews with health care providers across South Carolina, and now Felder is in the “data crunching” part of that phase. Next up are interviews with patients themselves. The target group is women who have completed other breast cancer treatments (e.g., surgery, chemotherapy), are now cancer-free and have been put on hormonal therapy to prevent recurrence. Felder’s study will focus on women with Medicaid coverage. “Research shows that Medicaid patients have worse outcomes than other patients, and for black Medicaid patients, the outcomes are even worse,” she says. The goal is to have at least 30 participants to help researchers develop and pilot test intervention strategies to improve use of the hormonal treatment. “Our hypothesis is that we have to address issues beyond the patient; we have to look at their support systems, their partners and providers,” she says. As part of her field research, Felder shadowed different oncologists and saw a wide variation in the bedside manner and rapport with patients. Providers’ attitudes, she says, can affect the way a patient views continued therapy and ultimately how well she sticks with it. As part of the award from the National Cancer Institute, Felder will be mentored by an interdisciplinary team of cancer disparities experts from the University of South Carolina: Ronit Elk and Sue Heiney from the College of Nursing, Daniela Friedman and James Hébert from the Arnold School of Public Health and Marvella Ford from the Medical University of South Carolina.
“Our hypothesis is that we have to address issues beyond the patient, we have to look at their support systems, their partners and providers.” survivors who experience excess rates of breast cancer mortality. “It’s one pill a day for up to 10 years,” Felder says. “But there are side effects, and the worst of those often happen in the first year. The irony is the worse the side effects are, the more effective the treatment seems to be.” It is those side effects, which mimic menopause symptoms like hot flashes and vaginal dryness, that can lead women to stop taking the medicine within the first year.
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BREATHE EASIER NURSE RESEARCHER TO PILOT PROGRAM FOR LUNG CANCER SURVIVORS A diagnosis of lung cancer used to be a near-certain death sentence, but as early detection of the disease continues to improve and treatment becomes more effective, survivors are growing in number. But just because they’re living longer and sometimes even cured of the disease, longterm survivors of lung cancer often must cope with distressing symptoms such as shortness of breath, fatigue, depression and anxiety. Karen Kane McDonnell, a nursing professor in USC’s College of Nursing, plans to test an intervention to reduce their symptom burden. She’s implementing a two-year, $750,000 grant from the Bristol-Myers Squibb Foundation’s Bridging Cancer Care to launch a pilot study with lung cancer survivors and their significant others. McDonnell is adapting a program known as mindfulness-based cancer recovery, created by Linda E. Carlson, director of psychosocial oncology research and a clinical psy-
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chologist at the Tom Baker Cancer Centre in Calgary, Canada. The intervention is based on the foundation of mindfulnessbased stress reduction, developed decades ago by Jon Kabat-Zinn, a now-retired medical professor at the University of Massachusetts Medical School. The eight-week program, called Breathe Easier, will include a regimen of breathing exercises, gentle yoga-like movements and meditations. “We want to help survivors and their significant others improve their ability to manage symptoms and improve their quality of life,” McDonnell says. “Unresolved symptoms negatively impact their sense of well-being and can be very isolating.” McDonnell is working with a team of clinical and research faculty members from the School of Medicine, the College of Social Work and the Department of Computer Science and Engineering to test the intervention and consider ways to develop it as a future mobile application so that survivors and their significant others can access the program from home.
The recruitment process for the face-toface program has started and the first eightweek session began this past summer, and McDonnell’s goal is to enroll as many as 40 survivors of non-small cell lung cancer who have completed medical treatment. Their significant others — spouses, close friends or other family members — will join them. The program will take place at Upstream: A Center for Mindfulness Practice & Holistic Mental Health in Columbia, founded by College of Nursing alumna Jemme Stewart (’85 B.S.N., ’90 M.S.N.) and T. Hilda White, who are also research team members. “It is important to recognize that both survivors and their family members and close friends react to serious illness, and as a result they both have a genuine need for support from health care providers,” McDonnell says. “Partners not only provide emotional and practical support, but also have to cope with their own concerns, including the stress and uncertainty surrounding the course of the illness and fear of losing their partner.”
