The Official Publication of the Oklahoma Nurses Association
Quarterly publication delivered to approximately 64,000 Registered Nurses and LPNs in Oklahoma
Volume 66 • Number 1
Shelly Wells, PhD, MBA, APRN-CNS, ANEF
As we look back at
2020, we cannot help but
reflect on the reality of the
International Year of the
Nurse and Midwife. The year
was designated to honor the
200th birthday of Florence
Nightingale and to bring focus
on the need to increase the
global professional nursing
workforce. In reality, our Year
of the Nurse more accurately Shelly Wells
reflected a 4H year – a year of
History, Heartbreak, Heroes and Hope. The year 2020
started with the knowledge that Nurses once again
topped the Gallup list of the most honest and trusted
profession in America. This was the 18th consecutive
year to be awarded the honor! Our patients, families
and public knew that they could trust nurses to
advocate for them. They knew nurses stood up for our
patients to advocate for the conditions that support
justice, health and dignity for everyone. This feeling of
reinvigorated pride in our profession was firmly tested
less than 90 days into the year.
In March 2020, the eyes of the public were on our
profession in a way we never could have dreamed.
We were thrust into the spotlight as the COVID-19
pandemic took hold, and the irreplaceable work of
nurses was highly visible for everyone to see. We
persevered in light of not having full understanding of
the invisible assault on our patients, their families, our
profession and ourselves. Nursing did what nursing
does best – we fought to provide the best care and
treatment we could for everyone – even at great cost
to ourselves. We witnessed an increasing physical
and emotional toll on our nurses as the COVID-19
pandemic unfolded, but we never quit. Fighting
through a shortage of personal protective equipment,
supporting patient care staff and proven therapies for
treating the infection, we understood our obligation to
the public. At great personal risk, nurses continued to
advocate for all in spite of the heartbreak we witnessed
as we cared for, and comforted, critically ill patients
and their families, all while dressed in plastic gowns,
vinyl gloves, eye goggles and a face mask that we may
have been wearing much longer than we thought it
Members of our communities recognized the work
we were doing as irreplaceable. Soon, across social
media and newspapers throughout the state, nurses
were being hailed as heroes. Nurses, acutely aware
of the risks to themselves, continued to volunteer to
work with infected patients in acute care and longterm
care facilities. Many isolated themselves from
their own children and other family members to care
for COVID-19 patients. Everyone knew nurses were
at the bedside caring for their loved ones 24 hours a
day. Nurses who usually served in other roles stepped
up to meet the ongoing need to comfort, educate and
advocate for the public who were under the continuing
assault of the COVID-19 virus. Nurse executives
and nurse educators came together to develop
strategies to support our colleagues at the bedside.
Nurses advocated for common-sense public health
measures in their communities to help control the
viral spread. Many found their voices when attending
both in-person and virtual city council meetings and
presenting the science, often being jeered by others.
Nurses appeared in television news and social media
President’s Message continued on page 2
current resident or
President’s Message. ................ 1
RN2Leader ........................ 3
CEO Report. ....................... 4
Educators Corner ................... 6
ONA Statement on COVID-19 Vaccination. 6
Three Lessons Learned During the
COVID Crisis. ...................... 7
Professional Clarity 2020: Motivational
Andragogy through Shared Student
Experiences. ....................... 9
The Value of Grit and Resilience. ...... 10
Emerging Nurses. .................. 11
Nurse Refresher Course ............. 13
Nursing Policy. .................... 14
The Oklahoma Nurse February, March, April 2021
Oklahoma Nurses Association Regions and Regional Presidents
Oklahoma Nurses Association
President: Lucas Richardson-
President: Donna Fesler
President: Leslie Davis
Representative: Leslie Collins
President: Nakeda Hall
President: Viki Saidleman
Contact information available at www.oklahomanurses.org
ONA 2020-2022 BOARD OF DIRECTORS:
President – Shelly Wells, PhD, MBA, APRN-CNS, ANEF
President-Elect - Angie Kamermayer, DNP, APRN-CNS, NEA-BC
Vice President – Angela Martindale, PhD, RN
Secretary/Treasurer – Amber Garretson MSN, APRN-CNS, CCRN
Membership Development Director – Amy Hutchens, PhD, RN
Education Director – Vanessa Wright, PhD, MSN, RN
Practice Director – Michele Bradshaw, BSN, RN
Political Activities Director – Megan Jester, MS, RN
Emerging Nurse Director – Tina Edwards, MBA, MSN, RN
Region 1 President – Lucas Richardson-Walker, BSN, RN
Region 2 President – Donna Fesler
Region 3 President – Leslie Davis, MSN, RN
Region 4 Representative - Leslie Collins, DNP, MSN, RN
Region 5 President – Nakeda Hall, DNP, APRN-CNP
Region 6 President – Viki Saidleman, RN
ONSA Consultant – Dr. Dean Prentice, Colonel (Retired),
USAF, NC, DHA, MA, BSN, NE-BC
Jane Nelson, CAE — CEO
Andrea Starmer — Director of Events and Education
Amber Feldpausch — Event Planner
Taylor Dempsey - Director of Communications
President’s Message continued from page 1
coverage describing the current situations in the area’s
hospitals and expressing concerns about the need to
not overwhelm the health care system. Some served
on expert panels with other health care providers
to offer consultation to leaders in government.
Most served as role models in their communities –
masking up when in public and teaching our friends
and families about the need to stay safe and vigilant
against the virus spread.
As the door hit the year 2020 in the tail-end, we
felt hopeful, even with the increasing numbers of
infected in our care facilities. With the approval and
distribution of the COVID-19 vaccines, we are hopeful
that our communities will begin to see a downturn in
the number of active infections, the number of those
requiring virus-related hospitalization, the occurrence
of terrible long-term effects and a decrease in the
number of our friends, families, colleagues and
community members who ultimately die related to
the virus. Pictures of nurses receiving the vaccine and
their experiences with the vaccine are noted through
social media and television coverage in an effort to
promote its acceptance. Nursing is now celebrating
its 19th year at the top of the Gallup list as the most
honest and trusted profession in America. With this
spark of hope is the need for nurses to continue
to be strong advocates for illness prevention and
educate others regarding the rapidly unfolding science
surrounding the spread, treatment and prevention of
the infection. We must continue to stand up for those
without a voice in the middle of this pandemic. We
must continue to combat the untruths that continue
to interfere with effective control, mitigation and
prevention. We must continue to use our voices and
skills to promote health for all in a time of uncertainty.
I look forward to a healthier 2021 and thank each
of you for your dedication to your patients and their
families, your communities, and the profession of
Clinical Health Facility Surveyor
$58,539.84 per year plus benefits
Positions available across Oklahoma. Preference is given to RNs
and LPNs with a valid permanent Oklahoma Nursing License.
Responsible for the inspection for nursing facilities, hospitals,
surgery centers, home care agencies, dialysis centers and
other health care facilities. Extensive Training Provided. 2-3 day
overnight travel required.
APPLY ONLINE JOBS.OK.GOV
Search Keyword “Surveyor”
Applicants must apply for each position for which they are interested.
Questions? - Surveyor@health.ok.gov AA/EEO
Oklahoma Nurses Association
6608 N Western, #627, Oklahoma City, OK 73116
The subscription rate is $20 per year.
THE OKLAHOMA NURSE (0030-1787), is published
quarterly every February, May, August and November by
the Oklahoma Nurses Association (a constituent member
of the American Nurses Association) and Arthur L. Davis
Publishing Agency, Inc. All rights reserved by copyright.
Views expressed herein are not necessarily those of
Oklahoma Nurses Association.
International Nursing Index and Cumulative Index to Nursing
and Allied Health Literature.
Copies of articles from this publication are available from the UMI
Article Clearinghouse. Mail requests to: University Microfilms
International, 300 N. Zeeb Road, Ann Arbor, MI 48106.
For advertising rates and information, please contact Arthur
L. Davis Publishing Agency, Inc., PO Box 216, Cedar Falls,
Iowa 50613, (800) 626-4081, firstname.lastname@example.org. ONA and
the Arthur L. Davis Publishing Agency, Inc. reserve the right
to reject any advertisement. Responsibility for errors in
advertising is limited to corrections in the next issue or refund
of price of advertisement.
Acceptance of advertising does not imply endorsement or
approval by the Oklahoma Nurses Association of products
advertised, the advertisers, or the claims made. Rejection
of an advertisement does not imply a product offered for
advertising is without merit, or that the manufacturer lacks
integrity, or that this association disapproves of the product
or its use. ONA and the Arthur L. Davis Publishing Agency,
Inc. shall not be held liable for any consequences resulting
from purchase or use of an advertiser’s product. Articles
appearing in this publication express the opinions of the
authors; they do not necessarily reflect views of the staff,
board, or membership of ONA or those of the national or
CONTACT THE ONA
Web site: www.oklahomanurses.org
Mail: 6608 N Western, #627, Oklahoma City, OK 73116
Questions about your nursing license?
Contact the Oklahoma Board of Nursing at 405.962.1800.
Want to advertise in The Oklahoma Nurse?
Contact Arthur L. Davis Publishing Agency, Inc.
at 800.626.4081 or email at email@example.com.
ONA CORE VALUES
ONA believes that organizations are value driven
and therefore has adopted the following core values:
• Safe Quality Care
• Ethical Care
• Health Parity
• Integrity and Accountability
• Practice Competence
• Professional Development
• Educational Advancement
ONA MISSION STATEMENT
The Mission of the Oklahoma Nurses Association is to empower
nurses to improve health care in all specialties and practice
settings by working as a community of professional nurses.
