North Dakota Nurse - April 2021


The North Dakota Nurse

We Celebrate Nurses!

May is Nurses Month!



Sent to all North Dakota Nurses courtesy of the North Dakota Nurses Association (NDNA). Receiving this newsletter

does not mean that you are a member of NDNA. To join please go to and click on “Join.”

Quarterly publication distributed to approximately 20,000 APRNs, RNs, and LPNs in North Dakota

Vol. 90 • Number 2 April, May, June 2021


Message from the President

Time to reflect on past and move

to future!

How To Help A Nurse With Their

Anxieties And Depression

Page 6

Learning and Working Through a


Page 8

ND Nurse: Resilience Series 5 of 7

Page 10

Greetings Nurses of North Dakota! I want to

start out with acknowledging each one of you

and extending my gratitude as the President of

the North Dakota Nurses Association. We have

now surpassed the year mark from the start

of the most memorable year of our working

lives as nurses. The last year in healthcare in

our state and our nation have been some of

the most uncertain, trying, fulfilling, and scary

moments most of us have ever been in and

will ever be in. It was completely humbling to

see all the wonderful nurses and healthcare

providers in our state come together for the

healthcare of our people. I also want to thank

the members and nurses for allowing me so

many opportunities in the last year to advocate

for you and speak on all our behalf as nurses!

Many of us are probably thinking, “What’s

next?” Well, spring is here, and summer is just

around the corner. As we welcome May, we

get to celebrate National Nurses Week! This is

an exciting time for us to reflect on our career

and the difference we make in the healthcare

industry especially in the last year. The year 2020

was “The Year of the Nurse,” and was it ever!

Did you ever wonder how many nurses there

are in the world? There are 19.3 million nurses

and midwives according to the World Health

Organization's World Health Statistics Report.

Hearing that, there is no question as to why we

ARE the backbone of healthcare. As discussed

by ANA, Nurses have been working on getting

recognized formally by establishing a Nurses Day

since Dorothy Sutherland of the U.S. Department

of Health, Education, and Welfare sent a

proposal to President Eisenhower to proclaim a

"Nurse Day" in 1953. According to ANA, “National

Nurses Week begins each

year on May 6th and ends

on May 12th, Florence

Nightingale's birthday.

These permanent dates

enhance planning and

position National Nurses

Week as an established recognition event.”

Tessa Johnson

During the past year, nurses just did what

we do! We packed away our celebratory

banners and put on masks and shields. Some

of us worked as never before, in dangerous and

heart-breaking situations. Others are physically

distanced from our vulnerable patients, doing

our best to care for them without the benefit of

proper assessments. Regardless of the situation,

without a doubt, nurses have stepped right in

and got the job done (Heale, 2020). I could not

be prouder of my nursing colleagues and to be

a nurse! I take this time to thank you all for your

heroic work. Like many of you, I look forward to

a new normal. I am now, more than ever, proud

to be a ND nurse!! We should be so proud of

ourselves for being brave, speaking and making

sure our voice was at the table and our hands

and hearts were safely at the bedside. We

make a difference and during the pandemic,

we reminded the world of that!! Be well, we

need all of you!

A., A., & A. (2019). National Nurses Week History. ANA

Enterprise. Retrieved March 5, 2019, from https://


Heale, R. (n.d.). Nursing and Post Pandemic Health

Challenges. BLOG; Evidence Based Nursing.



current resident or

Presort Standard

US Postage


Permit #14

Princeton, MN


Page 2 The North Dakota Nurse April, May, June 2021

Bismarck Tribune

Nurses, the Heart of Health Care

We are excited that our own association president,

Tessa Johnson, was nominated for the Bismarck Tribune -

Nurses, the Heart of Health Care”! Ten nurses will be selected,

and we will again be a part of the luncheon taking place on

May 12 in Bismarck. NDNA memberships will be given away to

two of the honorees, drawn at the event. Watch for the special

section in honor of National Nurses Week on Saturday May 8!

Welcome New Members

Brandon Anders


Kimberly Bearsheart


Stacie Bondy


Kayla Brown


Victoria Dassinger


Ashley Demakis


Sarah Domier

West Fargo

Melissa Fettig


Amy Fiala

Grand Forks

Cassidy Freeman

Turtle Lake

Blessing George


Colette Greek

Grand Forks

Denice Hanson


Melissa John

West Fargo

Now Hiring RNs and LPNs

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Flexible scheduling available

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visit our website at

Visit our new Facebook page

Brenda Kostelecky


Tia Kuntz


Chelsey Kuznia


Alexa Larson

West Fargo

Heather Letourneau


Amanda Mitchell


Kelsey Schwehr


Kimberly Sklebar


Jacinta Skretteberg


Luke Smith


Nicolle Trenda


Debra Vivatson


The North Dakota Nurse

Official Publication of:

North Dakota Nurses Association

General Contact Information:

701-335-6376 (NDRN)

Board of Directors and Staff


Tessa Johnson, MSN, BSN, RN, CDP


Melanie Schock, DNP, RN, CNE

Director of Membership

Kami Lehn, MSN, RN

Director of Education and Practice

Courtney Naastad, PMHNP-BC, MSN, BSN, RN

Director of Advocacy

Tania Brost, BSN, RN

Director at Large

Jarren Fallgatter, BSN, RN

Affiliate Member Representative (LPN)

Catherine Sime, LPN

Executive Director

Sherri Miller, BS, BSN, RN

Please go to our website to learn more about the

board and their roles:

Published quarterly: January, April, July, and October

for the North Dakota Nurses Association, a constituent

member of the American Nurses Association, 1515 Burnt

Boat Dr. Suite C #325, Bismarck, ND 58503. Copy due

four weeks prior to month of publication. For advertising

rates and information, please contact Arthur L. Davis

Publishing Agency, Inc., PO Box 216, Cedar Falls, Iowa

50613, (800) 626-4081, NDNA 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 North Dakota 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. NDNA 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 NDNA or those of the national or local


Writing for Publication in

The North Dakota Nurse

The North Dakota Nurse accepts manuscripts for

publication on a variety of topics related to nursing.

Manuscripts should be double spaced and submitted

electronically in MS Word to

Please write North Dakota Nurse article in the address

line. Articles are peer reviewed and edited by the RN

volunteers at NDNA. Deadline for submission of material

for upcoming North Dakota Nurse is 6/5/2021.

Nurses are strongly encouraged to contribute to the

profession by publishing evidence based articles. If you

have an idea, but don’t know how or where to start,

contact one of the NDNA Board Members.

The North Dakota Nurse is one communication

vehicle for nurses in North Dakota.

The Vision and Mission of the

North Dakota Nurses Association

Vision: North Dakota Nurses Association, a

professional organization for Nurses, is the voice of

Nursing in North Dakota.

Mission: The North Dakota Nurses Association (NDNA)

is the only professional organization representing

all nurses in North Dakota. The mission of NDNA is

to advance the nursing profession by promoting

professional development of nurses, fostering high

standards of nursing practice, promoting the safety

and well-being of nurses in the workplace, and by

advocating on health care issues affecting nurses and

the public.

April, May, June 2021 The North Dakota Nurse Page 3

Nurses in Public Policy

Beth Sanford, MSN, RN, ACN, CLC

From the days of the first community/public health

nurses in the late 19th century in England and the

United States, nurses have been on the front lines

of addressing the needs of the community, such

as poor nutrition and sanitation, transportation,

truancy, health education for patients, families,

and communities, guiding patients to community

resources, as well as direct patient care focused

on alleviating suffering. Florence Nightingale was

quoted as saying, "The work we are speaking of has

to do with maintaining health by removing things

Beth Sanford

which disturb it…dirt, drink, diet, damp, and drains."

An extension of community/public health nursing that affects

population health is the nurse's role as a legislator. Nurse Legislators may

not be giving direct patient care, but they advocate for patients and

communities and represent patients, healthcare workers, and agencies

in health care policy development.

As a result of the nurse's relationship with the community, public trust

in nurses is high. The 2020 Gallup poll ranked nurses as the number one

ranking profession for honesty and ethical standards for the 19th year in

a row (Gallup, 2021). Therefore, nurses engaging in politics seems like it

should be a natural avenue to utilize nursing leadership skills. From years

of higher education, nurses are well-equipped to be a legislator as they

bring a full toolbelt to the table that includes transferable skills, or soft

skills, applicable to the legislative role, including:

• Therapeutic Communication

• Conflict Resolution

• Critical Thinking

• Digital Fluency

• Diversity and Teamwork

• Ethics & Professional Responsibility

• Information literacy

In addition to transferable skills, nurses are

skilled at making tough decisions in times of crisis.