“These are Honors College students, the best of the best who apply to the university. Because they are admitted to the upper level immediately, it gives us the opportunity to offer them honors classes and earlier research classes,” she says. The expectation is for students to take graduate-level courses during their senior year to help prepare them for the rigors of Ph.D. or Doctor of Nursing Practice programs. “I am very interested in research and pursuing a higher-level degree after I complete my B.S.N.,” Fryer says. “The ability to join a faculty member in research or even begin my own research with the help of an experienced mentor has certainly made me rethink the possibilities I have to impact people as a nurse.” By capturing the cohort of graduate-school bound nursing students earlier, USC hopes to increase the number of nurses doing research and address the shortage of nurses who pursue doctoral degrees. That’s important because the average age when a nurse Dr. Robin Estrada and Lauren Fryer completes a doctorate is about 50, compressing the length of time available for them to complete research. “Most nurses graduate, go out and work, get involved in family life and don’t go back to school,” Estrada says. “This is basically a pipeline for moving younger people into positions of leadership and academic work.” Starting this fall, a cohort of nursing majors in the South Carolina Students who enter the cohort are not required to pursue graduHonors College will start on the path to a career that might include research and academia — along with clinical nursing practice. ate degrees. Estrada says she believes it is a good idea for a nurse The Smart Start Nursing Program includes all incoming Honors to practice for a little while before heading back to the classroom, College students who declare nursing as their major. Typically, stu- or to take classes while they are working as nurses. But even those who don’t want to continue classwork after earning their underdents must complete two years of a strict pre-nursing curriculum and then face tough competition from their peers to be admitted graduate degree will develop connections and research skills that to nursing’s upper division. The Smart Start students will be autowill open the door to higher quality internships and residencies. “Nurses are uniquely prepared to do health care research because matically accepted into the upper division of the College of Nurswe know what patients experience and we know what patients ing, as long as they maintain Honors College GPA requirements. need because we are in the trenches,” says Estrada, a pediatric “Immediate acceptance into the upper division of the nursing nurse practitioner who earned her doctorate at age 48. “What program has been an indescribable blessing,” says Lauren Fryer, made me a good researcher is that I was in practice for a long time.” an Honors College freshman. “To be a full nursing student from She says the work ethic and passion among nursing students at day one makes my goals seem that much more real and attainable. I’m free to use my energy to think of research I want to do or men- Carolina makes her excited about the future of nursing education. “I’m optimistic about students who come into our nursing protors I want to learn from, rather than stressing over my class rank.” Robin Dawson Estrada, director of the new program and an gram. They’re bright, they’re eager for knowledge, and they want assistant professor, said the program was developed to engage the to go out and change the world. And they have the tools to do that university’s top students in the nursing curriculum at the start of that my generation didn’t have,” Estrada says. “We’re impacting their time at USC and to quickly expose nursing students to rethe health of people in South Carolina and the quality of nursing care in South Carolina. It’s a very exciting place to be.” search in hopes they will consider careers in research and teaching.
A SMART START TO A NURSING CAREER
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A Rural Outreach Residents in rural South Carolina are more likely to be hospitalized for and die from certain health conditions, including congestive heart failure, cancer, diabetes and stroke. Improving rural health is a key focus for USC’s College of Nursing, which has initiatives in place to address rural health disparities, improve mental health access and respect cultural differences in health care decision making.
Staying local As a native of the area, Leigh Pate knew what she was getting into when she started working at the Community Medical Clinic of Kershaw County in Camden. Most of her patients don’t have transportation, health insurance or the means to pay. “I grew up in a rural area and understand the limited access to care,” says Pate, who is also a College of Nursing clinical instructor teaching USC Lancaster students. Her students volunteer at the Community Medical Clinic, and many of them have similar insight to the challenges facing rural residents. Many of Pate’s clients are dealing with high blood pressure, diabetes or being overweight — prevalent conditions that are treatable without hospitalization. Clinic staff members work to keep patients out of emergency rooms for non-life threatening ailments. When it began in 1998, the free clinic operated one day per week, but soon expanded to four. Now the clinic, run almost entirely by nurse practitioners, offers medical services at North Central middle and high schools and at four satelitte sites in Kershaw County.
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Pate sees the work at the clinic as an extension of her nursing classes. She recalls discussing lab results with one patient: “The woman said, ‘You’re the first person to explain it in a way that I actually understand,’” Pate says. Educating patients on how to manage chronic illnesses such as diabetes is a large portion of the nurse practitioners’ job. “Every time I go to work, I know that I’m helping people,” Pate says. It’s that interaction with patients that convinced her to go back and earn B.S.N. and M.S.N. degrees after getting a bachelor’s in healthcare management at Winthrop University. Pate is now working on her nursing doctorate, which she hopes to finish next spring. “You make a huge difference by being an educator,” says Pate, who hopes to inspire her students to help their community. “Our students are staying local after graduation.”
The Promise Zone USC’s College of Nursing is part of a collaborative effort among government agencies and nonprofit organizations to improve health care in Allendale, Bamberg, Barnwell, Colleton, Hampton and Jasper counties. The six rural counties, among the state’s poorest, were designated by the federal government as a Promise Zone to increase federal assistance in that region. To that end, the U.S. Department of Health and Human Services recently
awarded the College of Nursing a nearly $1 million grant to increase the number of nurse practitioners in the six-county area. The grant will pay for training 30 new family nurse practitioners a year for two years. “Research demonstrates that nurse practitioners are safe, autonomous providers who demonstrate excellent patient outcomes, high patient satisfaction and increase access to care,” says Stephanie Burgess, the college’s associate dean for practice. Eighty percent of the family nurse practitioner students selected for the funding will be low-income, first-generation “Promise Zone” residents or part of an underrepresented population in the nursing ranks. Students will do clinical training at mental health facilities, primary care and women’s health clinics, federally qualified health care centers, rural health centers, free clinics, migrant clinics and private primary care practices. Half of the students are expected to work in rural areas within six months of graduation. The college also received a grant to increase the number of doctoral students from the designated Promise Zone as a way to help address the nursing faculty shortage in the United States.