Creating opportunities through advocacy, education and
collaboration to become the leading voice for the nursing
profession in the State of Oklahoma.
Engaging Nurses to make a difference!
February, March, April 2021 The Oklahoma Nurse 3
Does it Matter?
Dr. Dean L. Prentice, Colonel (Ret), USAF, NC,
DHA, MA, BSN, NE-BC
Welcome to the New Year!
I think we can say we hope
2021 is going to be a better
year. Much has transpired
during 2020. In all that we
have lived through, there is
hope for the upcoming year.
The important question is,
does it matter?
We have seen the
profession of nursing
highlighted over and over
Dr. Dean Prentice
again this past year for the
work nurses have accomplished. The pandemic has
brought to the forefront just how powerful nurses
are when included on the healthcare team. For all
our concerns over being recognized as valuable,
this past year we have truly proven our worth to the
nation and the world.
Through it all, nurses have done really well to lead
the charge. Much like our first responder colleagues,
nurses didn’t exit healthcare when the disaster hit.
They ran into danger and went to work. They jumped
in front of the runaway bus and saved countless lives
with their nursing action and care. Evidence-based
practice, safety and compassion were offered to all.
Exhausted and overwhelmed at times, nurses
continued the fight. For equity in care, for education
and for preventive care. We took to airwaves, print
and social media to get out the message. Valued
and respected for their knowledge and reputation,
nurses were listened to in many communities as
voices of calm, patience and healing. And there is
more to do in the future.
Our battle with this pandemic is not over. And
what will be the next issue we face? From my
many years in nursing and healthcare, it has never
been more important for nurses and nurse leaders
to continue our push to be heard for the benefit of
our patients and communities. We must though, do
it correctly. Nurses should NOT be the pawns of
politics, bias or agendas for others that wish to use
our hard-earned identification as the “most honest
and ethical professions” for the past 19 years. We
need to protect this most precious reputation.
So what does our New Year hold? Is our diversity
going to make us stronger? Can we continue our
legacy of compassionate care? I look forward to
2021 in all its glory and trials! We are nurses and we
can weather any storm sent our way. Oh, we may
get weary and frustrated. We may cry and we may
just celebrate. However, we are nurses. We hold the
hand and celebrate with the new mother and we
hold the hand of the cherished dying father. There is
nothing we cannot face…if we do it together.
Does it matter? You decide for yourself. I
say, we march into 2021 with a renewed spirit of
commitment to our patients, our profession and our
communities. We stand in that gap and our world
needs us. For me…bring it 2021…I got you!
Before there was Covid, there was Cholera!
Heroes of the
1833 CHOLERA EPIDEMIC
in Lexington, Kentucky
A gripping account of the true story, with
lessons for our global health today! Researched
and written by Terry Foody, RN, MSN.
Buy New from Terry on Amazon or at TerryFoody.net.
For group rates or speaking: firstname.lastname@example.org
The MSN Family Nurse Practitioner Program at Texas
A&M University Commerce is a hybrid format combined
with online only courses. The program can be
completed in 2 years with full time study or 3 years
with part-time study. Spring and fall admissions are
available. Clinical can be in your community.
100% pass rate on the certification exam for
our first graduated class in May 2020!
For more information, please visit: http://www.
Submit applications to the Graduate School at:
Full time Nursing Faculty positions
Credentials and Experience:
1 A master’s or higher degree in nursing; or
2 A baccalaureate degree in nursing plus evidence of continued progress toward a
Send resumes to
master’s or higher degree in nursing with completion of a minimum of six (6) semester
hours per calendar year
3 Evidence of current practice with a minimum of two (2) years full-time equivalent
practice as a Registered Nurse in a clinical setting preceding the first date of first
employment as a teacher.
Special Requirements: Hold a valid license to practice as a Registered Nurse in the State
The Oklahoma Nurse February, March, April 2021
Jane Nelson, CAE
CEO Oklahoma Nurses
“Make the most of yourself
by fanning the tiny, inner
sparks of possibility into
flames of achievement.”
- Golda Meir
2020 has been a rough
year, and it looks as if 2021 Jane Nelson
is off to a rocky start. There
seems to be some light with the release of the
COVID vaccine, but time will tell. We need to take
these tiny sparks and fan them into achievements for
nursing. I love this quote by Golda Meir as it requires
us to take what is within us and build something in
return of which we can be proud. This also means
that we need to be strong so how we respond to
2021 is up to each of us. Part of this includes our
ability to breath, inhale and exhale.
I recently listened to Brene’ Brown’s Unlocking
Us podcast on Strong Backs, Soft Fronts and Wild
Hearts. While the podcast is focused on having
a strong back and a soft front, what was more
profound to me was the essentialness of inhaling.
We can exhale all day long but at some point, we
need to inhale. If we don’t inhale, we can’t continue
to exhale and if we don’t inhale, we can’t brave
the wilderness! So, as we walk forward into 2021,
we need to inhale! My sense is that we all need to
remember to be inhaling as we have spent most of
2020 exhaling. So let’s practice it right now. Take a
deep breath…Inhale…now slowing release the air to
exhale. Feel how you are rebuilding your body, your
soul and your emotions. Remember that sensation!
Don’t let it go.
Now let’s talk about moving into 2021! ONA is
continuing its work to advocate for nurses with both
the Governor’s office and the Legislature. We know
you need more staff, that patients both COVID and
non-COVID continue to need care in hospitals, long
term care and clinics. ONA has worked to develop
tools for you to use that include COVID Resources
including ones on the vaccine, along with position
statements specifically on the COVID Vaccine
(included in this paper), and Moral Distress in
Times of Crisis. We continue to work on our nursing
shortage and its effects on nurse staffing during
this pandemic. ONA has been convening nurse
leaders from acute care and nursing education
to discuss ways to build Academic and Clinical
partnerships. The result of this partnership work
includes sharing and replication of a model across
the state, utilizing nursing students in clinical sites
to not only work as techs but also work during their
clinical experiences and be paid for that experience.
Other sharing opportunities include job descriptions
and other innovations to extend the arms of the
ICU/CC nurse. The Nurse Refresher Course was
also updated in a timely manner as a result of this
partnership. As we worked to discuss mutual issues,
it became abundantly clear that we need help from
the Governor, so ONA sent a letter addressing our
concerns, work and suggesting solutions. After an
initial conversation and a media event, we have been
in continued conversation with the Governor’s Team
on solutions to our overflowing hospitals and the
need for more nurses.
The State Legislature begins meeting the first
Monday in February. We are working to ensure that
they hear nursing voices as well. We need your help
to ensure that Legislators hear your voice. There are
issues we know that are coming forward that include
Managed Care, Immunizations, funding for Nursing
Education and other issues that may affect patient
care and the nursing profession. ONA’s legislative
priorities for 2021 are listed below and reflect these
Nursing Practice and Workforce
Nursing is vital to the survival of a quality
health care system. Competent nursing
practice improves the health, safety and state
health rankings for all Oklahomans.
Promoting the role of the nurse and the
profession of nursing to ensure the best health
for all Oklahomans.
Consistently ensuring adequate numbers of
nurses to care for patients in hospitals, long
term care and other healthcare settings is of
critical importance in alleviating our longterm
nursing shortage. Nursing education is
a critical component in the development of
Oklahoma’s nursing workforce.
Providing sufficient quality care to
Oklahomans year-round, ensuring enough
nurses to provide testing, immunizations
and quality care needed during a Pandemic
is of vital importance to both the short-term
and long-term health and well-being of all
Removing barriers to safe practice such
as inadequate amounts of PPE, necessary
equipment, testing and treatments ensure that
• Pay Cards
For more information call today:
Tulsa, OK: (918) 665-1011 • Oklahoma City, OK: (405) 842-7775
Springfield, MO (417) 886-1001 • Dallas, TX (214) 631-9200
Golden Age Nursing Home
Golden Oaks Village
Willow Creek Health Care
RN Case Manager/
LPN Charge Nurse
Matching 401K/Paid Time Off
We are looking for responsible,
professional nurses to experience the
satisfaction of working with our family.
You have the opportunity to be part
of our team in Home Health, Hospice,
Long-term care, Skilled Nursing or
Assisted Living facilities. Our positions
are located in the Guthrie, Stillwater,
and Perry communities.
Apply on-line at
$2,000 Sign On Bonus
February, March, April 2021 The Oklahoma Nurse 5
nurses will remain healthy and able to practice
in caring for all Oklahomans.
Quality health care is supported when ALL
licensed Nursing professionals are able to
practice at the full extent of their education
Improving Oklahomans Health Status
A healthy Oklahoman is a productive
Promote the use of evolving scientific and
evidence-based data driven solutions to
provide access to health care for the wellbeing
of all Oklahomans.
Advocate for the use of vaccines and
social behaviors to mitigate the spread of
Adequate funding for vital health care
related services, including direct care, illness
prevention and nursing education is critical to
improving Oklahomans health outcomes.
Oppose privatization of state health related
agencies and health services. Privatization
increases costs, destroys healthcare
infrastructure, safe staffing and competent
care, while reducing overall access to health
care. Shifting public dollars to support private
companies and insurers will endanger the
health and well-being of all Oklahomans, while
increasing costs to taxpayers.
Creating shortfalls in funding for health and
behavioral health services will increase
costs in other areas of the state’s budget,
and will lead to dire negative consequences
for individuals, families and communities,
placing all at risk. When funding falls below
critical levels, every other health priority
for Oklahomans and nurses is negatively
impacted. Nursing is one of the few
professions in Oklahoma providing care to our
citizens from conception to grave.