Nurses are deeply committed to their patients

and communities. They are experienced people

managers, able to calm the hearts of patients and

families and collaborate with the interdisciplinary

team. Nurses strive to interact with all people with

integrity and discernment while demonstrating

compassion, respect, humility, and love for humanity.

Indeed, nurses have a lot to offer in the political

arena. Although statistically low numbers of nurses

are involved in politics, the NDNA would like to see

that number grow.

We are proud of our ND nurse legislators – Senator Kristin Roers

Kristin Roers, and Representative Karen M. Rohr.

Senator Roers is a Nursing Practice Specialist with

a BS in Business Economics, SDSU, a BS in Nursing,

SDSU, and an MS, Nursing and Healthcare Systems

Administration, U of Minnesota. She has been in the

Senate since 2019.

Representative Karen M. Rohr is from Mandan,

and holds a PhD in Nursing Research, an MSN in

Nursing Administration, and is a Board-Certified Nurse

Practitioner. She has been in the House since 2011.

These leaders will be featured in the upcoming

May issue of the NDNA eNews. Watch for this!

We admire and maybe even aspire to attain the

advocacy stature of both of these nurses. Here are

ways you can use your nursing voice to make a Karen M. Rohr

difference by getting involved in local and state governance:


o Provide testimony for bills

o Lobby on behalf of the profession of nursing in the state of North


Visit today!

o Become a member of the NDNA if you are not already and get


o Attend weekly legislative calls hosted by the North Dakota Center

for Nursing

o Run for a board position

o Attend annual meetings and conferences to network with other

nurses in the state

o Write an article for the quarterly publication that you are reading

right now – The North Dakota Nurse


-Run for office

o Schoolboard

o City council

o County commission

o State Representative or Senator

-Participate in local politics

o Get to know your district Representatives and Senator

o Participate in your local legislative district meeting

-Get involved in state health policy and advocacy

o Initiate a bill

o Support a bill with testimony or lobbying efforts

During the 2021 session, the NDNA and the ND Center for Nursing

monitored several bills initiated or supported by nurses including:

• SB 2268 Assault on a Health Care Facility Provider,

• SB 2145 Essential Caregivers for Long Term Care Residents,

• HB 1044 APRN Nurse Licensure Compact,

• HB 1328 Insurance Reimbursement for Vitamin D Screening,

• SB 2226 Licensure of Residential Hospice Facilities, and

• SB 2198 ND Center for Nursing Funding.

Search job listings

in all 50 states, and filter by

location and credentials.

Browse our online database

of articles and content.

Find events

for nursing professionals in your area.

Your always-on resource for

nursing jobs, research, and events.

Page 4 The North Dakota Nurse April, May, June 2021

Nursing Philosophy

By Linda Oswald (written 11/15/2000)

I believe Nursing is an art – a balanced blend of knowledge and

training, common sense and a sense of humor. It is a talent for caring

about people as well as for them.

A good nurse knows what she is doing.

An excellent nurse knows herself. In accepting herself as human, she is

able to unconditionally accept each patient entrusted to her care. She

is often that patient’s first impression of the doctor or the institution she

works for. To her, nursing is not just a job, it’s a way of life and it shows.

In this world of “big business” I will not be distracted by its politics. My

patient is not just a customer. He or she is a fellow traveler. Often life can

only get our attention when we are flat on our backs, looking up. It is a

privilege as a nurse to enter into that sacred space and watch God work.

Whether it’s giving that slippery newborn its first bath or the elderly

legless man his last, I am honored to be the glove into which God slips His

hand to touch a fevered brow, wipe away a tear, or paint a picture of a

brighter tomorrow.

Winston Churchill said, “We make a living by what we get, but we

make a life by what we give.” If I can be remembered as a nurse who

won the trust of my patients, earned the respect of my peers, and left

each life I touched with a positive memory, my career in nursing will have

been a profound success.

Find Your Perfect

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The Nurses on Boards Coalition (NOBC) represents

national nursing and other organizations working to build

healthier communities in America by increasing nurses’

presence on corporate, health-related, and other boards,

panels, and commissions. The coalition’s goal is to help

ensure that nurses are at the table filling at least 10,000

board seats by 2020, as well as raise awareness that all

boards would benefit from the unique perspective of nurses

to achieve the goals of improved health, and efficient

and effective health care systems at the local, state, and

national levels.

North Dakota is doing well and we want to keep the

momentum going! We are seeking nurses to join our state

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For an application or more information, visit

April, May, June 2021 The North Dakota Nurse Page 5

Alternative, Palliative Care Management

Appraised by:

Alyssa Wolf SN, Brooke Carr SN, Katie

Unbehaun SN, Aris Diep SN, Morgan Tisor SN

(NDSU School of Nursing at Sanford Bismarck)

Allison Sadowsky MSN, RN Assistant Professor

of Practice (Faculty)

Clinical Questions:

In palliative care patients, what is the effect

of adjunctive treatments compared to standard

care alone (opioids).

Sources of Evidence:

Elami, O., Moslemirad, M., Miami, E., Babual, A.,

& Rezael, K. (2019). The effect of religious

psychotherapy emphasizing the importance of

prayers on mental health and pain in cancer

patients. Journal of Religion and Health, 58, 444-

451. s10943-018-0696

Hauser, W., Fitzcharles, MA., Radbruch, L., & Petzke,

F. (2017). Cannabinoids in pain management

and palliative care medicine-an overview

of systematic reviews and prospective

observational studies. Dtsch Arztebl Int, 2017(114),


Hökkä, M., Kaakinen, P., & Pölkki, T. (2014). A

systematic review: Non-pharmacological

interventions in treating pain in patients with

advanced cancer. Journal of Advanced Nursing

(John Wiley & Sons, Inc.), 70(9), 1954–1969. https://


Peng, C. S., Baxter, K., & Lally, K. M. (2019). Music

intervention as a tool in improving patient

experience in palliative care. The American

Journal of Hospice & Palliative Care, 36(1), 45-49. 10.1177/1049909118788643

Wu, X., Chung, V. C., Hui, E. P., Ziea, E. T., Ng, B. F., Ho,

R. S., Tsoi, K. K., Wong, S. Y., & Wu, J. C. (2015).

Effectiveness of acupuncture and related

therapies for palliative care of cancer: Overview

of systematic reviews. Scientific reports, 5, 16776.

Synthesis of Evidence:

Five articles were reviewed as evidence

to this report. Three systematic reviews, a

qualitative study, and a mixed qualitative and

quantitative study.

Wu, et al (2015) conducted a systematic

review of 23 mixed studies for a total of 17,392

adult cancer patients who were currently

enrolled in palliative care. The interventions

they reviewed was the use of acupuncture

for the treatment of cancer related: nausea

and vomiting, pain, fatigue, leukopenia,

lymphedema, dyspnea, psychological

wellbeing, quality of life, xerostomia, hiccups,

and hot flashes. The findings from the review

“demonstrated favorable therapeutic effects in

the management of CRF, CINV and leucopenia

in cancer patients. Conflicting evidence exists

for the treatment of CRP, hot flashes, and

hiccups and in the improvement of QoL. The

currently available evidence is insufficient to

support or refute the potential of acupuncture

and related therapies in the management of

xerostomia, dyspnea, and lymphedema and in

the improvement of psychological well-being”

(Xinyin et al, 2015, pg. 12).

Peng, Baxter, and Lally (2019) examined

the effectiveness of live music and its impact

on patient symptoms who are also receiving

palliative care. This was a pilot study doing

both quantitative and qualitative research. The

quantitative research measured the changes in

six symptoms with use of a modified Edmonton

Symptom Assessment scale; the scale was

utilized before and after the intervention.

Researchers also measured opioid use, and if

applicable was obtained from the patient’s

medical chart. The scale measured symptoms

including pain, anxiety, nausea, depression,

shortness of breath, and overall well-being.

Of the 46 eligible participants, 43 completed

the study. This was assessed with an openended

questionnaire. The participants were not

randomly selected for a control group in order

to maximize and substantiate the end results. All

participants received music intervention from

a live flute musician who was experienced in

playing different genres allowing for patient

involvement. The study revealed that music

played a positive effect on the six symptoms

measured. Patients showed to have decreased

pain, anxiety, nausea, depression, shortness

of breath, while having increased feelings of

well-being. It also showed a trend towards

decreased opioid usage, indicating that music

adds a mild analgesic effect. The themes

that arose from the patients’ questionnaire

regarding their experiences fell into five

categories: spirituality, comfort, connection,

escape, and reflection.