room — those are the clients we’re addressThe protocol was completed, then fieldCultural sensitivities tested at Beaufort Memorial Hospital. The ing,” says McKinney, who also is a clinical The most difficult conversations a health palliative care physician followed all of the associate professor of nursing. care professional will ever have involve community’s recommendations. “Rural providers don’t have many regiving a patient a terminal prognosis. One Such community-based participatory sources, so we beam in, talk to clients and of the most thorough studies of end-of-life research provides a way to partner respectmake recommendations for treatment. communications was undertaken by USC fully with a community, Elk says, and the We also provide a list of behavioral things nursing professor Ronit Elk. method has proven successful in reducing a patient needs to be coached on and what Over a two-year period, Elk worked racial disparities in health outcomes. resources are available in that area.” with older rural Southerners, black and “If you’re going to do a program that McKinney’s project, funded by the white, in Beaufort County, S.C. Elk’s team will affect a certain group, wouldn’t you Duke Endowment, trains students to work conducted focus groups with people who want to consult that community?” Elk says. in interprofessional teams while getting had recently lost a relative or loved one, “That’s the heart of communication.” experience in both mental health treatment and from those discussions came a list of and telehealth technology. themes about how they thought health “Telehealth takes a bit of getting used A virtual presence care professionals performed and what to, especially if you’re accustomed to using As director of the College of Nursing’s could be done better. therapeutic touch. If the patient starts psychiatric mental health nurse practitioElk’s team then met with a diverse crying, you can touch without saying ner program, Tena McKinney oversees an group of community advisory board memanything,” says Danielle Simmons, a interdisciplinary educational program for bers who examined the themes from their teams of graduate nursing students, Master mental health nurse practitioner student. own cultural perspectives and shared their of Social Work students and graduate phar- “In telehealth, I would say, ‘I see you’re community’s preferences for how certain upset, can you tell me what you’re feeling? macy students who use telehealth technolsituations should be handled by health Tell me the best you can, I don’t care what ogy to consult with patients. care professionals. words you use.’” “There’s a gap in mental health between Key differences were noted about being OK and being in the emergency terminal prognoses. “Doctors think, ‘I should tell my patient that they have only two weeks left to live so they can get their affairs in order and say goodbye,’” Elk says. “Yet in the African-American community, the belief in hope is extremely strong and a very important concept. The miracle that can happen — that God can bring about — that is always a factor.” Another difference is in enabling patients to make their own decisions. “But this practice is based very much on the white middle-class model in which patient empowerment, individual decision-making, is highly valued,” Elk says. “Yet, this does not fit with the African-American community model in which families make shared Tena McKinney teaches a graduate student using telehealth techniques. decisions, especially in such circumstances.”
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Making dreams come true NURSING ALUMNA ENDOWS SCHOLARSHIP A nursing degree from the University of South Carolina helped make Patricia Edens Eddy’s dreams come true. Now, she wants to help make that experience available for others. Eddy and her husband, Nelson, have established the Patricia Edens Eddy Nursing Endowed Scholarship Fund to award scholarships to College of Nursing students. “The university gave us such an opportunity to pursue an education and make our dreams come true,” Patricia Eddy says. “I didn’t want a young man or young lady to be held back by not being able to afford school. It’s important to have great nurses, and Carolina is a wonderful nursing program — one of the best.” After her graduation in 1987, Eddy began her nursing career in Columbia, where she worked as an RN on a medical-surgical floor at Baptist Hospital (now Palmetto Health Baptist) and later moved to the operating room at Baptist. “I didn’t like the operating room as much because the patients are asleep,” she says. “I liked the contact with the patients.” She met her husband, a Carolina graduate, in Columbia while she was working as a nurse and he was a dentist. The couple later moved to Boston, where she worked as a nurse on an oncology floor at Beth Israel Deaconess Medical Center, a Harvard Medical School teaching hospital, while her husband completed his residency as a periodontist. They moved home to
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Rock Hill, S.C., in 1992, and Eddy was an obstetrics nurse for the S.C. Department of Health and Environmental Control until the couple’s first child was born. They have four children: Joseph, a sophomore in dental school at the Medical University of South Carolina; Sarah, a junior studying exercise science at University of South Carolina; Libby, a senior at Northwestern High School who plans to attend Carolina; and Maggie, a high school sophomore. Since she was a young child, Patricia Eddy knew she wanted to serve others through a career in nursing. Now, as her children are older, she plans to once again get involved in health care. In September, she begins her term on the College of Nursing Partnership Board, and she says she’s interested in looking at areas such as gaps in geriatric coverage and advocating for the elderly. Her gift to USC will help future students as they prepare for careers in nursing. “With benefactors like Nelson and Patricia Eddy, the College of Nursing is able to recruit and support high-achieving, diverse students who choose nursing as a career path,” says Jeannette Andrews, dean of the College of Nursing. “The Eddys’ endowment for student scholarships is not only critical to the college in our journey to educate our future nursing workforce, but equally important to each individual student who receives financial support during their education here at Carolina.”
Nurses without borders
Nursing faculty members and students provide care, learn new systems around the globe
T
hree groups of USC nursing students and faculty members recently traveled the globe for study abroad and medical mission trips.