Preserving the Board of Nursing’s oversight
and regulation of nursing practice. Nursing
is the largest group of healthcare providers
including LPN, RN and APRN, each one
with its own unique scope of practice. The
Oklahoma Board of Nursing is already
a consolidated licensure and regulatory
entity governing nursing practice. Ensuring
professional nursing oversight of this board
provides for the critical health and safety
of the public. This self-sustaining, nonappropriated
Board contributes revenue to the
state general fund while providing for efficient,
focused regulation of the nursing profession.
Working with the Executive and Legislative
branches, along with state agencies, to
address nursing workforce issues.
Legislators need to hear from nurses on the
importance of all these issues. ONA works to keep
members up to date on these issues with talking
points and legislative alerts so that we can all speak
with one voice on these very complicated issues.
So what does this all mean? It means being aware
of current legislation affecting the nursing profession
and your patients.
We have ways for you to get involved, some
of which looks different this year. Typically, ONA
supports the Nurse of the Day program that allows
nurses to go to the Capitol and speak to legislators
one-on-one about issues that are important to you
and nurses throughout Oklahoma. However, we
are still working to ensure that this is run in a safe
manner. So please watch for details on social media,
email and ONA’s website www.oklahomanurses.org.
Another way to get involved is attending Nurses
Day at the Capitol on March 2. This event will be
held virtually (more information is available on the
ONA website), and it means sending emails or
making phone calls to your legislators.
So remember, to inhale before exhaling, and
keep your voice raised as we work to make 2021
better than 2020. Let’s all strive to make the most
of our voices by fanning those tiny inner sparks into
The Oklahoma Nurse February, March, April 2021
Time to Plant
Do plants/flowers flourish because we talk to them or because by talking to
our plants we become aligned in the goal of improvement? As educators, we
plant seeds daily. So just like when planting, we must take better care of the
things we want to flourish when teaching. How? One way is to reach out and
tell our real-life stories as nurses. Applicable Occupational Reflection is a great
Dr. Linda Cook has been blogging for a few years to nurses and nursing
students. It is my privilege to begin sharing some of her blogs as a perfect
example of reaching out, reflecting on practice and telling our stories:
To Nursing Students
Because you chose to be a nurse:
You will spend intense years of preparation.
You will work long shifts short-handed.
You will have neighbors at your door asking if you will, “just take a look at this rash.”
You will be the person in the family whose opinion is sought for everything from
bunions to Alzheimer’s, regardless of your area of specialization.
Your children will be ones who don’t go to the Emergency Room unless a bone is
You will end the occasional shift with an empty stomach and a full bladder.
You will find humor in many things that most people find disgusting.
You will eat breakfast twice a day when working night shift.
You will discover that nursing is sometimes hard, scary, sad and stressful.
But you will also discover that:
Patients may forget your name but always remember the way you made them feel.
Balloons made from latex gloves can stop a toddler’s
A smile from a difficult patient makes a difficult shift
Wearing pajamas (AKA scrubs) to work every day can be
You’ve developed the patience of a saint and a heart so
big that you can see the fear in an angry patient’s eyes.
You really do save lives and, deep in your heart, you know
that you could never do anything else.
Linda Cook, PhD, RN, PMHCNS, CNE, is a Full
Professor and Associate Dean of Kramer School of
Nursing at Oklahoma City University.
Marla Peixotto-Smith, MSN, PhD, RN, CNE, is an
Associate Professor & Coordinator of the RN2BSN
Program at Rogers State University. Marla invites you to
contribute to the “Educators Corner.” Please send your
thoughts, experiences, or strategies to marlasmith@rsu.
Now Hiring in
RNs, LPNs, CMAs
Work with a Family,
Not Just a Team
Contact Valerie Moreland, 520-262-5736,
Easy Apply Online at jobs.corecivic.com
Excellent Pay Rates! Tiered Pay Scale Based on
Years of Nursing Experience
CoreCivic is a Drug Free Workplace & EOE - M/F/Vets/Disabled.
ONA Statement on COVID-19
Nurses have worked selflessly to care for others during
the COVID-19 Pandemic. Now they have the opportunity
to protect themselves and others by getting immunized
against this new virus. Nurses and other healthcare
workers have been selected to be among the first to be
vaccinated because of their contact with patients and
their potential for infection.
To be effective, the COVID-19 vaccine must be
received by a large percentage of the adult population, and
nurses who serve as frontline caregivers and make informed
choices to be vaccinated serve as role models and trusted patient educators.
Indeed, nurses’ decisions to be vaccinated against COVID-19 can help
to shorten the duration of the pandemic while protecting the public from
community spread. Ultimately, widespread effective vaccination will reduce the
burden of this disease on acute and critical care units. If a vaccine allows more
nurses to stay healthy, then there will be more support for patient care and
As of December, 21, 2020, the Oklahoma Nurses Association has joined
with the American Nurses Association (ANA) and other nursing organizations
such as the American Association of Critical-Care Nurses (AACN) to strongly
recommend that nurses be vaccinated against COVID-19.
This decision is ultimately up to each individual. We encourage nurses to use
trusted knowledge, ethical frameworks and current science-based resources as
the foundation for their decisionmaking. ONA and ANA believe that there should
be no retaliation against nurses who choose not to take a COVID-19 vaccine.
Nurses, as trusted health care professionals, have a critical role to play in
administering COVID Vaccines to Oklahomans. COVID-19 vaccines can be
safely administered by nurses and nursing students under the supervision of
faculty or other appropriate licensed practitioners.
Our knowledge about COVID-19 and related vaccines is continuously
evolving. (See attached COVID-19 Vaccine Facts.) ONA and ANA will share
information from reliable sources as we advance our understanding on this
topic. Nurses, the most trusted profession, must scrutinize all sources of
information, decline to accept misinformation and disseminate only accurate
information from credible scientific sources.
• Oklahoma Vaccine Plan https://oklahoma.gov/covid19/vaccineinformation.html
• Centers for Disease Control and Prevention: Vaccine Recommendations
and Guidelines of the ACIP
• CDC COVID-19 Vaccination Communication Toolkit for medical centers,
clinics, and clinicians
• CMS COVID-19 Provider Toolkit
• CMS COVID-19 FAQs
• U.S. Food and Drug Administration: COVID-19 Vaccines
• Summary infographic of vaccine types from CHEST
• ANA webpage on COVID-19 Vaccines
• ANA webinar and video on COVID-19 Vaccines
• AACN blog on vaccines: "What's Up With the COVID-19 Vaccine?"
• AACN’s position statement: "Science Must Drive Clinical Practice and
Public Health Policy”
• AACN’s blog on how to sort through online information: "Going Viral:
COVID-19 and the Internet"
COVID-19 Vaccine Facts:
• Current vaccines have been FDA approved for Emergency Use
Authorization following three phases of testing on thousands of people.
• The CDC’s Advisory Committee on Immunization Practices recommends
that healthcare personnel be among those offered the first doses of
• The Oklahoma State Department of Health has approved current
COVID-19 vaccines for distribution in Oklahoma with healthcare workers
among the first to be given the opportunity to be vaccinated.
• Both approved COVID-19 vaccines are mRNA vaccines, like the measles
vaccine. These mRNA vaccines protect against infectious diseases
by instructing our cells how to make a protein — or just a piece of a
protein — that triggers an immune response inside our bodies. That
immune response produces antibodies that protect us from acquiring
infection when exposed to the actual virus. COVID-19 mRNA vaccines
give instructions for our cells to make a harmless piece of what is called
the “spike protein.” The spike protein is found on the surface of the virus
that causes COVID-19. Our immune systems recognize that the protein
doesn’t belong there and begin building an immune response and making
antibodies, like what happens in natural infection against COVID-19.
• The vaccine is a two-part vaccine, requiring that you get two doses to
assure immunity. For the Pfizer vaccine the doses are 21 days apart. For
the Moderna vaccine, the doses are 28 days apart.
• The vaccine is 95% effective for all adults, based upon the clinical trials.
• Few side effects were reported, but included fever, headache and fatigue.
• Please continue to follow all transmission-based protocols even after
being fully vaccinated.
February, March, April 2021 The Oklahoma Nurse 7
Three Lessons Learned During the COVID Crisis – As a Family
Member, A Caregiver and the Importance of the 3 C’s
Viki Saidleman, MS, RN
#1: Lessons Learned as a Family Member During
a COVID Crisis
When COVID is in the Room….
Nurse is eyes and ears
For so concerned family,
Of true compassion
When family not allowed.
CARE IS PALPABLE
#2: Lessons Learned as a Caregiver
Finally home after a 10-day hospital stay for
COVID-19 complications, my husband announced
his emergency. He could not find his cell phone.
Then, the search began. I immediately lapsed into
nurse mode. I interviewed him regarding the phone’s
last known location. I inspected the immediate
surrounding environment. I listened carefully for
possible sounds emitted by the phone. I palpated
around his body in the recliner to find the phone. I
knelt down to look more closely under his chair.
I looked up from my position on the floor as
he looked down from his seat in his chair. I was
prepared to declare the search a failure and the
phone permanently missing. Then I spotted it.
I used one hand to rest upon my husband’s
arm as I used my other hand to point to the phone
resting in his shirt pocket. I looked at him with
a victorious smile as he gazed at me with an
appreciative, gentle grin and slight nod.