Hauser, et al (2017), completed a systematic

review of the use of cannabinoids in controlling

of pain and other complications associated

with end stage disease and palliative care.

They found 750 publications and of those 11

systematic reviews; three prospective long-term

observation studies were included in the final

data review. Given the studies they used the

researchers came to the conclusion that there

are conflicting findings regarding the use of

cannabis-based medications in the use of pain

management/palliative care

Inadequate evidence to support the

established indications that medical marijuana

helps with loss of appetite, N/V, and pain in

advanced disease stages. Further there was

a lack of evidence to support the claimed

positive effects in patients with internal

disorders. They found sufficient evidence for

the use of CBD/THC in neuropathic pain. They

did a meta-analysis based on individual patient

data on the use of medical marijuana to treat

neuropathic pain yielded high results of positive

pain relief. However, they did question some

of the validity to the studies as some has small

sample sizes and limited length of study.

Eilami, et al (2019), conducted a study on the

effects of religious psychotherapy on mental

health and pain in cancer patients. This was a

randomized control trial with 76 participants

who were instructed to pay attention to the

meaning of prayer when read prayers 15 and 23

of the book SahifehSaijadiyehs. The participants

were split into a control and experimental group

and completed a demographic questionnaire,

a general health questionnaire and asked to

rate their pain. After the study was concluded

it was shown that the control groups had

significant improvement of pain and mental

health. It was also shown that life expectancy

was increased with these patients. Due to the

improvement it is recommended that religious

interventions be implemented to increase the

health of cancer patients.

Hokka and Polkki (2014) conducted a

systematic review of 10 studies with a total

of 1,047 people with advanced cancer

pain. “The aim of the study was to assess

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and synthesize the current available clinical

evidence concerning the use of nonpharmacological

therapies in treating cancer

pain.” (Hokka, Polkki 2014) The study used a

variety of non-pharmacological therapies,

including: massage, aromatherapy massage,

physical therapy, transcutaneous electrical

nerve stimulation, acupuncture, reflexology,

and wrapped warm footbath. Once the

studies were concluded, massage, attention

relaxation TENS, and acupuncture showed

promising short-term effects. The studies were

simply not rigorous enough by lacking sample

sizes and interventions times to examine the

effects and safety of the non-pharmacological

interventions that were used to evaluate

patients with advanced cancer.


In conclusion, the five studies had a variety

of non-pharmacological therapies tested

however, some did not give conclusive

data on whether the interventions were

useful. The study by Hokka and Polkki (2014)

showed promising short-term effects of

massage, attention relaxation TENS, and

acupuncture but needed larger sample sizes

and intervention times. The study by Eilami,

et al (2019) showed improvement in pain and

increased life expectancy in their patients. The

study by Peng, Baxter, and Lally showed music

therapy decreased pain, anxiety, nausea,

depression, and shortness of breath and

increased feelings of well-being. Hauser, et

al (2017) found conflicting findings regarding

the use of cannabis-based medications but

found sufficient evidence for CBD/THC use

in neuropathic pain. The study by Wu, et al

showed favorable therapeutic effects in the

management of cancer related fatigue,

nausea and vomiting, and leucopenia.

However, there is conflicting evidence for the

treatment of cancer related pain, hot flashes,

and hiccups, and in the improvement of quality

of life.

Implications for nursing practice:

For patients receiving palliative care, the

use of pharmaceuticals is the best option for

a pain reliever, however; music, acupuncture,

and massage show promising short-term effects

at managing pain. It was also advised to add

religion and prayer into the patient’s treatment

plan as that showed improvement in pain and

life expectancy. Overall, it would be beneficial

to add one or more of these interventions

to improve the patient’s pain and overall


Page 6 The North Dakota Nurse April, May, June 2021

How To Help A Nurse With Their

Anxieties And Depression

Member Highlight:

Susan Indvik

By: Stanley Popovich

Do you know a nurse who suffers from fear, anxiety, and depression

and do not know what to do? It can be frustrating to watch someone

you know suffer and not be able to help them.

Here are six ways to help the person cope in these kinds of situations.

1. Learn as much as you can in managing anxiety and depression:

There are many books and information that will educate you on

how to deal with fear and anxiety. Share this information with the

person who is struggling with their mental health issues.

2. Be understanding and patient with the person struggling with their

fears: Dealing with depression and anxiety can be difficult for the

person so do not add more problems than what is already there. Do

not get into arguments with the person whose having a difficult time

with their anxieties.

3. Talk to the person instead of talking at them: It is important not to

lecture the person who is struggling with anxiety and depression.

Talk to the person about their issues without being rude. Most

people will listen if you approach them in a proper manner.

4. Ask for help: Seek assistance from a counselor who can help your

friend or relative with their mental health issues. A counselor can

give you advice and ideas on how you can help your friend or

relative who is struggling.

5. Find out why the person won’t get help: Address the issues on why

the person will not seek treatment. Many people who are struggling

are fearful and frustrated. Try to find out the reasons why he or she

won’t get the help they need and then try to find ways that will

overcome their resistance of seeking assistance.

6. Remind the person on the consequences of not getting help:

Anxiety and depression will not go away by themselves. Explain to

the person that ignoring their mental health issues will only make

things worse in the long run.

New Nursing Display at


A new, revised Cass County nursing history display will open at

Bonanzaville in West Fargo on May 1, 2021. The previous display was in

a building that was removed. The new display will be available for two

years in the main building.

Members of NDNA have been working on display items and scripts

for about a year. Watch for announcements of an opening event

celebration date for nurses. Sanford, NDNA (former District 4), and

individuals are financing the display.

For additional information, contact Marlene Batterberry (701-282-4575)

or Evelyn Quigley (701-237-5942).

by Sherri Miller

What position(s) do you hold with the North Dakota

Nurses Association?

I currently am in the position of “Nominating

Committee Member”

What is your background?

I have worked in the medical field my entire

adult life. I started out as a CNA in my early 20’s, I

then decided to go back to school and became a

respiratory therapist. Then in my mid-forties I decided

I did not want to be that what if person. My desire

has always been to become a nurse. I took the

leap and enrolled in the nursing program at Dakota

Susan Indvik

College at Bottineau and have not looked back.

I am very proud of my successes and because of my age I needed to

do and work as much as possible. I have always had the support of my

family who encouraged me throughout this entire process.

What are your favorite nursing areas you have worked in?

I have enjoyed every area that I have worked in because I have

had the opportunity to work with great people, meet family members

and care passionately for my patients. I have worked in Acute Care,

ER, Chemotherapy, Charge floor nurse, & Med/Surg. I have worked as

a travel nurse all over the states of ND, SD, MT, and MN. I currently hold

my RN license in ND & MN. The best place I have worked is for the Mayo

Clinic Health System, in MN. I learned so much and is an experience that

I will never forget.

What are you up to in nursing right now?

I recently began teaching as a Clinical Nursing instructor/Faculty

Allied Health and remain the Student Health Nurse at Dakota College at


How long have you been a nurse?

I started my nursing school in the fall of 2011 and graduated May of

2014 and have been working multiple jobs and positions ever since

graduation. I have continued my education since enrolling in my first

class, I currently have my Master’s and am enrolled in my Doctorate


What or who inspired you to be a nurse?

I have had many great nurses who inspired me throughout my life but

can honestly say it was many family members of patients I helped care

for as a CNA that inspired me the most.

Nursing is rewarding. Describe one of your most rewarding experience in


When I run into a patient or family member and they tell me what a

difference I made in their or family members life.

What advice would you give new grads or students?

You are never too old to become a nurse. Never let anyone tell you

“you cannot.” And inspire to be great every day. Be the inspiration.

What do you feel are the most critical issues regarding nursing and/or

healthcare right now?

The shortage of nurses is at an all time “critical” high. Nursing burnout,

nurse to patient ratio, and lack of training time for graduate nurses, on

the floors.

In what ways has membership to NDNA benefitted you?

There is so much up to date information on what is happening in our

state. Support for areas of concern and so much more.