In March, a group went to Nicaragua to provide services to under-
privileged communities, and in May, one study abroad group traveled to the Netherlands, while another traveled to Germany to gain new per-
spectives on health care. Nursing faculty members Joan Creed and Kate Chappell along with nurse practitioner students Margaret Darr and Maureen Nwajaiku traveled to the Netherlands as part of a partnership between Inholland University in Amsterdam and the Alpha Xi chapter of Sigma Theta
Nuremberg, Germany
Tau International. “A group from the Netherlands has come to South Carolina for 11 years, and this trip started what we hope will be an annual one to the Netherlands and Inholland University,” Creed said. During the six-day trip, the students and faculty members studied the health care system of the region by visiting several hospitals and their departments, including emergency, palliative, pediatrics, OB and birth places and general practitioner clinics. Another trip took seven undergraduate College of Nursing students to Nuremberg, Germany, to study transcultural nursing, ethics and the German health care system. Led by faculty members Deborah McQuilkin and Kelley Wilson, the group engaged with patients in a palliative care Alzheimer’s end-of-life residence and visited a world-class pediatric rheumatism pain clinic. They also shadowed nurses in a 2,000-bed hospital and attended lectures by a health care ethicist on the German Bismarck health system. The trip was in partnership with Evangelische Hochschule Nüremberg, one of the first universities to build a bachelor’s degree to
Inholland University in Amsterdam
further educate nurses. The German partners will visit USC in September. For a second year, the College of Nursing has partnered with OneWorld Health for a medical mission trip to Nicaragua. OneWorld Health creates medical centers that offer low-cost services to underserved communities. Seven B.S.N. students, three nurse practitioner students and faculty member Karen Worthy were among 42 volunteers on the trip. USC’s five health disciplines — nursing, pharmacy, social work, medicine and public health — participate in the interprofessional collaboration. The B.S.N. students managed the triage team for the week, obtaining vital signs, prioritizing patients, assessing acuity and managing all labs. Nurse practitioner students provided primary health care services to the patients. Nurse practitioners took health histories and provided focused physical examinations, diagnosed and treated many common acute and chronic problems, interpreted lab results and ultrasounds, prescribed medications, provided health teaching and counseling, and made referrals to support healthy lifestyle behaviors and prevent illness. In five days the volunteer team provided care for more than 1,100 underprivileged patients.
Medical mission trip in Nicaragua
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Destined to help
ALUMNUS TAKES ROAD LESS TRAVELED FOR A MALE NURSE Kahlil Demonbreun always knew what he wanted to do, even if he couldn’t put an exact name to it. Demonbreun, the 2016 recipient of the University of South Carolina College of Nursing Alumni Award, grew up in Michigan surrounded by strong women whose influence led him down a somewhat unusual career path. “I knew very early in life, probably about 14 or 15, that I wanted to be what I now understand the role of a nurse practitioner to be,” Demonbreun says. After earning his registered nurse license through the Henry Ford Hospital School of Nursing in conjunction with the University of Michigan, Demonbreun began looking for additional educational opportunities. That search led him to Carolina, where he received his bachelor’s degree in nursing in 1994 and his master’s in 1998. Demonbreun, who received a Doctor of Nursing Practice from the Medical University of South Carolina, is currently the women’s health medical director at the WJB Dorn Veteran Affairs Medical Center. While male nurses are not rare, male women’s health nurse practitioners are not commonplace. Demonbreun says males make up roughly 11 percent of the country’s 3.4 million nurses. “When a provider, whether it’s a male or a female, comes into a room, you have about a minute to say, ‘OK, I can work with this provider,’ or ‘I cannot work with this provider,’” he says. “When I walk into a room for the first time, the advantage that I have is that I’m different than what the patient might be used to or what they might have been expecting. This difference opens them up.
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I have to make the patient at ease and earn their trust.” Demonbreun is a fellow in the American Association of Nurse Practitioners, is the AANP’s South Carolina representative and serves as an adviser on the association’s health policy committee. He is also on the Board of Directors for the National Certification Corporation and the Board of Directors for the South Carolina Nurses Association. He credits Carolina faculty members with inspiring him during his early days in nursing education. “There were a lot of influential males there who I could emulate,” Demonbreun says. “None of them were in women’s health, but they inspired me because they were national leaders.” While men provided motivation in college, women have formed the foundation of his success. Demonbreun, whose wife is an internal medicine physician, has two daughters and was raised by his paternal grandmother. “She was a pretty straightforward person and a disciplinarian,” he says. “She set a standard of work ethic and a belief that if you worked hard at something, you could achieve it. She was always a giving person, willing to go the extra mile for anyone, so obviously that set an example of what kind of person I should be.” Demonbreun was honored along with Stacy Collier, the chief nursing officer of KershawHealth in Camden, S.C., this past November. Collier, who received her bachelor’s degree from Carolina in 1997 and her master’s in 2000, was a Palmetto Gold Nursing Excellence Award winner in 2006 and is vice presidentelect of the USC College of Nursing Partnership Board. Demonbreun says a large part of his longevity is thanks to the women who’ve supported his practice — including the ones who sometimes name babies after the man who delivered them. “That’s a testament to the work. People do appreciate when you care for them,” he says. “Our profession is really about caring for other humans. It’s about helping people have a better life, a better state of health. I think I was destined to do that.”