In that moment, we really connected. We found
not only the phone, but much more. In the midst of
the pandemic, we found each other. We effectively
communicated care and compassion for one
another without uttering a word. The search was
In the frantic frenzy of my search for the
phone, I failed to truly take in the whole picture. I
orchestrated a near miss. I lost sight of not only the
phone but I also lost sight of my husband. He and
the phone were inches from me, but I was totally
oblivious and unaware.
While seeking the lessons learned during the
search, I asked myself some pointed questions.
How often do I during a task-focused day cause
near misses? How often am I so busy that I fail to
really see my family, my student, my patient and my
colleague? How often do I teach the importance of
the unique individual and preach patient centered
care, but how often do I actually practice these
concepts? Do I really take time to effectively
communicate care and compassion?
As a result of a successful search, I have begun
my next quest to achieve new future personal goals
for 2021. These goals are particularly appropriate
for a COVID crisis and apply to relationships with
family, students, patients and colleagues. I vow to
be more mindful in my interactions, more committed
to my search for the unique individual, more fixed
upon person-centered care and more attuned to my
mission to truly communicate care and compassion.
#3: Lessons Learned On the Importance of the
3 Cs during a COVID Crisis
As a nurse who has practiced 40 years with 30
years in nursing education, I have committed to lifelong
learning. With the evolving COVID pandemic,
I have discovered new lessons applicable to my
roles as nurse, patient, family member and nurse
educator. My personal experience confirms the
current increased importance of three key nursing
concepts. The 3 Cs are caring, compassion and
Although often difficult to describe, a challenge to
teach and even harder to develop and practice, it is
easy to detect when the 3 Cs are present.
As a nurse, I see the appreciation and relaxation
in a patient’s body language when I show caring,
compassion and effective communication. I
take the time to sit, be mindfully present, listen,
therapeutically communicate and use appropriate
touch all while social distancing, masking and using
appropriate hygiene. I see the difference.
As a patient, I feel the 3 Cs when my oncology
team takes the time in their busy day to return my
calls and answer my many questions, listen to my
story, empathize with my side effects and offer
possible solutions in a respectful manner.
As a family member of a parent in long-term care
during the pandemic, I detect 3 Cs when staff set
up window visits and Face-Time visits and relay
cards and messages for me. I appreciate when the
3 Cs are shown to me when hospice staff offer and
deliver lost glasses to my home after my mother’s
death because it was important to me even when it
was an extra 20 mile trip for them.
As a family member of a spouse hospitalized
during the pandemic when no visitors were allowed,
I sense the 3 Cs during unhurried phone updates
even though they occur without benefit of facial
expressions, body posture, gestures or touch. They
include the conscious effort of positive words of
hope, careful timing, appropriate tone and a perfect
use of silence. I feel care when staff call me and
hold the phone for my husband so we can visit for a
few moments. I experience care when staff ask how
I am doing, too.
As a nurse educator, I can detect students’
frustration and their anxiety learning in a totally
different environment, in preparing to enter practice
during a pandemic and in fearing if they will be
fully prepared with virtual learning and clinical
experiences. When I begin a 3 C conversation
addressing their possible feelings, I can hear
and almost palpate their sigh of relief as they
receive acceptance and acknowledgement of their
experiences and begin to verbalize them.
During this current COVID climate, multiple
barriers may block the 3 Cs. When patient census
is high and acuity heavy, when staffing is often suboptimal,
when competing priorities tax available
resources, when masks, social distancing and
isolation are present, when visitors may not be
allowed and when an even more stressful than usual
health care environment exists, the 3 Cs may take a
I choose to identify strategies to maintain,
develop and improve the 3 Cs of caring, compassion
and effective communication during a pandemic.
As a nurse, I will mindfully plan for the 3 Cs
by practicing smiling while sporting my personal
protective equipment, by providing adequate time
to communicate with both patient and family and
by finding opportunities to facilitate communication
virtually if possible.
As a patient and family member, I will thank
health care providers in person, by written notes
and in hospital surveys as I cite specific positive
experienced examples of the 3 Cs. I will verbally
relate what those caring behaviors and acts of
compassion mean to my family member and to me.
As a nurse educator, I will provide adequate time
to address affective learning outcomes that address
key soft skills. I will use personal stories, case
studies, simulations, role-play and critical thinking
in the classroom to develop and practice the 3 Cs.
I will select reflection and discussion activities for
clinical conferences to improve the 3 Cs. I will role
model the 3 Cs in my interactions with students,
Three Lessons Learned During the COVID...continued on page 13
The Oklahoma Nurse February, March, April 2021
Three risk areas nurses face in the time of COVID-19
Georgia Reiner, MS, Senior Risk Specialist,
Nurses Service Organization (NSO)
The spread of the coronavirus (COVID-19)
reinforces the dedication and selflessness of nursing
professionals. This is a scary and uncertain time
for everyone, especially nurses on the frontlines
working tirelessly to help curb the spread of
COVID-19 and balancing an influx of patients.
As nursing professionals work to provide the
best care possible to their patients during a difficult
time, they need to know the steps to take to mitigate
the risks that can impact their license, career and
Three risk areas nurses need to have on their
Using social media best practices
Nurses are held to a higher standard than others
because of their role as caretakers and because
they have intimate access to patients’ private
information. Their social media presence should
reflect this heightened responsibility, especially in
this uncertain time. Nurses must carefully consider
a patients right to privacy and act professionally
As the media and social media are consumed
by COVID-19 news, nurses may want to join in
and share their thoughts or may be tempted to air
their grievances. Online comments, or comments
to members of the media by a nurse regarding
employers or co-workers, even if posted from home
during nonwork hours, may violate their employer’s
social media or media relations policies. Violations
of employer policies may lead to employment
consequences for the nurse, including termination.
Nurses may want to think twice before posting or
otherwise giving the appearance they are speaking
on behalf of his or her employer unless authorized
to do so and must follow all applicable employer
Preventing medication errors
Nurses must continue to work to catch their own
potential medication errors, as well as the errors
of other healthcare providers in the medication
administration chain. Research has found that the
medication errors result from human factors, including
inadequate communication, biased reasoning,
reduced memory and insufficient training and
inexperience. 1-5 Nurses also identify distractions and
fatigue as contributing to medication errors - which are
factors that the COVID-19 crisis can exacerbate. 2
Since the beginning of April 2020, the Institute
for Safe Medication Practices (ISMP) has received
reports of COVID-19-related medication errors. 6
One error involved a redeployed OR nurse who
administered the wrong type of inhaler after
failing to engage unfamiliar barcode medication
administration technology. 6 Other missed dose
errors have been reported due to communication
failures between nurses and respiratory therapists. 6
To prevent medication errors and other adverse
outcomes, nurses pulled to an unfamiliar unit should
be oriented to the patient population, technologies,
processes and medications typically used on the
newly assigned unit. 6 Nurses should also employ
communication techniques such as a doublecheck/“check
back” to verify they understand all
verbal orders and instructions. 7
Preparing to accept unfamiliar assignments
Nurses are at the forefront of this public health
crisis—treating, educating and preventing the spread
of COVID-19. As the pandemic continues to evolve,
nurses may be given patient assignments outside of
their accustomed practice areas and locations. No
circumstances change nurses’ obligation practice
ethically, but nurses should be aware of their
employers’ protocols for protecting nurses operating
in extreme conditions and scarcities, and to ensure
that the public receives the most adequate treatment
and care possible in the situation.
With so much still unknown about the
coronavirus, it’s also important for nurses to be
aware of the steps they can take if they do not
feel equipped to handle an assignment. When the
assignment is within a nurse’s scope of practice
but not within their realm of experience or training,
saying “no” could lead to dismissal. In these
scenarios, nurses need to share their concerns
with his or her supervisor. Nurses should describe
the task or assignment they don’t feel equipped
to handle, the reason for their feelings, and the
training they would need to be more confident and
better prepared. Speaking up can lead to positive
outcomes for nurses and patients.
These are trying times for healthcare workers.
Being aware of potential risks helps nurses take
steps to protect themselves as they care for others.
1. The Joint Commission. Sentinel event data: root
causes by event type 2004-2012. 2012.
2. Choo J, Hutchinson A, Bucknall T. Nurses’ role in
medication safety. J Nurs Manag. 2010;18(7):853-
3. Brady AM, Malone AM, Fleming S. A literature review
of the individual and systems factors that contribute
to medication errors in nursing practice. J Nurs
4. Benner P, Sheets V, Uris P, Malloch K, Schwed K,
Jamison D. Individual, practice, and system causes
of errors in nursing: a taxonomy. J Nurs Adm.
5. Saintsing D, Gibson LM, Pennington AW. The novice
nurse and clinical decision-making: how to avoid
errors. J Nurs Manag. 2011;19(3):354-359.
6. Institute for Safe Medication Practices. COVID-19-
Related Medication Errors. 14 May 2020. Retrieved
7. Agency for Healthcare Research and Quality. Pocket
Guide: TeamSTEPPS. Content last reviewed January
Georgia Reiner, MS, Senior Risk Specialist,
Nurses Service Organization, Healthcare Division,
Aon Affinity, Philadelphia. Email: Georgia.Reiner@
This information has been provided as an
informational resource for Aon clients and business
partners. It is intended to provide general guidance
on potential exposures and is not intended to
provide medical advice or address medical
concerns or specific risk circumstances. Due to
the dynamic nature of infectious diseases, Aon
cannot be held liable for the guidance provided. We
strongly encourage visitors to seek additional safety,
medical and epidemiologic information from credible
sources such as the Centers for Disease Control
and Prevention and World Health Organization. As
regards insurance coverage questions, whether
coverage applies, or a policy will respond to any risk
or circumstance is subject to the specific terms and
conditions of the policies and contracts at issue and
This risk management information was provided
by Nurses Service Organization (NSO), the nation's
largest provider of nurses’ professional liability
insurance coverage for over 550,000 nurses since
1976. Oklahoma Nurses Association (ONA) endorses
the individual professional liability insurance policy
administered through NSO and underwritten
by American Casualty Company of Reading,
Pennsylvania, a CNA company. Reproduction
without permission of the publisher is prohibited. For
questions, send an e-mail to email@example.com or
call 1-800-247-1500. www.nso.com.