Letter from Susan’s Students

To whom it may concern,

Hello, my name is Tia Blanchard and I am writing on behalf of our AD

nursing class in which Susan Indvik taught for the Spring 2020 Semester

through Fall Semester 2020 at Dakota College at Bottineau. When Susan

told us that she was to be highlighted in the next issue of The North Dakota

Nurse, we were thrilled for her. Though Susan’s time spent in our class

was short, she left a major impact. Susan is an amazing nurse, instructor,

mentor, and woman in general. She has such a caring and genuine heart

and it was felt through her teaching. She is a true example that nursing

is a life-long commitment to learning and continuing education, no

matter the age or phase of life. She is living proof that hard work pays off

and helped to inspire us stay the path, especially when things got tough

through nursing school. We are so proud to see her being recognized and

cannot wait to see what else she does throughout her career.


ADN Students:

Tia Blanchard

Jayme Rafiu

Jessie Newsome

Ashley Mikula

April, May, June 2021 The North Dakota Nurse Page 7

Nonpharmacological Pain Management

Interventions for Older Adults

Appraised by:

Alanna Rohweller SN, Morgan Erickson SN,

Brielle Marman SN, Kyla Schock SN, Morgan

Erickson SN, (NDSU School of Nursing at Sanford


Allison Sadowsky MSN, RN Assistant Professor

of Practice (Faculty)

Clinical Question:

In the elderly population, what are the health

effects of nonpharmacological interventions

on pain management compared with

pharmacological interventions.

Sources of Evidence:

Fitzgerald, S., Tripp, H., & Halksworth-Smith, G. (2017).

Assessment and management of acute pain in

older people: Barriers and facilitators to nursing

practice. Australian Journal of Advanced

Nursing, 35(1), 48-57.

Koo, V., Shicheng Jin, Wan, B. A., Ahrari, S., Lam, H.,

Rowbottom, L., Chow, S., Chow, R., Chow, E., &

DeAngelis, C. (2018). Pain management in older

adults with dementia: A selective review. Journal

of Pain Management, 11(4), 333–344.

Park, J., & Hughes, A. K. (2012). Nonpharmacological

approaches to the management of chronic

pain in community-dwelling older adults:

a review of empirical evidence. Journal of

the American Geriatrics Society, 60(3), 555–

568. https://doi-org.ezproxy.lib.ndsu.nodak.


Qi Zhang, Lufei Young, & Feng Li. (2019). Network

Meta-Analysis of Various Non Pharmacological

Interventions on Pain Relief in Older Adults with

Osteoarthritis. American Journal of Physical

Medicine & Rehabilitation, 98(6), 469–478.

Tang, S. K., Tse, M. M. Y., Leung, S. F., & Fotis, T. (2019).

The effectiveness, suitability, and sustainability

of non-pharmacological methods of managing

pain in community-dwelling older adults: a

systematic review. BMC Public Health, 19(1),

1–10. https://doi-org.ezproxy.lib.ndsu.nodak.


Synthesis of Evidence:

Older adults usually receive pharmacological

treatment for pain management of chronic

pain, but because of age related changes,

older adults are at a significantly higher risk

of adverse effects from pain medications

including liver and kidney damage,

gastrointestinal bleeding, high blood pressure,

worsening of heart failure, and constipation.

Five articles were reviewed as evidence in

this report. Four of the articles were systematic

reviews that used randomized control studies,

and one article that was a systematic review

including cluster randomized trials, double

blind randomized study, double-blind doubledummy

placebo-controlled crossover study,

randomized double blind placebo controlled

crossover trial, open medication study, quasiexperimental

design, and a pilot randomized

controlled trial. Non Pharmacological

interventions may be most appropriate

for individuals who cannot tolerate pain

medications because of the side effects or are

reluctant to take pain medications and are

seeking alternative methods for controlling

chronic pain. In addition, non-pharmacological

interventions may be suitable for older adults

who are taking multiple medications for

numerous chronic diseases and who seek

to reduce dosages and frequency of pain

medications and drug-drug interactions that

can result from taking multiple medications.

Non-pharmacological pain regimens may

provide alternative therapeutic balance to pain

relieving medication, decreasing the doses of

medications needed and minimizing adverse

events and side effects (Park & Hughes, 2012).

Fitzgerald, Halksworth-Smith, and Tripp (2017)

conducted an integrative literature review of

a combination of quantitative and qualitative

studies. The review included 13 articles with a

total of 9,161 older adult patients and 756 nurses.

The aim of the review was to examine pain

management practices of nurses and identify

barriers and facilitators to assessment of pain

and management of pain for older adults in

the acute hospital setting. A total of 101 findings

were taken from the 13 studies. These findings

were synthesized into fourteen themes, which

were grouped into four categories; nursing

practice, organizational factors, knowledge

and education, and power balance. Findings

indicated that nurses need to improve their

communication and interactions with older

patients, as well as their knowledge of pain

assessment and pain management.

Koo, Shicheng, Wan, Ahrari, Lam, Rowbottom,

Chow, S., Chow, R., Chow, E., and DeAngelis

(2018) conducted a systematic review of

a variety of studies. The systematic review

included 11 different studies. The study

types consisted of cluster randomized trials,

double blind randomized study, doubleblind

double-dummy placebo-controlled

crossover study, randomized double blind

placebo controlled crossover trial, open

medication study, quasi-experimental design,

and a pilot randomized controlled trial.

The goal of this study was to examine the

different options for pain management in

older adults that have dementia. There were

a total of 1102 participants that included older

adults aged 67-91 who have dementia and

pain. The interventions included a variety of

nonpharmacological and pharmacological

methods to reduce pain. The main interventions

used were acetaminophen, stepwise protocol,

morphine, oxycodone, music therapy, ear

acupressure, massage therapy, and Namaste

care. Some of the interventions were also

carried out by leadership, proper staffing,

and quality care. This systematic review

displays data from multiple studies that show

acetaminophen, or the combination of a

stepwise program can sufficiently decrease

pain the best in elderly patients with dementia.

However, the findings were also consistent

throughout the articles stating that music

therapy, ear acupressure, massage therapy,

and Namaste care can also significantly reduce

pain in the elderly.

Park & Hughes (2012) used randomized

control trials (RCTs) of physical and psychosocial

interventions to summarize existing evidence of

nonpharmacological interventions. All of the

studies were conducted in the United States,

except for one in South Korea and one in Hong

Kong. The mean age of the participants in the

28 articles were aged 65 and older, community

dwelling older adults, and noncancer chronic

pain was a primary outcome measured in

the study. All 28 articles reviewed the Visual

Analog Scale (VAS) and the Western Ontario

and McMasters Universities Index (WOMAC).

The study looked at the effects of both physical

and psychosocial interventions. The physical

interventions included: TENS, TENS and electoacupuncture,

TENS and acupuncture, exercise,

exercise with light resistance, acupuncture,

acupuncture with exercise, acupuncture with

exercise and advice, exercise (walking) and

education, Qigong, and Qigong with exercise.

The psychosocial interventions included: selfmanagement

education, cognitive - behavioral

therapy, mindfulness meditation, music listening,

and guided imagery. This study showed

nonpharmacological interventions most

appropriate for individuals who cannot tolerate

pain medications because of side effects or

are reluctant to take pain medications and

are seeking alternative methods for controlling

chronic pain. In addition, these interventions

may be suitable for older adults who are taking

multiple medications for numerous chronic

diseases and who seek to reduce dosages and

frequency of pain medications and drug-drug

interactions that can result from taking multiple

medications. The review fell short in identifying

the most appropriate non-pharmacological

pain interventions for this population.

Zhang, Young, & Li. (2019) authored a network

meta-analysis to compare the effectiveness

of different nonpharmacological interventions

on pain relief in older adults with osteoarthritis.

They conducted this study by collecting

articles only using randomized controlled

trials. The articles were dated between 1997

through 2017. The sample sizes ranged from

21 to 454 patients. Altogether, 32 articles and

3228 patients were included. 11 of the articles

came from the United States, six from China,

three from Denmark, and the remaining from

Brazil, Israel, Japan, New Zealand, Norway,

Italy, France, Netherlands, and Canada. The

nonpharmacological interventions used were

resistance training, neuromuscular electrical

stimulation, walking, gait training, nordic

walking, targeted dynamic balance training,

cycle ergometry, whole-body vibration,

strengthening exercise, usual care, activities of

daily living, health education, yoga, stretching

exercise, acupuncture, aquatic exercise,

healing touch, heat treatment, intervention in

a heated pool, short-wave diathermy therapy,

balneotherapy, mud-bath therapy, Tai Chi,

and weight loss. Out of the interventions used

acupuncture was the least effective while

strengthening exercise had the greatest long

term effect on pain management.