Better together STUDENTS FROM ALL HEALTH SCIENCES DISCIPLINES CONVERGE WITH INTERPROFESSIONAL COLLABORATIVE
C
ombining resources and working together makes more sense than trying to go it alone. That’s the driving belief behind the Interprofessional Education Collaborative push among the health sciences disciplines at the University of South Carolina. The overarching goal of the national initiative, led at USC by the Interprofessional Education for the Health Sciences Committee, is to find ways for students in medicine, nursing, pharmacy, physical therapy, public health, social work and speech-language pathology to learn from each other and become more efficient, effective health care professionals. “If we don’t work as a team, then quality, safety and job satisfaction suffer,” says Bev Baliko, an associate professor in the College of Nursing who has helped spearhead the IPEC program. “Practices occur in silos and isolation. We don’t have true teamwork.” The four core competencies of the national IPEC program stress mutual respect, defined responsibilities, communication and teamwork. Interprofessional opportunities include classes, clinical education, cocurricular activities and community engagement. USC strives to meet those competencies via course offerings, though coordinating the schedules of the 14,000 health science students across the USC system is a complicated endeavor. While more than 2,600 students have taken part in the introductory Transforming Health Care for the Future since 2012, other handson learning opportunities also provide valuable experience. “We’re in our second year of an HIV interprofessional training grant that involves social work, pharmacy, nursing and medicine, with groups of students that train at two-week intervals in our infectious disease clinic,” Baliko says. “That’s going wonderfully well. Because they’re planning together and doing their assessments together, they see where their disciplines overlap, where they differ and where they can complement each other. Understanding builds respect.” That speaks directly to an IPEC goal: to graduate competent health care professionals capable of entering any health care system and communicating with other professionals to improve patient outcomes. Other, more tactile aims of the USC push are to increase health sciences enrollment and to obtain external funding for education and research.
“I would love to be able to do more classes. We’re a huge university, though, and some of our programs are really large,” Baliko says. “We have to look at what’s feasible.” Additional clinical practice programs, for instance, would facilitate more opportunities for students, Baliko says. That, of course, would require additional funding for programs that largely involve graduate students. USC has 17 nationally ranked health science graduate programs as determined by U.S. News & World Report. “If we want to recruit students and bill this as a strength, we need to have something to offer them, so they can continue to learn with, from and about each other,” Baliko says. In April, Baliko and four other IPEC committee members attended training in Charlottesville, and as the fall semester approached, committee members sat down for planning sessions to assess the program’s progress. “It’s an evolving thing. We look at the facilitator feedback and student feedback and try to meet needs,” Baliko says. “We’re way more alike than different, especially in our goals and some of the things that we do. If we understand that, we can better work together to achieve a broader goal.”
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faculty notes P UB L ICATION S
G RAN TS Jeannette Andrews, PI, “Jonas Nurse Leaders Scholars Program 2016-2018,” Jonas Center for Nursing Excellence. Co-PI, and Tena Hunt McKinney, Co-PI, “Leveraging Mental Health Access in South Carolina with Psychiatric Health Nurse Practitioners and Telemental Health,” Fullerton Foundation Susan Beverung, “University of South Carolina College of Nursing — Midlands Area Seamless Nursing Academic Progression Model,” The Foundation of the National Student Nurses’ Association Inc. Stephanie Burgess, “Choose Well Initiative,” New Morning Foundation, and “Advanced Education Nursing Traineeship,” HRSA Joan Culley, PI, “Validating Triage for Chemical Mass Casualty Incidents — A First Step,” NIH/NLM Sara Donevant, PI, “An Evidence-Based Evaluation Tool to Assist Health Care Providers in Their Assessment of Effective mHealth Applications of the Management of Chronic Health Conditions,” NIH Dr. Ronit Elk, PI, “Culturally Tailored Goals of Care Conversions at Endof-Life,” the West
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Foundation, and “Culturally Tailored Conversations at EOL: What African American Patients Want Physicians to Know,” ASPIRE I; “Community-Engaged Hospitalists’ Training,” from USC Provost/ Social Sciences; “Reducing Disparities in the Quality of Palliative Care for Older African Americans through Improved Advance Care Planning (EQUAL ACP),” from the Patient-Centered Outcomes Research Institute Robin Estrada, PI, “A Patient-Centered Asthma Management Communication Intervention for Rural Latino Children,” NHLBI/NIH Tisha Felder, PI, “Improving adherence to adjuvant hormonal therapy among Disadvantaged Breast Cancer Survivors,” NIH/NCI Ronda Hughes, PI, “READI (Readiness Evaluation and Discharge Interventions): Implementation as a Standard Nursing Practice for Hospital Discharge,” ANCC/ Marquette University; “South Carolina One Voice One Plan Action Coalition Future of Nursing State Implementation Program,” Robert Wood Johnson Foundation