• RN System Chief Nursing Officer
• RN Manager Pre-Admission Testing
• RN Director of Education
• RN Administrative Director, Revenue Cycle Management
Community Hospital South:
RN ICU/Med Surg Nights, FT*
RN Med/Surg Nights, FT*
RN Pre-Admission Testing, FT*
RN Employee Health, FT
RN Quality Improvement Specialist
RN Pain, FT
RN ER, PRN
RN Med-Surg, PRN
*Sign On Bonus
$10,000 for FT Circulator
$10,000 for FT Med-Surg Nights
$7,500 for FT Med-Surg Days
$3,000 for FT Pre-Admission Testing
$3,000 for FT PreOp/PhaseII
Community Hospital North:
RN Med-Surg Nights, FT*
RN Circulator, FT*
RN Pre-Admission Testing, FT*
RN PreOp/Phase II, FT*
RN Med-Surg PRN
Northwest Surgical Hospital:
RN Lead OR Circulator, FT*
RN Lead PreOp/PACU, FT
RN Circulator, FT*
RN Med-Surg, PRN
RN PACU, PRN
Come join our award winning team!
3 LOCATIONS IN OKLAHOMA CITY!
COMMUNITY HOSPITAL SOUTH
COMMUNITY HOSPITAL NORTH
NORTHWEST SURGICAL HOSPITAL
Community Hospital/Northwest Surgical Hospital complies with Federal Civil Rights laws and
doesn’t discriminate on the basis of race, color, age, disability or nationality. Community
Hospital and Northwest Surgical Hospital are facilities in which physicians have an ownership
or investment interest. The list of physician owners is available upon request.
To apply, please visit www.communityhospitalokc.com or www.nwsurgicalokc.com.
David Ward, Recruiter, firstname.lastname@example.org, call or text 405-312-7496
February, March, April 2021 The Oklahoma Nurse 9
Professional Clarity 2020: Motivational Andragogy through
Shared Student Experiences
Samantha Acosta, Ian Fraser, Payton Hill, Amy
Hutchens, Sarah Kellog, Holly Leverett, Rachel
Pacheco, Kaylee Tompkins, The University of
Oklahoma Health Sciences Center
Adult students come with a wide variety of life
experiences and serve as rich resources for learning
(Knowles,1973). Andragogy conveys respect for people
by making use of their experience as a resource for
learning (Knowles, 1973). In the spring of 2020, The
University of Oklahoma Fran and Earl Ziegler College
of Nursing hosted the “OU Inspire” event. This event
engages principles of andragogy by giving nursing
students the opportunity to provide inspiration
and insight to their fellow students via motivational
speaking. The theme was Professional Clarity: 2020.
Junior and senior nursing students emceed the event
and delivered the content.
The first presenter delivered content on
mindfulness. The talk was titled “Mindfulness: Personal
and Professional.” The audience was led through a
guided imagery session and discussed the importance
of mindfulness in one’s daily activities. Mindful
meditation is the process of allowing thoughts to come
and go. Mindfulness and meditation is the ability to
exist in the present moment and not allow things to be
distracting (Kabat-Zinn, 1994). The oxford dictionary
defines meditation as “a mental state achieved by
concentrating while calmly accepting the feelings and
thoughts that come to you, used as a technique to
help you relax” (2020). Mindful meditation can help you
regulate emotions. In nursing, mindfulness has been
associated with a reduction in errors and increased
levels of compassion (Lin, Eckerle, Peng, & Moser,
The second presentation discussed
interprofessional communication. Effective
communication is not only about conveying a message
that you want to say, but it is about conveying the
message so that other people understand and
respond to it. (Communication: Effective vs Ineffective,
n.d). Ineffective communication can occur and lead
to communication breakdown as both parties fail to
deliver or process the received message. Effective
communication stems from listening, not interrupting,
confirming and your understanding (Forbes Coaches
The third speech was titled “Transitioning from
Student to Professional: Testimony from New Nurses.”
Testimony was gathered from previous graduates and
a current student reported on the findings. Advice was
shared on transitioning from student to nurse. Coming
to work with an eagerness to learn, being teachable,
asking questions and self-care were recommendations
provided by novice nurses. The three key components
easing the transition from student to professional
included addressing your insecurities now, taking
care of yourself now and cultivating your “why.”
Addressing insecurities includes talking about anxiety,
being authentic with faculty and employers, practicing
coping strategies and knowing that anxiety does not
make you a bad nurse. The components of self-care
included taking care of your physical self so that you
can take care of others and keeping your mind sharp.
Cultivating your “why” was noted as what drives
passion. For many nurses this is the patient. The
presentation concluded with a quote from Abraham
Lincoln. “Next to creating a life, the finest thing a man
can do is save one.”
The last talk delivered was “A Nurses Impact During
Life Changing Events.” The student spoke about the
emotional impact of health care professionals during
end of life and included the story of a very personal
loss. Below is an excerpt of the presentation.
Nurses have the biggest impact in creating a
positive death story. By showing emotion and
assisting the family in the grieving process,
the nurse will impact the family’s experience
forever. It is acceptable for the nurse and
healthcare workers to show emotion during a
tragic experience or death! When healthcare
providers display emotion and sympathy it
shows the family that they care about the patient
and value the patient’s life. Death is inevitably
going to happen to all of us and it is up to the
nurses to help orchestrate a beautiful death by
inviting and empowering the family and allowing
them time to heal. If you find yourself becoming
desensitized to death, take a step back and take
time to reflect on the situation and the patient.
Every patient deserves the upmost respect
during their death. In 2016, my 13-year-old
daughter was involved in a fatal ATV accident.
The healthcare team and law enforcement
officers showed emotion and listened to my
wishes, aiding me and my family in our grieving
process. Their actions helped orchestrate a
positive death experience. Looking back if
the healthcare team was emotionless and
unsympathetic, the hospital experience would
have negatively impacted and haunted us all for
the rest of our lives.
In the words of my daughter, “Your goal in life
shouldn’t be to live forever, but to create something
that will…a legacy is my goal.”
I encourage all of you nurses to think about what
kind of impact you are going to have as a nurse
and what legacy you are going to leave behind.
For further information on how to enhance your
thinking around the end of life experience please
visit the End Well Project at endwellproject.org.
Utilizing principles of Malcolm Knowles andragogy
nurse educators can draw on student experiences to
provide long lasting and impactful learning. Nursing
students come with their own life experiences and can
provide peer directed education that is unforgettable
and enthusiastically received by their classmates.
Communication: Effective vs Ineffective. (n.d.).
Retrieved August 25, 2020 from https://
Forbes Coaches Council. (2017, August 29). Council Post:
16 Effective Ways To Break Bad Communication
Habits. Retrieved August 25, 2020 from https://www.
Kabat-Zinn J. (1994) Wherever You Go, There You Are:
Mindfulness Meditation in Everyday Life. New York, NY:
Knowles, M. (1973) The Adult Learner: A Neglected Species.
Houston Texas: Gulf Publishing Company
Lin, Y., Eckerle, W. D., Peng, L. W., & Moser, J. S. (2019). On
Variation in Mindfulness Training: A Multimodal Study of
Brief Open Monitoring Meditation on Error Monitoring.
Brain sciences, 9(9), 226. https://doi.org/10.3390/
The Oklahoma Nurse February, March, April 2021
The Value of Grit and Resilience During a Global Pandemic
Heather M. Humphreys, DNP, RN, CNE, and
Dana S. Woody, DNP, RN
Reprinted with permission from American Nurse
changed the landscape
of the healthcare
industry. In fact, it has
warped an already
and made for one that
breeds higher levels of
stress and anxiety than
ever before. Do you know
what is needed to not
only survive, but to thrive,
as a nurse during this time of crisis?
In 2006, the Robert Wood Johnson Project
brought increased awareness of nurse attitudes
and turnover rates with The RN Work Project. Data
indicated that around 18% of new nurses leave
their first nursing job within one year, and 26.2%
leave within two years. Recent (2019) data from NSI
Nursing Solutions indicates an increasing trend,
with approximately 23% of new RNs leaving their
jobs in the first year and one-third leaving within two
years. Overall, bedside RN turnover ranges from
4.5% to 43.9%, and national RN vacancy rates are
of concern at about 9%. Sadly, many nurses also
report feeling burnt out and being disengaged.
Though we have yet to see the full impact of
COVID-19 on nurses in the United States, a recent
study published in JAMA Network Open indicates
that healthcare professionals in China involved
in direct care of COVID-19 patients experienced
symptoms of depression and increased anxiety,
insomnia, and distress. What are we waiting for?
The time is now to address what nurses need to
remain on the frontlines and maintain their passion
for the nursing profession.
Grit and resilience
Angela Duckworth defines grit as passion
and perseverance to achieve long-term goals.