Tang, Tse, Leung, and Fotis (2019) wrote a

systematic review of randomized controlled

studies. This systematic review was conducted

to evaluate the effectiveness, suitability, and

sustainability of non-pharmacological pain

management interventions for communitydwelling

older adults. The information was

collected from 10 different articles searched

on five different databases. The interventions

included acupressure, acupuncture, guided

imagery, periosteal stimulation, Qigong,

and Tai chi. The different pain rating scales

were the visual analogue scale, numeric

rating scales, and the Western Ontario and

McMaster University Osteoarthritis Index

(WOMAC). These studies compared the preintervention

mean pain intensity, compared

to the post-intervention mean pain intensity.

After implementing non-pharmacological

pain interventions, pain intensity decreased

by anywhere from one to three on a zero to

ten rating scale. The study concluded that

non-pharmacological methods of managing

pain were effective in lowering pain levels in

community-dwelling older adults and can be

promoted widely in the community.


All five articles indicated success with nonpharmacological

interventions in reducing

pain in older adult populations. The articles

also mentioned that with the use of nonpharmacological

interventions, there was

a decreased need for pharmacological

interventions, therefore decreasing the risk of

side effects associated with those medications.

Another benefit was the cost effectiveness

of non-pharmacological interventions as

healthcare costs increase. The literature review

by Fitzgerald, Halksworth-Smith, and Tripp (2017)

concluded that there is a need for nursing

education, and the promotion of individualized

effective pain management within institutions,

to overcome these barriers and promote better

outcomes for the older population.

Implications for Nursing Practice:

Consistent implications that we saw within

all five articles were educating nurses to

better assess and individualize pain for each

older adult, as well as educating nurses on

ability to implement non-pharmacological

interventions. Another consistency was being

able to equip older adults with skills to improve

their self-efficacy in managing pain, taking

into consideration racial/ethnic disparities,

cognitive function, and ability to perform the

non-pharmacological interventions, rather

than solely investigating the effectiveness

of the interventions themselves. Similarly,

all articles mentioned implicating a way to

maintain sustainability of pain reductions, and

stay ahead of the pain, rather than the nonpharmacological

interventions only being

effective for a short time.

Page 8 The North Dakota Nurse April, May, June 2021

Appraised by:

Kyra Lind SN, Sarah Huentelman SN, Chloe

Evenson SN, and Samantha Eckroth SN (NDSU

School of Nursing in Bismarck)

Allison Sadowsky MSN,RN Assistant Professor

of Practice (Faculty)

Clinical Question:

In intensive care patients, what are the

effects of early mobilization on patient

outcomes compared with intensive care

patients not receiving early mobilization?

Sources of Evidence:

Clark, Diane E, Lowman, John D., Griffin, Russell L.,

Matthews, Helen M., Reiff, Donald A. (2013).

Effectiveness of an early mobilization protocol

in a trauma and burns intensive care unit: A

retrospective cohort study. PubMed, 93(2), 186-


Engel, H. J., Needham, D. M., Morris, P. E., & Gropper,

M. A. (2013). ICU early mobilization: From

recommendation to implementation at three

medical centers. Critical Care Medicine, 41, 69-

79. doi:10.1097/ccm.0b013e3182a240d5

Engel, H. J., Tatebe, S., Alonzo, P. B., Mustille, R.

L., & Rivera, M. J. (2013). Physical therapist–

established intensive care unit early mobilization

program: Quality improvement project for

critical care at the University of California San

Francisco Medical Center. Physical Therapy,

93(7), 975-985. doi:10.2522/ptj.20110420

Zafonte, R., Eikermann, M. (2016). Early, goal-directed

mobilisation in the surgical intensive care unit: A

randomised controlled trial. Lancet, 388(10052),

1377–1388. https://doi-org.ezproxy.lib.ndsu.

Synthesis of Evidence:

Intensive Care patients who do not receive

early mobilization are at an increased risk for

death or hospital readmission within one year

of hospital discharge compared to those who

receive early ICU physical therapy. Early mobility

and rehabilitation of critically ill patients is

associated with significant improvements in both

short and long-term physical and neurocognitive

outcomes in ICU survivors and resulted in shorter

length of stays for patients in both the ICU

and generalized hospital stays. Four articles

were reviewed as evidence in this report: A

retrospective analysis of a quality improvement

project, a retrospective cohort study, a

multicenter blinded randomized control trial, and

a systematic review with an integrative approach.

Engel & Tatebe et al. (2013) conducted a

nine-month retrospective analysis of a quality

improvement project. The analysis included

patients admitted to the 9th floor medicalsurgical

ICU at the UCSF medical center that

were referred to the early mobility program

by nurse practitioners. There was a total of 179

By: Jarren Fallgatter

Featuring: Heidi Hilz, SN and CNA

No one imagines living and working during

a pandemic, however, as usual, healthcare

workers persist on. The COVID pandemic has

brought on a lot of change to the healthcare

field, and it certainly had an effect on nurses,

physicians, pharmacists, therapists, and

assistants. One population that got put on the

back burner in a lot of cases were the student

nurses. In order to gain a better perspective, I

chose to interview a fellow coworker, Heidi Hilz,

on working and learning during this time. Heidi

is a second-semester senior nursing student

at North Dakota State University (NDSU) in

Bismarck. In order to help pay for college and

gain bedside experience, she also works as a

certified nursing assistant (CNA) in the intensive

care unit (ICU) at Sanford. Luckily, Bismarck was

delayed compared to the rest of the country

with the pandemic surge, but when COVID

first hit in March, classes and clinical changed

significantly; it all went online. When asked

about the transition, Hilz said, “It was quite

unfortunate and frustrating because nursing

is a profession that requires a lot of hands-on

work that a book doesn’t teach you. Therefore,

having clinical online wasn’t ideal for learning.

Early Mobilization for ICU Patients

patients included in 2009 and 294 patients

included in 2010. The intervention promoted

was early mobilization. The findings compared

patients from 2009 to 2010 and they showed

that initiation of physical therapy decreased

from three to two, distance walked in the ICU

increased from 40 to 140 ft, ICU length of stay

decreased from six to 4 days, hospital length of

stay decreased from 14 to 12 days, percentage

of patients discharged home increased from

55-77%, ICF rating level of assistance increased

from three to four, and percentage of patients

ambulating increased from 43 to 50. The

project was ultimately successful, and the

implementation was continued.

The second study by Clark et al. (2013)

created a retrospective cohort study of an

interdisciplinary quality-improvement program.

This study showed that patients who participated

in early mobility demonstrated a decrease

in hospital stay, as well as in nosocomial

complications and adverse events. The study

included 2,176 patients in the trauma and burns

ICU at University of Alabama at Birmingham

hospital. 1,044 of them were treated before the

implementation of the early mobility program,

and 1,132 were treated after. Overall, the study

found that the hospital stays decreased by 2.4

days, and decreased occurrences of airway,

pulmonary, and vascular complications.

The third study by Zafonte and Kikermann

(2016), conducted a multicenter, international,

parallel-group assessory blinded randomized

controlled trial. This randomized controlled

study included a total of 200 participants, ages

18 years and older. Using these participants,

this study examined the effects of early, goal

direct mobilization on three main outcomes

such as the mean Surgical Intensive Care Unit

Optimal Mobilisation Score (SOMS) level patients

achieved during their SICU stay, patient’s

length of stay on SICU, and the Mini-Modified

Functional Independence Measure Score

(mmFIM) at hospital discharge. The interventions

of this study involved a daily mobilization goal

defined in morning rounding and early, goal

directed mobilization implementation across

shifts. It was implemented through closedloop

communication of inter-professionals. In

conclusion, the results showed a decreased

length of SICU days, increased independent

function-ability, and increased delirium free

days in the interventional group compared to

those in the control group.