Karen McDonnell, PI, “Advancing Quality Lung Cancer Survivorship in South Carolina,” Bristol-Myers Squibb Foundation Inc. Tena Hunt McKinney, PI, “Telemental Health Connect (TeleCon): Expanding Collaboration and Comprehensive Service Penetration,” Duke Endowment Grant DeAnne Messias, PI, “ENLACE: A Promotora-Led Physical Activity Intervention Trial for Latinas in Texas (Year 5),” R01 subaward National Institutes of Health/UTHSC San Antonio; PD, “Nurse Faculty Loan Program (NFLP),” HRSA Bernardine Pinto, PI, “Peers Promoting Exercise Adoption and Maintenance among Cancer Survivors,” NIH/NCI; “Stakeholder Interviews to Inspire Moving Forward — Administrative Supplement,” NIH/ NCI; “Peers Promoting Exercise Adoption and Maintenance among Cancer Survivors,” American Cancer Society; “Promoting Physical Activity in Young Adult Cancer Survivors using mHealth and Adaptive Tailored Feedback Strategies,” NIH Subaward with UNC Chapel Hill
Nathaniel Bell, “Data capture and communication during transfers to definitive care in an inclusive trauma system,” in Injury Nathaniel Bell, and Tsion Kidanie and Bo Cai, “Geographic variation in access to outpatient healthcare services following spinal cord injury,” Archives of Physical Medicine and Rehabilitation Nathaniel Bell and Bo Cai “The reliability of the American Community Survey for injury surveillance,” Injury Prevention Nathaniel Bell, Laura Reparaz and Alejandro Luis, “Insurance status and diagnostic imaging as a measure of quality of trauma care,” BMC Medical Imaging Stephanie Burgess, “Results of a nine month home-based physical activity intervention for people living with HIV,” International Journal of Clinical Trials Mary Foster Cox and Laura Hein, “Gender queer: Politics may be the death of us,” Nursing Inquiry Joan Culley, “Validating Signs and Symptoms from an Actual Mass Casualty Incident to Characterize an Irritant Gas Syndrome Agent
(IGSA) Exposure: A First Step in the Development of a Novel IGSA Triage Algorithm which has been published in the Journal of Emergency Nursing,” Journal of Emergency Nursing Robin Dail, “Body temperature in premature infants during the first week of life: Exploration using infrared thermal imaging,” Journal of Thermal Biology Ronit Elk and Cristy DeGregory, “Spiritual Care and Nursing: A Nurse’s Contribution and Practice,” HealthCare Chaplaincy Network and Spiritual Care Association Ronit Elk, “The First Step Is Recognizing, Acknowledging, and Respecting the Inequity, Disrespect, and Disregard Our African American Patients Have Experienced,” Journal of Palliative Medicine; “A CommunityDeveloped, CulturallyBased Palliative Care Program for African American and White Rural Elders with a Life-Limiting Illness: A Program By The Community for the Community,” Narrative Inquiry in Bioethics Robin Estrada, “Rural Asthma: Current Understanding of Prevalence, Patterns, and Interventions
for Children and Adolescents,” Current Allergy and Asthma Reports; ”Carbon monoxide poisoning: The silent killer,” American Nurse Today; “Urban-Rural Differences in School Nurses’ Asthma Training Needs and Access to Asthma Resources,” Journal of Pediatric Nursing Kay Lawrence, Robin Estrada and Jessica McCormick, “Teachers’ Experiences With and Perceptions of Students With Attention Deficit/ hyperactivity Disorder,” Journal of Pediatric Nursing Helen Mulhern-Halasz, “Advising Strategies for Graduate Student Degree Progression,” Academic Advising Today Pearman Hayne, Swann Adams and Sue Heiney, “The relationships between psychosocial factors and group cohesion in African American women with breast cancer,” Journal of Oncology Navigation & Survivorship Sue Heiney, “Fatalism Revisited: Further Psychometric Testing Across Two Studies,” Journal of Religion and Health; co-author on an international collaboration, “Effect of a group intervention for children and their parents who have cancer,” Palliative and Supportive Care Sue Heiney, Abbas Tavakoli and Pearman Hayne, “Mediators of Social Connection in a Group Teleconference Intervention,” Research and Theory for Nursing Practice Sue Heiney, DeAnne Messias and Tisha Felder, “African American Women’s Recollected Experiences of