Individuals who are “gritty” are engaged in their
work and able to persevere in spite of negative or
difficult life events. They are motivated and flexible
in using a variety of strategies to reach goals, which
cushions them against the impact of hardships.
Resilience is defined as the ability to bounce back
after adversity or failure. Grit and resilience increase
well-being and decrease burnout.
Globally, the nursing profession is celebrating
“The Year of the Nurse and the Midwife.” Nurses
make up the majority of the worldwide healthcare
workforce and are now recognized as “essential
workers” and “heroes.” Despite positive public
opinion and the rewarding nature of the profession,
we are experiencing a nursing shortage. The
Bureau of Labor Statistics predicts that the United
States will need an additional 200,000 nurses per
year from now until 2026; this is just projected for
one country. Your gifts and talents are needed and
appreciated. The statistics sound daunting, but
consider these characteristics of grit and resilience
as you grow in the profession of nursing.
How to thrive
Do you know what it takes to thrive in the new
healthcare landscape? Literature provides insight
regarding the need for grit and resilience in nursing.
Consider these strategies in your nursing practice:
Realize that mindset does matter. Though
nurses are educated using a generalist approach,
our clinical practice usually focuses on a single
specialty area. After becoming accustomed to one
specialty, it can be intimidating to work in a new
and unfamiliar setting or with a different patient
population—reverting back to the novice nurse. If
we approach recent changes in healthcare with a
growth mindset, realizing we are capable of learning
new things, we are more likely to have a positive
Let learning renew your passion. Florence
Nightingale defined the art and science of the
nursing profession; this includes a life-long
commitment to learning. Nurses working in a time of
crisis can build on their existing skills and learn new
ones to deepen their passion for the profession. Get
your game on, renew your passion, and find your
Remember your purpose. Perhaps you started
your nursing career with the “dream job” mindset;
now you are questioning your purpose. According
to the American Nurses Association, nursing is
the protection, promotion, and optimization of
health and abilities, prevention of illness and injury,
alleviation of suffering, and advocacy in the delivery
of care. This is YOU—remind yourself of your
Maintain “wholeness of character.” As nurses,
we know the importance of providing holistic care
for our patients, but we frequently neglect selfcare.
The ANA Code of Ethics tells us that we owe
SEVERAL POSITIONS AVAILABLE:
• Emergency Room
• Labor and Delivery
• Home Health
• Operating Room
• Med/Surg • ICU
• Hospice • Cath Lab
• Rehab • Resource/Float
LUCRATIVE BENEFIT PACKAGE • 97% EMPLOYEE SATISFACTION
Modern Healthcare’s Best Places To Work - 8 Years in a row!
the same duties to ourselves as to others, including
maintaining “wholeness of character.” One essential
aspect of self-care is spiritual self-care, which can
involve a variety of activities such as attending
religious services, prayer, and reflective journaling.
Spiritual care promotes spiritual well-being, which
is associated with resilience among nurses,
supporting a decrease in emotional exhaustion that
is often associated with working in a high-stress
Cultivate a strong support system. The
support of family, friends, and co-workers is integral
to building grit and resilience. Staying connected
and avoiding feelings of isolation are pivotal.
Recent literature suggests that COVID-19 has
greatly impacted the mental health of the nursing
workforce, and steps need to be taken to ensure
mental well-being in this time of uncertainty and
Surround yourself with support, keep up the
social distancing norm, and find ways to take care
The time is now
Evidence supports the association of grit
and resilience with feelings of well-being, career
satisfaction, decreased emotional distress, and
decreased attrition rates. The time is now to
consider these characteristics in your professional
mindset and ensure you have the grit and resilience
to thrive in your nursing career.
Heather M. Humphreys is associate professor and
Dana S. Woody is associate professor at the Liberty
University School of Nursing in Lynchburg, Virginia.
American Nurses Association. Code of ethics with
interpretive statements. https://www.nursingworld.org/
American Nurses Association. What is nursing? n.d.
Duckworth A. Grit: The Power of Passion and
Perseverance. Scriber; 2016.
Duckworth A. 2020. Angela Duckworth Q&A: What is grit?
Dweck C. Mindset: The New Psychology of Success: How
We Can Learn to Fulfill our Potential. The Random
House Publishing Group; 2006.
Lai J, Ma S, Wang Y, et al. Factors associated with
mental health outcomes among health care workers
exposed to coronavirus disease. JAMA Netw Open.
Mealer M, Jones J, Meek P. Factors affecting resilience
and development of posttraumatic stress disorder in
critical care nurses. Am J Crit Care. 2017;26(3):184-92.
NSI Nursing Solutions, Inc. 2019 NSI National health
care retention & RN staffing report. 2019.
O’Keefe PA, Dweck CS, Walton, GM. Implicit theories
of interest: Finding your passion or developing it?
Psychol Sci. 2018;29(10):1653-64.
Pines EW, Rauschhuber ML, Norgan GH, et al. Stress
resiliency, psychological empowerment and conflict
management styles among baccalaureate nursing
students. J Adv Nurs. 2012;68(7):1482-93.
PRC. National nursing engagement report. 2019.
Rushton C, Batcheller J, Schroeder K, Donohue P. Burnout
and resilience among nurses practicing in highintensity
settings. Am J Crit Care. 2015;24(5):412-20.
Salles A, Cohen G, Mueller C. The relationship between grit
and resident well-being. Am J Surg. 2014;207(2):251-
Suzuki Y, Tamesue D, Asahi K, Ishikawa Y. Grit and work
engagement: A cross-sectional study. PLoS ONE.
World Health Organization. The international year of the
nurse and the midwife. 2020. https://www.who.int/
February, March, April 2021 The Oklahoma Nurse 11
I Give You Permission
to Fall Apart
By Sherry Stofko, MSN, RN
Reprinted with permission from Nevada RNformation August 2020 issue
Nurses Never Stop Learning
Tina Edwards MBA, MSN RN
ONA Emerging Nurse Director
Dear fellow nurse:
I give you permission to be anxious, fearful, angry, broken-hearted. I free
you of your unwavering sacrifice, loyalty, grit, and determination. I am granting
you liberty to experience your brokenness, exhaustion, overwhelm, and grief.
I encourage you to drop into your shadow emotions and to let them out with
a death wail or Irish funeral cry in the open Nevada landscape. I give you
permission to fall apart.
Our lives took an unprecedented turn in mid-March, one we never
anticipated, but certainly now find as no surprise: a respiratory-spread,
communicable disease passed effortlessly around our globally-connected
world and “suddenly” rocking the human race. How could “we” not have had
forethought and been ready for this? Clearly, we were not prepared in any way;
we were not equipped with PPE, with governance and policy, or with coping
mechanisms. In my 25 years as a hospital-based RN, I have never experienced
such widespread risk, fear, uncertainty, misinformation, rapid change, and
lack of strong leadership, let alone all of this concurrently. For many, the
associated emotional roller coaster involves denial, anger, sadness, isolation,
and boredom. For healthcare workers, we have the privilege of adding in several
• Shock: “How is this happening in the United States in 2020?”
• Betrayal: “They want us to wear the same mask for a week?”
• Envy: “Stop complaining that you’re bored at home when I’m getting
pummeled at work.”
• Frustration: “If I get one more 500-word email about another new policy, I
• Fear: “What if I bring it home to my family?”
• Exhaustion: “I can’t bear to drag myself in there again tonight.”
• Terror: “The nightmares and insomnia are killing me.”
• Grief: “What happened to my old life?”
• Guilt: “I wish I could do more.”
All of these reactions are completely normal during a disaster, a global
catastrophe, a pandemic, or any crisis event. The issue here is that this is not
merely an incident; it’s ongoing with no clear end in sight. Our stress levels, and
therefore our cortisol and epinephrine levels, are chronically elevated. We are
living in our sympathetic nervous systems - freeze, fight, or flight. We spend
most of our time trapped in a limbic hijack. As nurses, we have no refuge –
both work and home are incredibly stressful. It’s during times like these when
we discover if our coping mechanisms and resilience are strong enough to
withstand the chaos and uncertainty.
And they are. My dear healthcare brothers and sisters, we are enduring. It
may not be pretty; in fact, it is probably embarrassingly messy. There should be
no shame in it. Times are really tough. Nothing is ideal. But we are enduring. We
are fluctuating through the stages of grief and, ever so slowly, we are moving
towards acceptance and maybe even finding meaning in it all. During this
time, be gentle with yourself. Reach out for help. Finally make that counseling
appointment. Find a support group. Journal. Share. Practice self-compassion.
Scream out loud in the woods. When I feel emotionally flooded, I find calmness
in pausing for a few seconds, then incorporating the acronym “RAIN.” It stands
• Recognize what is happening: thoughts, behaviors, emotions.
• Allow the experience to just be there without trying to change anything.
• Investigate what you are feeling with curiosity and non-judgement.
• Nurture yourself with self-compassion and self-care (Brach, 2013).
Being in a new environment with increased expectations and an atmosphere
of seasoned nurses may give some a feeling of unease. There is a wealth of
knowledge surrounding you, yet you don’t want to be seen as the new nurse
who is unsure of her/himself. If only nursing school provided a survival guide
along with the gazillion other courses and assignments, we may feel more
ready. Despite that feeling of uncertainty, you are not alone. Those seasoned
nurses are still learning too! Education does not stop after graduating nursing
school; with multiple changes in healthcare, new medications, shifts in
paradigms and the pandemic crisis, we are all learning something new every
day and every shift.