In the last article by Engel et al. (2013), three

ICU early mobilization quality improvement

projects are summarized utilizing the Institute for

Healthcare Improvement Framework of Plan-Do-

Study-Act. The article reviewed three different

Learning and Working Through a Pandemic

I missed clinical in specialty areas such as OB

and NICU, which was hard because that would

have been my only chance to experience that

specific population of patients.” Meanwhile,

as a CNA in the ICU, Hilz continued to provide

patient care. In fact, the ICU cohort got the

opportunity to work with and care for some of

the sickest COVID patients in the area. Hilz was

essentially living a double life. She understood

that the school wanted to keep students safe

and to decrease exposure to the patients, but

she also saw first-hand the learning experiences

that her classmates, that did not work directly in

healthcare, were missing out on. She stated, “I

work the COVID unit in the hospital and noticed

that people with COVID sometimes needed

much more care. I think that the pandemic

could have been a great learning opportunity

to see how the hospital and staff had to come

together and adapt to such a dramatic

change.” One year after COVID first impacted

Bismarck, the virus is still not completely gone,

nor is it going anywhere fast. Hilz is grateful that

school is back to normal for the most part, even

though the students are still not allowed to care

for COVID patients. She stated, “COVID has

brought on a lot of change to the healthcare

field, and I am thankful to be back to class in

person and attending clinical as usual.” Upon

institutions that implemented early mobilization

programs. The institutions reviewed included

the medical ICU at Wake Forest University, the

medical ICU at Johns Hopkins Hospital, and the

mixed medical-surgical ICU at the University of

California San Francisco Medical Center. The

systematic review included a total sample size of

860 ICU patients. Outcome measures included

frequency of therapy, adverse events, ICU and

hospital length of stays, days until out of bed,

pain and delirium scores, distance walked,

discharge disposition, medication dosing, number

of physical therapy consultations obtained,

frequency and type of mobility used for each

patient, days on a ventilator, and number of

readmissions. Findings concluded that early

mobilization in ICU patients is safe and feasible,

patients received an increased number of

treatments, decreased ICU and hospital length of

stay, net cost savings for the hospital, decreased

dosages of sedating medications made early

mobilization possible, decreased delirium rates

were found in ICU patients receiving early

mobilization, no change in patient reported pain

scores, patients were able to walk increased

distances, and there was an increase in the

number of patients who were able to discharge

home rather than to a rehabilitation facility.


All four articles indicated a decreased length

of ICU stay with the implementation of early

mobilization. Engel & Tatebe et al. (2013) showed

sooner implementation of physical therapy as

well as a decreased overall hospital stay. Clark

et al. (2013) did not find a decrease in ICU length

of stay but did find a decrease in overall length

of hospital stay as well as a decrease in patient

complications. Zafonte et al. (2016) showed

an increase in functional independence at

discharge with a decrease in delirium. Engel

et al. (2013) showed early mobilization resulting

in multiple positive patient outcomes including

but not limited to decreased delirium, increased

distances tolerated while walking, an increase

in number of patients able to discharge home

rather than to a rehabilitation facility, and overall

net cost savings for the hospital.

Implications for Nursing Practice:

There is evidence to suggest implementing

early mobilization in ICU patients could improve

patient outcomes. An early mobilization program

could help reduce patient length of stay in

the ICU, increase the percentage of patients

discharged home from the hospital, and save

the hospital money. The effects of early mobility

in ICU patients improves patient outcomes and

should be a recommendation for practice.

graduation, Hilz will become a nurse in the same

ICU where she is a CNA, and she will assume

care at a higher level for patients, including

COVID patients. Overall, nurses have noticed the

lack of skills and experience in new graduates,

due to no fault of their own; online clinical and

class proved to be not as effective as the handson

clinical. But just like anything, nurses will

continue to roll with the punches, educate the

new, and adapt to whatever comes.

Jarren and Heidi

April, May, June 2021 The North Dakota Nurse Page 9

Noise Reduction in NICU Patients

Appraised By:

Kelsie Gustin SN, Heidi Hilz SN, Lisa Wentz SN,

Kaitlynn Fuhrmann SN, and Katherine German

SN (NDSU School of Nursing at Sanford Bismarck)

Allison Sadowsky MSN, RN Assistant Professor

of Practice (Faculty)

Clinical Question:

- Does noise reduction/quiet environment

influence the overall health status of NICU

patients during their stay in the NICU?

Sources of Evidence:

Abdeyazdan, Z., Ghasemi, S., Marofi, M., & Berjis,

N. (2014). Motor Responses and Weight

Gaining in Neonates through Use of Two

Methods of Earmuff and Receiving Silence in

NICU. The Scientific World Journal, 2014, 1-5.


Abdeyazdan, Z., Ghassemi, S., & Marofi, M. (2014).

The effects of earmuff on physiologic and motor

responses in premature infants admitted in

neonatal intensive care unit. Iranian journal of

nursing and midwifery research, 19(2), 107–112.

Casavant, S. G., Bernier, K., Andrews, S., & Bourgoin,

A. (2017). Noise in the Neonatal Intensive Care

Unit: What Does the Evidence Tell Us? Advances

in Neonatal Care, 17(4), 265-273.

Khalesi, N., Khosravi, N., Ranjbar, A., Godarzi, Z., &

Karimi, A. (2017). The effectiveness of earmuffs

on the physiologic and behavioral stability

in preterm infants. International Journal of

Pediatric Otorhinolaryngology, 98, 43-47.


Smith, S., Ortmann, A., & Clark, W. (2018). Noise in the

neonatal intensive care unit: A new approach to

examining acoustic events. Retrieved October

25, 2020, from


Synthesis of Evidence:

Five articles were reviewed as evidence in

this report. A thorough review was conducted

resulting in three randomized control trials, one

correlational study, and one systematic review

relevant to the clinical question. Compared

to the intrauterine environment, the NICU

is an excessively complex and noise-filled

environment. The immature auditory systems in

preterm infants make them highly susceptible

to excess noise, which can negatively affect

their ability to self-regulate. This inability to

self-regulate the body can lead to prolonged

ventilation, apnea, sleep disturbances, changes

in respiratory and heart rates, and nutritional

requirements. Furthermore, the excessive noises

prevalent in the NICU setting have shown to

be negatively impactful on preterm infant’s

developmental and health statuses.

In the first study by Abdeyazdan, Z.,

Ghassemi, S., & Marofi, M. (2014) a randomized

control trial was conducted. This study showed

the effects between earmuffs and silence

versus normal routine cares, and how those

interventions affected preterm infant’s weight

gain and motor responses. 108 preterm infants

who stayed in the NICU were included in the

study. There were 12 total dropouts due to

discharges and apnea spells. Infants were

placed into the three different groups by a

coin toss. Silence hours and earmuffs were

implemented from 9-11 am, 4-6pm and 11pm-

5am as well as during routine cares. The study

concluded that implementation of both silence

hours and earmuffs were effective in increasing

weight gain and decreasing motor responses in

preterm infants in the NICU.

The second study by Abdeyazdan, Z.,

Ghassemi, S., & Marofi, M. (2014) was a

randomized control trial. The study was

conducted to examine the effects of earmuffs

on the physiologic and motor responses of

premature infants in the NICU. The study

consisted of 64 premature infants who were

randomly assigned to study and control

groups. Within the study group there were 22

males and 10 females, and within the control

group there were 19 males and 13 females.

The study group’s intervention consisted of

wearing earmuffs from 9:00am-11:00am and

4:00-6:00pm along with routine treatments

and care. The control group received only

routine treatments and care. The results of the

study concluded that the use of earmuffs on

premature infants during the morning and

afternoon periods improves physiologic and

motor responses, including increased arterial

O2 saturations, decreased heart and respiratory

rates, and decreased motor responses.

The study by Khalesi, N., Khosravi, N., Ranjbar,

A., Godarzi, Z., & Karimi, A. (2017) was a crossed

over controlled trial. The study was conducted

at Aliasghar Hospital (Tehran, Iran) in 2014.

Thirty-six preterm infants who were cared for in

closed incubators were assigned to group A

or B. On the first day group “A” wore a pair of

silicon earmuffs while group “B” wore nothing.

On the second day the groups switched, and

group “B” wore the earmuffs while “A” wore

nothing. During the two consecutive days, all

subjects were observed as their own controls

(without earmuffs). Throughout the study

physiologic (body temperature, heart rate,

respiratory rate, systolic, diastolic pressures,

arterial oxygen saturation) and behavioral

responses (according to the Anderson

Behavioral State Scoring System) were assessed

every two hours from 8am-4pm for the two

consecutive days. The results showed that the

application of earmuffs could decrease heart

and respiratory rate while also increasing the

amount of oxygen saturation.

Smith, S., Ortmann, A., & Clark, W. (2018)

conducted a correlational study, to see if

reducing the noise in the neonatal intensive

care unit had an effect on the infants. The

study was conducted in a level IV NICU at St.