Adherence to Breast Cancer Treatment,” Oncology Nursing Forum DeAnne Messias and Robin Estrada, “Patterns of Communication Technology Utilization for Health Information among Hispanics in South Carolina: Implications for Health Equity,” Health Equity Tena Hunt McKinney, Abbas Tavakoli and JoAnne Herman, “PsyConnect: Constructing layered engagement for optimal learning in clinical education,” Journal of Nursing Education Alexandra Nitsos, Robin Estrada, and DeAnne Messias, “Tummy Time for Latinos With Limited English Proficiency: Evaluating the Feasibility of a Cultural and Linguistically Adapted Parent Education Intervention,” Journal of Pediatric Nursing Bernardine Pinto, “Mentors delivering a physical activity intervention for cancer survivors: Effects among mentors,” Translational Behavioral Medicine; “Feasibility and acceptability of active book clubs in cancer survivors — An explorative investigation,” Acta Oncologica; “Does a peer-led exercise intervention affect sedentary behavior among breast cancer survivors?” PsychoOncology. “Moving Forward Together: Breast Cancer Survivors Are Helping Each Other to Get and Stay Physically Active,” Cure Today Kristen Starnes-Ott and Lydia T. Madsen, “Establishing an individual writing
practice” and “Starting an advanced practice provider professional writing group,” Journal of the Advanced Practitioner in Oncology Abbas Tavakoli, “Comparing behavioral health models for reducing risky drinking among older veterans,” American Journal of Drug and Alcohol Abuse; “PSYCONNECT: Constructing Layered Engagement for Optimal Learning in Clinical Education,” Journal of Nursing Education Kelly Wilson, “School Nurse Intervention: When the High School Coach is a Bully,” NASN School Nurse Jeannette Andrews, M. Mueller, G.S. Magwood, S.D. Newman, M. Dooley and M.S. Tingen, “Effect of a smoking cessation intervention for women in subsidized housing neighborhoods: A randomized controlled trial,” Preventive Medicine Robin Estrada, I.L. Annang, C.B. Tinago, S. Wilson, S.L. Wright, T. Bevington, B. Carlos, E. Cornelius, E.R. Svendsen and J. Ball, “Off the rails in rural South Carolina: A qualitative study of healthcare provider perspectives on the long-term health impact of the Graniteville train disaster,” Rural and Remote Health Sue Heiney, M. Baruth, S. Wilcox and C. Der Ananian, “Effects of home-based walking on quality of life and fatigue outcomes in early stage breast cancer survivors: A 12-week pilot study,” Journal of Physical Activity and Health
Joan Culley and D. Becker, “Diabetic peripheral neuropathy: The learning curve,” Federal Practitioner DeAnne Messias, C.D. Bergeron, D.B. Friedman, S.M. Spencer and S.C. Miller, “Older women’s responses and decisions after a fall: The work of getting ‘back to normal,’” Health Care for Women International, and, with same coauthors, “Involvement of family members and professionals in older women’s post-fall decision making,” Health Communication, and, with same co-authors and R. McKeever, “An exploratory survey of older women’s post-fall decisions,” Journal of Applied Gerontology Stephanie Burgess, B. Bookstaver, J. Foster, K. Lu, J. Mann, C. Ambrose and A. Grant, “Hepatitis B virus seroconversion rates among health sciences students in the southeastern United States,” Journal of American College Health Swann Adams, Sue Heinery, K. Dhotre, J.R. Hebert and M. Bottai, “Oncology professionals’ experiences with patients who choose to discontinue cancer chemotherapy,” Oncology Nursing Forum Karen McDonnell, J.L. Ersek, J.M. Eberth, S. Strayer, E. Sercy, K. Cartmell and D.B. Friedman, “Knowledge, perception and use of low-dose computed tomography for lung cancer screening among family practice physicians,” Cancer
Tisha Felder, Sue Heiney, D.P. Do, Z. Lu, L.S. Lal and C.L. Bennett, “Racial differences in receipt of adjuvant hormonal therapy among Medicaid enrollees in South Carolina diagnosed with breast cancer,” Breast Cancer Research and Treatment Sheryl Mitchell, Cristy DeGregory and M.W. Hand, “Advance directives in the provision of care for incarcerated adults: A scoping review protocol,” JBI Database of Systematic Reviews and Implementation Reports Jeannette Andrews, J. Heath, K. Butler, S. Craig, J. Anderson and C. Barone, “Relationships between tobacco cessation interventions and attributes of individual and organizational excellence in acute and critical care practice,” American Journal of Critical Care, and, with C. Kollath-Cattano, J.F. Thrasher, O. Osman and S.M. Strayer, “Physician advise for e-cigarette use,” Journal of American Board of Family Medicine Sheryl Mitchell and D. Linton, “Physical examination of the eye: The fundus matters,” The Journal for Nurse Practitioners DeAnne Messias, M.M. McEwen, L. Clark, J.S. Boyle and B. Smith, “American Academy of Nursing on Policy: Support for humanitarian aid to refugee children,” Nursing Outlook Jeannette Andrews, L.S. Nemeth, C.J. Jenkins, E.C. Jauch, S. Wolf, A. Pearlman, I. Spruill, L. Brown, J. Linnen and F. Linnen, “Community engaged assessment to facilitate
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stroke elimination (CEASE),” Research in Nursing & Health Research Joan Culley and M. Pallon, “Differences in practices between rural and urban first responders: Examining how first responders handle irritant gas syndrome agent (IGSA) disasters in rural versus urban settings,” Carolina Fire Rescue EMS Journal
Homecoming Weekend Friday, Oct. 27 • 9 a.m.-noon Voices of Nurse Leaders: Impacting our Future Keynote speaker: Roy Simpson Viana McCown Lecture Columbia Metropolitan Convention Center $25
5:30-7:30 p.m. Alumni Oyster Roast College of Nursing patio $35
Saturday, Oct. 28 • 2 hours prior to kickoff Tailgating at Williams-Brice Stadium Cockaboose No. 11 Free
For more information visit www.sc.edu/nursing/alumni.