With all that being said, you should continue to educate yourself continuously
and create a mindset that there is much to learn.
- Have a patient with an illness or disease you have never heard of? Study
- A new medication is developed for heart failure. Read about it.
- A different theory on nursing practice. Acquire the knowledge.
- A new policy or procedure in your department. Teach and live by it.
Continuing education does not necessarily mean that you have to go on
to graduate school, it simply means that you are empowering yourself to not
become stagnant and obsolete. At times of uncertainty I often look to this
quote for guidance and inspiration to continue learning, “Let us never consider
ourselves finished nurses…. we must be learning all of our lives.” - Florence
Hiring Experienced Nurses for
M/S • PCU • ICU • SDU and
New Grad Residency Program available for Med/Surg/PCU
Sign-on bonus available!
We offer competitive pay and
a comprehensive benefits package!
Apply online today!
Contact our HR office
for more information,
Perhaps all this falling apart can help us come together… together with
our loved ones, with our co-workers, with other nurses nationally. It is time to
prioritize our self-care and strengthen our resilience as nurses and as humans.
Now, we ought to finally demand our employers recognize and mitigate the
effects of work-related trauma on the mental wellbeing of their employees. We
must band together, focusing on what is important in our field: safety, wellness,
and solidarity of nurses, which inevitably and undeniably leads to improved
safety and wellness of the patients in our care and in our communities.
Let us all give each other permission to fall apart during this time. In the
falling, I encourage us to explore ways to cushion the fall. And in our collective
falling apart, let us “fall forward together.”
Brach, T. (2013). The RAIN of self-compassion. https://www.tarabrach.com/wp-content/
Chisholm, C., Personal conversation, 5/6/2020
Moskowitz, M. (2020). Emotional world of healthcare providers. https://www.
The Oklahoma Nurse February, March, April 2021
The Importance of Nurses Addressing Implicit Bias
Ahnyel Jones-Burkes, DNP, RN-BC
Director of Leadership and Professional
Reprinted with permission from Louisiana State
Nurses Association Pelican News July 2020 issue
Implicit Bias functions in an unconscious or
unintentional manner, and this type of bias does not
necessitate the perceiver to approve it or dedicate
attention to its expression (Blair, Steiner & Havranek,
2011) Research shows there is a correlation between
implicit bias and healthcare disparities. Issues like
COVID-19 and maternal mortality have highlighted
the impacts of health disparities. The Center for
Disease Control defines Health Disparities as
preventable differences in the burden of disease,
injury, violence or opportunities to achieve
optimal health that are experienced by socially
disadvantaged populations. (Centers for Disease
Control and Prevention, 2018). We are in the perfect
position as the most trusted profession to ensure
we address healthcare disparities while guarding
against implicit and explicit biases because it can
negatively impact patient care.
Health Disparities can be caused by poverty,
environmental threats, inadequate access to
health care, individual and behavioral factors, and
educational inequalities (Centers for Disease Control
and Prevention, 2018) In recent events we have seen
just how important it is to understand the issues
impacting the communities we serve. These events
should strengthen our commitment as a profession
to provide the best possible care for each patient
We must strive for health equity which is defined
by Healthy People 2020 as the “attainment of the
highest level of health for all people” (Healthy People
2020). To achieve health equity, we as healthcare
providers must take an active role in examining
the patient holistically while striving to eliminate all
barriers and biases.
The Institute for Healthcare Improvement
recommends the below strategies to reduce Implicit
• Stereotype replacement – identifying
responses based on stereotypes and
consciously changing the response.
• Counter-stereotypic imaging – Imaging the
individual as the opposite of the stereotype.
• Individuation – Seeing the person as an
individual rather than a stereotype (e.g.,
learning about their personal history and the
context that brought them to the doctor’s
office or health center).
• Perspective taking – “Putting yourself in the
other person’s shoes.”
• Increasing opportunities for contact with
individuals from different groups – Expanding
one’s network of friends and colleagues or
attending events where people of other racial
and ethnic groups, gender identities, sexual
orientation, and other groups may be present.
• Partnership building – Reframing the
interaction with the patient as one between
collaborating equals, rather than between a
high-status person and a low-status person.
(IHI Multimedia Team, 2017)
The above recommendations also align with
recommendations from the Joint Commission
regarding overcoming implicit bias. If you would
like to gauge your own implicit bias there is an
assessment which is a free tool named the Implicit
Blair, I. V., Steiner, J. F., & Havranek, E. P. (2011).
Unconscious (implicit) bias and health disparities:
where do we go from here?. The Permanente journal,
Centers for Disease Control and Prevention. “Disparities.”
Centers for Disease Control and Prevention, Centers
for Disease Control and Prevention, 17 Aug. 2018,
“Disparities.” Disparities | Healthy People 2020, www.
IHI Multimedia Team. “How to Reduce Implicit Bias.”
Institute for Healthcare Improvement, 26 Sept. 2017,
Hiring for Assistant
Professor of Nursing
Tulsa Community College is an enjoyable
and exciting place for both students to
learn and continue their education and
for employees to develop career-long
JOIN OUR TEAM AS A
Public Health Nurse
and make a difference in the lives of Oklahomans.
u Licensed Practical Nurses
u Registered Nurses
u Nursing Managers
u Advanced Practice
May be eligible for the
NURSE CORPS LOAN
Find out more: jobs.ok.gov
Filter by Agency g State
Department of Health
Statewide locations g competitive salary and benefits
package (includes a generous benefits allowance) g
paid time off g retirement g M-F, 8-5, off nights g
weekends and holidays, etc.
Questions? Call: 405-271-4171
February, March, April 2021 The Oklahoma Nurse 13
Nurse Refresher Course
Three Lessons Learned During the COVID...continued
from page 7
Kim R. Hinds, DNP, RN, CNE
Jaye Lynn Robertson, MS, MA, DNP, RN, CNEP
For more than two decades, there has been a
shortage of licensed practical nurses and registered
nurses in Oklahoma. Today, Oklahoma does not
have enough nurses to meet the needs of critically
ill COVID-19 patients and continue to meet the inpatient
and out-patient needs of medical-surgical,
pediatric, neonatal and all other types of patients.
Health system nurse executives and their academic
partners are collaborating to address this acute
One strategy being used in Oklahoma to increase
the number of available registered nurses (RNs)
and licensed practical nurses (LPNs) is the offering
of a Nurse Refresher Course by the University
of Oklahoma, Fran and Earl Ziegler College of
Nursing in collaboration with Oklahoma Career Tech
System. This course is designed to update nursing
knowledge and skills in order to meet continuing
qualifications for practice as required by the
Oklahoma Board of Nursing.
Recently, based on changes in policy made
by the Oklahoma Board of Nursing, the Nurse
Refresher Course has been revised to use a
competency-based framework where specific
knowledge and skill outcomes are used to evaluate
achievement. This methodology recognizes that
students learn differently and may require a
different amount of time to achieve the competency
requirements of the course.
The updated Nurse Refresher Course allows
students to move through the course at their own
pace, while focusing on his or her specific learning
needs to meet continuing qualifications for practice
as required by the Oklahoma Board of Nursing.
After completing the online didactic portion of the
course, students may now complete the skills and
clinical experience portion of the course in as little
as 40 hours. Using a competency-based framework
and reducing the number of clinical hours decreases
learning and time barriers and potentially increases
the number of available registered RNs and LPNs for
Oklahoma nurses seeking to return to practice
and/or refresh their nursing knowledge and skills
should review the Oklahoma Board of Nursing
Instructions for reinstatement or return to active
status of RN or LP single-state license (https://
nursing.ok.gov/reinstateappl07.pdf) and the
Oklahoma Board of Nursing Refresher Course Policy
the Oklahoma Board of Nursing is also encouraged
to ensure enrollment in the Nurse Refresher Course
meets the continuing qualifications for practice
requirements for one’s particular situation.
To register for the Nurse Refresher Program,
contact an approved Career Tech Center and
complete an application. Additional information
about the Oklahoma Board of Nursing Board-
Approved Refresher Courses can be found at
Flyer.October.2020.pdf. The course fee is $2,000
and includes access to the online course or four
months, lab and simulated clinical experience
With the COVID-19 pandemic surge, creating
a way for nurses to update their knowledge, skills
and meet the continuing qualifications for practice
is one strategy nurse leaders have implemented to
increase the number of available registered nurses
(RNs) and licensed practical nurses (LPNs) for
clients and families. I will take time to check-in with
the students regarding their emotional health.
In the current COVID crisis, much has changed.
As nurses, social distancing and isolation
interventions change our practice. As patients
and family members, health care changes as
family members may not be able to be physically
present to provide support. As a nurse educator,
the educational environment changes with social
distancing as we adjust teaching/learning strategies
for class, lab and clinical.
What has not changed is the critical importance
of the nurse equipped with the ability and skills
to provide much needed care, compassion
and effective communication–even in a COVID
pandemic. May we all rise to the challenge, adapt
to the new health care climate and do what we do
best as nurses–provide the 3 Cs and truly make a
Work in June and July, room & board + stipend (DOE).
Perfect for a school nurse looking for extra income but
wanting some summer vacation!
YMCA Camp Takatoka is the overnight camp for the
YMCA of Greater Tulsa. Conveniently located just 45 minutes east of
Tulsa on 410 acres of beautiful lakefront land with diverse geography
at Fort Gibson Lake, children experience life-changing programming
based on the YMCA’s four core values of Caring, Honesty, Respect &
Camp Takatoka at
NursingALD.com can point you
right to that perfect NURSING JOB!