Louis Children’s Hospital, which included three

critically ill infants. Two infants were placed in

a shared room, and the third infant was in a

private room. A Greenwhich Mean Time (GMT)

synced clock was used to track the onset

and duration of the acoustic events. Different

sound levels were tested at various times and

the infants physiological state was assessed by

their heart rate and oxygenation status. Several

times there were changes in the heart rate

during an acoustic event. However, respiratory

responses were inconsistent. The infants did

have large disturbances when the acoustic

environment was stable, however the patients

are critically ill they are more easily susceptible

for physiological changes. Both baby B (in an

open room) and C (in a private room) showed

significant physiological changes during

acoustic events but baby A (in an open room)

remained stable. The results showed that noise

does overall effect the physiological state of the

infant, by decreasing the noise levels the infants

physiological state would remain relatively


Casavant, Bernier, and Andrews (2017)

looked at twenty different studies comparing

noise reduction measures within the NICU

setting. They searched four different databases:

ScienceDirect, PubMed, CINAHL, as well as the

Cochrane Database of Systematic Reviews.

Bottineau, ND

Full-Time RN/LPN

Also hiring CNAs and

CS/ER Technicians

Competitive Salary,

Shift Differential

ND licensure/certification required.



For more information or an application, please contact

Human Resources at 228-9314 or visit our website at

The studies that were included in the review

consisted of NICU departments that were level

three (respiratory support, intravenous fluids,

and care for babies born 28 weeks or greater),

or above, as well as neonates having been

born before 32 weeks gestational age at birth.

The studies that were conducted found that

education and awareness to staff was a crucial

aspect of decreasing noise levels as well as the

need to implement these interventions in order

to promote neonatal neurodevelopment and



Critically ill infants in the neonatal intensive

care unit (NICU) go through extensive amounts

of stress and physiological changes as they

are developing. Excessive environmental

changes can impact the infants and cause

stress; there are various strategies to decrease

environmental stressors such as excessive

noise. Through the use of earmuffs on infants

in the NICU for a minimum of two hours in the

morning and afternoon periods, significant

improvements in both physiological and

motor responses can be made. In addition,

making an effort to minimize preventable

noises from the nurses working in the NICU and

implementing “quiet time” periods can improve

infant physiologic responses as well. Although

eliminating all noises is not possible, as some

are emergency alarms, reducing the amount of

added noise is beneficial.

Implications for Nursing Practice:

Specific techniques that can be implemented

to reduce the effects of noise on NICU patients

would include earmuffs, quiet time periods,

private rooms, clustering cares, and decreasing

traffic through patient rooms. By decreasing the

amount of noise, it can reduce an infant’s stress

response and improve their overall health status

during their stay in the NICU, therefore, benefiting

the patient.


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Page 10 The North Dakota Nurse April, May, June 2021

ND Nurse: Resilience Series 5 of 7

Melanie Schock, DNP, RN, CNE

Assistant Professor of Nursing, Dakota Nursing

Program, Bismarck State College

In part one of this series, an introduction to

resilience was presented which set the stage for

its extensive impacts on the nursing profession,

as well as those we serve.

For part two of this series, insights toward

resilience and its importance in the lives of

nursing students and nurse educators were

revealed. Additionally, strategies to enhance

resiliency within the academic setting were


Part three of this series focused on the

new nurses, specifically outlining their unique

challenges and needs, and why resilience

is essential for transitioning to practice. To

conclude the segment, strategies for surviving

(and thriving) in the face of adversity were

shared that can benefit all nurses.

The fourth part of this series spoke to resiliency

for nurses in special settings. Unique nursing

populations were highlighted in the article

with hopes of tailoring to resilience needs.

Certainly, we all can glean relevance here as

resiliency has universal impacts, no matter our

professional (or personal) circumstances.

In part five of this series, those we serve (the

patients) will be addressed and how resilience

plays a part in their wellness, illness, and

recovery trajectories.

Resilience is not only a relevant concept for

nurses. It proves to be a beneficial trait for our

patients as well. Research surrounding resilience

in various conditions, both acute and chronic,

continue to evolve and we are gradually

affirming its positive impacts. Specifically,

the realms of breast cancer, burn injury, and

juvenile fibromyalgia syndrome will be shared

as follows.

Tehranineshat et al. (2020) conducted a

descriptive, cross-sectional study involving 305

burn patients in south-east Iran. The authors

discovered that there was a statistically

significant, positive correlation between burn

patients’ resilience and self-efficacy. “Coping

self-efficacy is the ability that effectively

controls trauma, which has a significant

protective impact on the traumatized

population.” (p.1366). Resilience also had a

positive correlation with patients’ quality of

life. This result emanated from finding positive

meaning in life, even in the face of stressful

situations and ensuing problems.

The same authors highlighted the findings of

other studies that investigated the relationship

between resilience and burn injuries. Better

relationships with oneself and others to improve

positive social connections was enabled

by resilience. Similarly, resilience helped

burn survivors to develop positive coping

strategies [Acoviello & Charney as cited in

Tehranineshat et al. (2020)]. Gucclone as

cited in Tehranineshat et al. (2020) found that

resilience helped to motivate burn patients to

improve their physical health, quality of life, and

performance of self-care activities.

Ye et al. (2018) investigated the protective

factors and risk factors that influenced resiliency

and transcendence in 342 Chinese women with

breast cancer. Risk factors included: emotional

distress, physical distress, and intrusive thoughts.

Protective factors included: self-efficacy social

support, courage-related strategy, and hope. A

definition for each of the factors was shared by

the authors:

Emotional distress=degrees of anxiety,

depression, and illness uncertainty (perceived

during treatment).

Physical distress=degrees of pain, nausea,

and fatigue (perceived during treatment).

Intrusive thoughts=degrees of being

distressed or bothered by such thoughts (during


Hope=a motivated state to reach desired


Courage-related strategy=using direct,

optimistic, and supportive coping strategies to

manage the cancer experience.

Self-efficacy=confidence in one’s ability

to cope with a variety of problems (during


Social support=degree of emotional and

instrumental support (during treatment).

Juvenile fibromyalgia syndrome (JFMS) was

the topic of interest for Gmuca et al. (2021)

and its relationship to resiliency and suicidal

risk. Thirty-one children aged 12-17 years were

studied. It was discovered that suicidality was

associated with lower resilience, and greater

depression and anxiety. Further, lower resilience

was independently associated with suicidality.

Resilience in this study was defined as “…a

dynamic process of positive adaptation or

continued development in the context of

adversity.” (p.2). A 14-item Resilience Scale

(RS-14) was used to conduct the investigation

and highlighted the domains of purpose,

perseverance, self-reliance, equanimity, and

authenticity. Specifically, Gmuca et al. (2021)

affirmed that with every one-point increase on

the RS-14, adolescents had 10 percent lower

odds of endorsing suicidal ideation. Overall,

the findings suggest that resilience training

programs or coaching may be of benefit

for JFMS. There is clearly a need for earlier,

preventative measures before suicidal ideation


In part six of this series, the topic of resilience

in our personal lives will be addressed. In the

interim, especially during these trying times, stay

well, support one another, and treasure being a

North Dakota nurse.


Gmuca, S., Sonagra, M., Xiao, R., Miller, K. S., Thomas,

N. H., Young, J. F., Weiss, P. F., Sherry, D. D., &

Gerber, J. S. (2021). Suicidal risk and resilience

in juvenile fibromyalgia syndrome: A crosssectional

cohort study. Pediatric Rheumatology

Online Journal, 19(1), 1-8.


Tehranineshat, B., Mohammadi, F., Mehdizade

Tazangi, R., Sohrabpour, M., Parviniannasab,

A. M., & Bijani, M. (2020). A study of the

relationship among burned patients' resilience

and self-efficacy and their quality of life. Patient

Preference and Adherence, 14, 1361-1369.

Ye, Z. J., Peng, C. H., Zhang, H., Liang, M. Z., Zhao,

J. J., Sun, Z., Hu, G. Y., & Yu, Y. L. (2018). A

biopsychosocial model of resilience for breast

cancer: A preliminary study in mainland China.

European journal of oncology nursing: The

official journal of European Oncology Nursing

Society, 36, 95-102.