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Ronda Hughes, C.L. Petersen, M.F. Callahan, D.O. McCarthy, R. WhiteTraut and N.K. Bansal, “An online educational initiative improves pediatric oncology nurses’ knowledge, attitudes, and spiritual care competence,” Journal of Pediatric Oncology Nursing Karen McDonnell, R. Qiu, J. Eberth, A. Copeland and N. Porter, “Planning and implementation of lowdose CT lung cancer screening programs in the U.S.: A mixed methods study,” Clinical Journal of Oncology Nursing Bernardine Pinto, C. Rabin and J. Fava, “Randomized trial of a physical activity and mediation intervention for young adult cancer survivors,” Journal of Adolescent and Young Adult Oncology
Swann Adams, M.E. Samson, N.G. Porter, D.M. Hurley and J.M. Eberth, “Disparities in breast cancer incidence, mortality, and quality of care among African American and European American women in South Carolina,” Southern Medical Journal Jeannette Andrews, K. Sell, E. Amella, M. Mueller and J. Wachs, “Use of social cognitive
theory to assess salient clinical research in chronic disease selfmanagement for older adults: An integrative review,” Open Journal of Nursing
Evaluation of Health Care Quality for DNPs, 2nd Edition, J.V. Hickey and C.A. Brosnan, editors, Springer Publishing Company, New York
Jeannette Andrews, M.S. Tingen, J. Heath, L. Williams, C. Schroeder, P. Dainer, S. Khleif and J. Waller, “Tailored parental cessation delivered concurrently with tobacco prevention in children enrolled in urban and rural southern elementary schools,” Cancer Epidemiology, Biomarkers & Prevention
DeAnne Messias and Robin Estrada, “An Introduction to Community Activism,” in Policy and Politics in Nursing and Healthcare, 7th Edition, D.J. Mason, J.K. Leavitt and M.W. Chaffee, editors, Saunders/Elsevier, Philadelphia
B OOKS & CH A P TE R S Swann Adams and DeAnne Messias, “Epidemiology,” in Public Health Nursing: Population-Centered Health Care in the Community, 9th Edition, M. Stanhope and J. Lancaster, editors, Elsevier, Philadelphia Bev Baliko, Mary Boyd and Stephanie Burgess, “Mental Health Care for Survivors of Violence,” in Essentials of Psychiatric Nursing, M.A. Boyd, editor, Lippincott, Williams, & Wilkins., Philadelphia Carolyn Harmon, a chapter in the 2017 Handbook of Informatics for Nurses and Healthcare Professionals Mary Foster Cox and R. Wittmann-Price, “Women’s Health Care,” in NCLEX-RN EXCEL: Test Success through Unfolding Case Study Review, WittmannPrice, editor, Springer, New York Ronda Hughes, “Chapter 7: Evaluation of Patient Care Standards, Guidelines, and Protocols,” in
Kelley MillerWilson, “Chapter 45: Assessment of Visual Function,” in Adult Health Nursing: Making Connections to Practice, Hoffman and Sullivan, editors, F.A. Davis, Philadelphia, also, same book, “Chapter 46, Coordinating Care for Patients with Visual Disorders,” “Chapter 47: Assessment of Auditory Function, “Chapter 48: Coordinating Care for Patients with Hearing Disorders,” and “Chapter 52: Assessment of the Musculoskeletal System”
What ‘big data’ can do for health care What can “big data” do for health care? Plenty, says USC College of Nursing professor Ronda Hughes, who is working with her team of researchers and computer and data science specialists to improve decision-making and gain new knowledge that will enhance health care itself across all types of health care organizations. Health care leaders and clinicians are pushing for the right analytic tools and better metrics to address the ever-changing health care environment. But if health care is to truly improve, Hughes says, nursing leaders and researchers must harness the depth and breadth of data, using techniques such as predictive analytics and machine learning. Every database, from insurance claims data to staffing data to readmissions data and population health data, is an opportunity to identify patterns, ideal outcomes and what needs to change. While many decisions are made based on experience or gut feelings, the rapid growth in large databases throughout health care is providing potential insight into how to improve delivery of health care services and population health. That includes establishing a relational source of performance data, working with and giving feedback to decision makers in real time, optimizing care delivery processes and providing coaching for decision makers to use data more effectively. Through the new Excellence in Nursing Consortium, a partnership with hospitals in the state and region, health care providers and health care organizations, Hughes and her team are working to make sense of data, creating a culture of evidence-based decision making that brings the contributions of nurses to the forefront. The consortium will enable interprofessional teams to bring findings from research and data to decision makers from the boardroom to the bedside. Because health care teams are responsible for the quality and outcomes of health care, nursing — the nation’s largest health profession — is at the core of health care transformation. When new protocols or requirements are initiated, it is nurses who interface with and care for patients, ensure that all key steps are taken and gather data to assess and demonstrate organizational performance. Hughes’ team is working with nurse leaders to strategically use data and evidence-based tools to improve the nurse-patient interface and patient outcomes. With more tools and better understanding of data, nurses can lead the health care team to realize needed changes that bring society closer to improved systems and availability of health care that will help current and future patients.
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BY THE
1st 99.3% Nursing honors program in South Carolina
NCLEX pass rate for May 2017 cohort
Named nation’s best nursing college by American Assembly for Men in Nursing
$796,763 2017 total in scholarships awarded to 177 nursing students
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TOP TEN USC College of Nursing’s rank for three consecutive years in U.S. News & World Report
NUMBERS
246% 9,600+
Percentage increase in graduate program
Number of alumni; 132 faculty members (full and part
time); 1,789 students
top 31
enrollment in the past five years
$12 million
Amount of new faculty grant awards in the past three years
NIH ranking among colleges of nursing nationwide. USC’s nursing college was unranked as recently as 2012.
100%
Percentage of the college’s full-time faculty
members who are doctorally prepared or enrolled in doctoral programs
fifty-six Number of students and faculty members who studied abroad (in 10 countries) last year
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Nonprofit U.S. Postage PAID University of South Carolina
Columbia, SC 29208
AIKEN
BEAUFORT
COLUMBIA
LANCASTER
PALMETTO COLLEGE
SALKEHATCHIE
We make South Carolina healthier. Kimberly Eaker knows a soldier’s life. As an RN and now a nurse practitioner, she has been caring for soldiers with traumatic brain injuries and PTSD since 2012. “I connect with them really well,” she says. “Soldiers protect me and our country, and I want to protect them.”
CAROLINA CHANGES EVERYTHING SOUTHCAROLINA.EDU/HEALTHY
KIMBERLY EAKER B.S.N., 1986 USC COLUMBIA
SUMTER
UNION
UPSTATE