Free to Nurses
Easy to Use
E-mailed Job Leads
The Oklahoma Nurse February, March, April 2021
Nursing Policy in Times of Uncertainty surviving,
thriving on the edge
Leadership in policy and
care quality and safety
Rebecca M. Patton, DNP, RN, CNOR, FAAN
Margarete L. Zalon, PhD, RN, ACNS-BC,
FAAN, Ruth Ludwick, PhD, RN-BC, APRN-
CNS, FAAN, Marian K. Shaughnessy
Nurse Leadership Academy
Case Western Reserve University
As we confront new and existing realities
and move into this decade launched by
the Year of the Nurse and Midwife, we
critically examine the history and the future
of nursing by inaugurating a new column
called, Leadership in Policy, Care Quality
and Safety. The purpose of the column is
to engage nurses in dialogue and galvanize
them to take leadership in the individual but
overlapping aspects of policy, care quality
and safety. Each quarter you will find a short
column on a topic related to one or more of
these intersecting factors. Leadership is the
framework that underpins each column. We
believe that no matter where nurses work or
the position held, leadership is a critical skill
for all nurses not only those who hold titles that
imply leadership, e.g. manager, director, dean,
but every nurse regardless of practice setting
or role. Our goal is to raise awareness about
the leadership opportunities in policy, care
quality, and safety across settings, specialties,
communities and the globe by focusing on
inspiring exemplars and action steps that can
be taken by nurses.
Rebecca M. Patton, DNP, RN, CNOR, FAAN
Margarete L. Zalon, PhD, RN, ACNS-BC, FAAN
Ruth Ludwick, PhD, RN-BC, APRN-CNS, FAAN
Marian K. Shaughnessy
Nurse Leadership Academy
Case Western Reserve University
Call to Action
As we write this column during the COVID-19
pandemic, we are in the midst of unprecedented
change and risk for our personal lives, our families,
our professional lives, our communities, our country,
and our world. Little did we think when we planned
this column about policy, leadership, quality and
safety that we would be facing one of the greatest
challenges in our lifetimes. This crisis has thrust nurses
into the forefront of the public’s mind. How ironic that
this coincides with the World Health Organization’s
declaration that this is the Year of the Nurse and the
CSL Plasma is seeking FT LPNs to join
our medical staff associate team in our
Oklahoma City and Norman facilities.
We offer competitive salary,
great benefit package which
includes medical, dental,
401K, career advancement
reimbursement, and 3
weeks vacation the first year.
APPLY ONLINE AT CSLPLASMA.COM
Midwife. While nurses are essential on the frontlines
at the sharp edge of care, it is the lens of nurses that
provide critical insights in evaluating and formulating
policy to achieve quality and safety patient care
Everyday nurses walk the tightrope of uncertainty.
The uncertainty of practice is a constant that
requires the attention of all nurses, vigilance, and
most importantly activism. COVID-19 has magnified
these unknowns to astronomical proportions. The
accelerated pace of uncertainty with COVID-19 has led
to care dilemmas and crises, with variations in practice
standards that negatively impact health outcomes.
We are bombarded with challenges like mass
shootings, climate change, water supply, and emerging
diseases. Now we are in the midst of a pandemic,
which not only impacts the health of our communities
and workforce, but has dire financial consequences
for so many. How many of these challenges have
you faced? What challenges have you faced that are
not even listed here? What will come next? We don’t
always know what will come next. We do know that
nurses will be there on the frontlines. When nurses
are asked to volunteer in a crisis, they show up for
wars, disasters, and pandemics. Nurses are in the
frontlines of policy implementation. Often in times of
crisis, policies are disregarded, ignored, or unofficially
discarded. Nurses often know whether a policy is
workable, flawed or whether it is doomed to fail. We
have seen policy failures like changing instructions
on the use of personal protective equipment (PPE) as
supplies dwindle. On the other hand, times of crisis
can lead to policy gains as illustrated by a willingness
to allow advance practice registered nurses full
To counteract policy failures, correct flaws and take
advantage of opportunities for policy advancements,
we need to be knowledgeable, and prepared. This
means participating in policy so that we understand
concerns expressed by broad constituencies and take
action using our nursing expertise. This expertise is
needed so that the policies are realistic, workable and
meet the needs they were designed to address. Policy
is more than enacting a law; it includes formulating
rules, regulations and guidelines. Policies occur at
many levels, often simply referred to as Big “P” and
little “p”, the former often focus on state, federal or
international laws and the latter to local government or
local associations or organizations.
Move to Action
Moving to action requires identifying the preferred
outcome with clarity. This is achieved by examining the
data, sharing information, and capitalize on your skills
to move an issue forward.
Know the data, appraise credibility of sources, and
interpret its meaning
“In God we trust, but everyone else needs to bring
This quote attributed to Edward Fisher when
testifying before Congress (Source) is a fitting start
for policy involvement. Nurses have the knowledge
and are in a unique position to use and leverage
Come and join our
Visit our website for full job descriptions,
or to apply online: www.eomchospital.com.
Give our HR Department a call at 918-635-3360.
Nurse Practitioner | RN | LPN | CNA
Eastern Oklahoma Medical Center - Poteau, Oklahoma
Taking care of your family since 1950.
data for patient advocacy. Knowing the data,
appraising sources and interpreting its meaning are
critical steps in the processes for research, quality
improvement and evidence-based practice. Nurses
all have intellectual capital related to these processes
regardless of their practice setting or role. Your
intellectual capital can be enhanced with the following
• Use the resources available from professional
associations: the American Nurses Association,
state nurses associations, specialty nurses
associations and interdisciplinary professional
• Subscribe to a wide variety of data sources
including journals, news alerts, list servs
• Track and identify progress on issues you are
• Determine the credibility of sources
• Verify the facts
• Identify content experts for policy issues
• Interpret the meaning
• Identify policy implications of research and
quality improvement projects
• Identify the strengths and weaknesses in the
data in support of your
• Sift fact verifying the facts and determining the
credibility of sources
• Interpret the meaning of information
Have the stories, share them widely.
Stories can be more powerful than only presenting
data. Stories provide an emotional tug, create drama,
and provide context. Stories get attention, but data
strengthens the power of stories. Most stories have
multiple audiences. Framing your story in a way that
varying audiences understand transmits important
knowledge and fosters identification with stark
realities. Storying telling is subject to several caveats.
With the advent of social media, sharing stories has
become easier, it also has created a medium for
false stories to grow exponentially (as they are often
salaciously framed). Second, be aware of people
and organizations that try to block stories, especially
when bad news happens. (p 320 book) As the most
trusted profession, nurses have a strategic position
opportunity to frame and share their narratives widely
with a variety of audiences at the little p to the Big P
to level as outlined below varying audiences and frame
stories using the following avenues. These strategies
are not static and can be adapted to the virtual world.
Garnering the support of colleagues, stakeholders and
the public can be accomplished with these strategies:
• Post digital content (social media)
• Disseminate facts and reports in print media
(fact sheets, policy briefs, articles, letters, press
• Disseminate research findings
• Engage key stakeholders
• Contact legislators about key issues on an
ongoing basis and when votes come up
• Speaking up at public meetings
• Presenting in public forums
• Model inspirational behaviors
• Participate in town hall meetings
• Meet with legislators and regulators
• Create elevator speeches
• Be social media savvy
Know your skills, capitalize on them.
Nurses have the skills to move beyond only being
implementers of policy and only on the sharp edge
of policies; we need to be the developers of policies.
To capitalize on the potential of four million nurses, all
nurses in any setting or role need to assess how their
skills can be applied to policy. This positions nurses to
enhance practice and the work environment as well as
advance issues of importance to nurses and the public
we serve. Policy work needs to become ingrained as
part of the culture of nursing. P. 470
Common and overlooked strategies to improve an
individual policy role would include the following which
you can act upon immediately :
February, March, April 2021 The Oklahoma Nurse 15
• Register and vote
• Be a poll worker
• Join interest-based organizations and become an active member
• Finding a mentor
• Volunteer to work on a campaign.
• Serve on a workplace committee, task force or practice council
• Attend networking events
• Participate in legislative days
• Contribute to candidates and political action committees
• Complete your profile for Nurses on Boards (nursesonboard.org)
• Seek local community board positions
• Communicate with elected officials
• Capitalize on workplace communication channels for policy discussions
• Volunteering for an organizational or community-based initiative
The following are generally are longer term actions, but can be done in the shortterm
as well depending your policy trajectory:
• Assume a leadership role for a workplace committee, task force or practice
• Be a mentor
• Representing your organization to the external community
• Seek an internship or fellowship with a legislator or other policymaker
• Further your formal policy and content education
• Serve on a political action committee board
• Seek a board position
• Volunteer for appointed office
• Run for office in your organization or community
In times of uncertainty, there are certainties. One certainty is the mandate for
all nurses becoming involved in policy. The American Nurses Association’s Code
of Ethics for Nurses’ (2015) supports nurses’ roles in policy with the expectation
that nurses advocate for the health and safety of patients, collaborate in the
promotion of health, work to improve the ethical environment of practice settings,
and advance the profession through nursing and health policy.
We have highlighted strategies that nurses should use to increase their
involvement in making policy decisions to strengthen our practice and improve the
health of the public we serve. The collective action of over four million nurses in our
country and 21 million nurses across the globe has the potential to be a powerful
force for policy change.
American Nurses Association. (2015). Code of Ethics for Nurses with interpretive statements. Silver
Spring, MD: Author. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/codeof-ethics-for-nurses/