April, May, June 2021 The North Dakota Nurse Page 11

Focus on Fighting the Pandemic, Not Each Other

Angela Fountain, RN

Reprinted with permission from

Arizona Nurse January 2021

With the stress of fighting the yearlong

pandemic while nurses are being stretched to

new lengths in their work environments, it is a

good time to revisit the topic of incivility. What is

it? Does it really matter? How can I prevent my

work environment from having the toxic effect

of incivility?

Incivility – What is it?

Incivility has been referred to as lateral

violence, horizontal violence, and bullying

(Blair, 2013). Incivility has further been defined

as “any behavior toward a coworker that is

perceived as or intended to humiliate, demean,

belittle, diminish, and/or isolate and leads

to a power relationship in which the abuser

attempts to control the victim” (Bunk & Magley,

2013, p. 87). Incivility violates social norms of

workplace etiquette and can involve being

condescending, displaying impatience, refusing

to answer questions and general disrespect

toward another co-coworker (Kaiser, 2017). We,

as nurses, should focus on understanding the

impact of uncivil behaviors as incivility affects

all personnel and can diminish communication,

which is vital to promoting the delivery of safe

patient care.

Incivility – Who does it? Does it really matter?

Incivility has the potential to occur in all

workplaces in all parts of the world. Healthcare

has had especially high incidences of reported

bullying worldwide and the subject of incivility

has been studied in undergraduate programs,

advanced practice specialties, medical school

programs, residencies, and some advanced

practice student roles in all areas of the world

(Winston, 2017). Within the United States, incivility

has been studied specifically within the nursing

profession and has been reported to be as high

as 48% (Keller, Budin, & Allie, 2016). Professional

advocacy agencies, like the American Nurses

Association, (ANA) have taken strong positions

against bullying in an attempt to reduce

medical errors and improve the health care

and safety of patients (ANA, 2015).

In order for us to know about whether there

is incivility within our workplace, workplace

culture should be assessed periodically as

culture can change rapidly. As nurses, we

recognize that for every action, there is a

reaction. This should prompt us to think about

the collateral damage uncivil work cultures

cause. Not only can errors be made, or patients

harmed, there are physical consequences

for persons exposed to incivility. Sauer et al.,

(2017), found that nurses who experience

bullying, have decreased physical functioning,

have more complaints of body pain, and

overall felt in poorer general health. Healthy

nurses are better able to care for patients,

have fewer complaints of burnout and display

less compassion fatigue. By assessing and

understanding the direct relationship between

perceived bullying and burnout, we can

prevent burnout, keep our patients safe and our

staff healthy.

Feng et al., (2016) found that varying levels of

experience and work areas are key contributors

of workplace bullying. Areas that are highly

stressful such as intensive care units, emergency

departments, and operating theaters yield a

higher perceived level of incivility. Novice nurses

also perceived more incivility than did more

experienced nurses. While this has a variety of

factors that can be the cause, it is important to

recognize and support novice nurses as they

begin their practice while providing ongoing

support for more experienced nurses. Through

the study of incivility, it has been identified that

colleague support and promoting professional

competence reduce incivility in the workplace

while increasing job performance and


How can I prevent the ill effects of incivility in my


It takes work but promoting a civil work

environment is not only personally rewarding by

having a work environment where we enjoy, it

promotes better patient care, better outcomes

and less attrition. Reforming flawed processes of

tolerating incivility may help reduce chronically

high turnover which also helps reduce the

costs associated with turnover. Promoting

civil work environments supports effective

communication which yields to greater patient

safety and the promotion of an effective team

environment. An effective team environment

may result in a decrease in attrition with the

possibility of providing greater productivity.

Creating a positive workplace culture is a winwin-win.

You win, patients win, the hospital

wins. Don’t let your workplace culture become

tainted by incivility. This pandemic is hard

enough on us- take care of each other.


American Association of Nurse Anesthetists [AANA].

(2014). Promoting a culture of safety and healthy

work environment practice considerations.

Retrieved from:


PPM Promoting a Culture of Safety and Healthy

Work Environment.pdf

Apt, C. (2016). The bullying of nurses by nurses.

Psychology and Education: An Interdisciplinary

Journal, 53(1-2), 50-55. Retrieved from http://


Blackstock, S., Harlos, K., Macleod, M. L. P., & Hardy,

C.L. (2015). The impact of organizational factors

on horizontal bullying and turnover intentions

in the nursing workplace. Journal of Nursing

Management, 23(8), 1106-1114.

Blair, P. (2013). Lateral violence in nursing. Journal of

Emergency Nursing, 39(5), e75-e78. Doi: 10.1016/j.


Boyd, D., & Poghosyan, L. (2017). Certified registered

nurse anesthetist working conditions and

outcomes: A review of the literature. American

Association of Nurse Anesthetist Journal, 85(4),


Bunk, J. A. & Magley, V. J. (2013). The role of

appraisals and emotions in understanding

experiences of workplace incivility. Journal of

Occupational Health Psychology, 18(1), 87-105.


Chrysafi, P., Simou, E., Makris, M., Malietzis, G.,

& Makris, G. C. (2017). Bullying and sexual

discrimination in the Greek health care system.

Journal of Surgical Education, 74(4), 690-697.


Clark, C. M. (2011). Pursuing a culture of civility: An

intervention study in one program of nursing.

Nurse Educator, 36, 98-102. Doi:10.1097/


Cuff, P. A, & Institute of Medicine. (2014). Establishing

transdisciplinary professionalism for improving

health outcomes: Workshop summary.

Washington, D. C.: National Academies Press.

Retrieved from http://www.napedu/catalog/


Elblad, R., Kodjebacheva, G., & Lebeck, L. (2014).

Workplace incivility affecting CRNAs: A study

of prevalence, severity, consequences with

proposed interventions. AANA Journal, 82(6),


Giorgi, G., Mancuso, S., Perez, F., D’Antonio, C. A,

Mucci, N., Cupelli, V. & Arcangeli, G. (2016).

Bullying among nurses and its relationship

with burnout and organizational climate.

International Journal of Nursing Practice 22(2),



Guidroz, A., Geimer, J., Clark, O., Schwetschenau,

H. & Jex, S. (2010). The Nursing Incivility

Scale: Development and Validation of an

Occupation-Specific Measure. Journal of

Nursing Measurement. 18. 176-200. 10.1891/1061-


Henson, R. (2001). Understanding Internal

Consistency Reliability Estimates: A Conceptual

Primer on Coefficient Alpha. Measurement and

Evaluation in Counseling and Development, 34.


Hutchinson, M., & Hurley, J. (2013). Exploring

leadership capability and emotional

intelligence as moderators of workplace

bullying. Journal of Nursing Management,

21(3), 553-562. http://dx.doi.orgezproxy1.lib.asu.


Kaiser, J. A. (2017). The relationship between

leadership style and nurse to nurse incivility:

Turning the lens inward. Journal of Nursing

Management, 25(2), 110-118.

Keller, R., Budin, W. C., & Allie, T. (2016). A task force to

address bullying. American Journal of Nursing,

116(2), 52-58.


Krathwohl, D.R., Bloom, B.S., Masia, B.B., (1964).

Taxonomy of educational objectives: The

classification of educational goals. Handbook

II: Affective Domain. David McKay Co., Inc: New


Li, Y., & Zhang, L. (2016). Workplace bullying among

nurses in south Taiwan. Journal of Clinical

Nursing. 25(8). 2450-2456. Retrieved from http://


Livine, Y., & Goussinsky, R., (2017). Workplace bullying

and burnout among healthcare employees: The

moderating effect of control-related resources.

Nursing & Health Sciences, 1-10. 10.1111/nhs.12392

Logan, T. R., & Malone, M. D. (2018). Nurses

perceptions of teamwork and workplace

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T., & Root, L. (2014) Principles of successful

partnerships. Nursing Administration Quarterly.

38(4), 340-347.

Occupational Safety and Health Administration.

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Olsen, E., Bjaalid, G., & Mikkelsen, A. (2017). Work

climate and the mediating role of workplace

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experience, coping self-efficacy beliefs, job

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Vessey, J. A., Demarco, R. F., Gaffney, D. A., &

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Page 12 The North Dakota Nurse April, May, June 2021


French Spring Soup


¼ cup butter

1-pound leeks, chopped

1 onion, chopped

2 quarts water

3 large potatoes, chopped

2 large carrots, chopped

1 bunch fresh asparagus, trimmed and cut

into 1 inch pieces

⅓ cup uncooked long-grain white rice

4 teaspoons salt

½ pound fresh spinach

1 cup heavy cream


Step 1

Melt the butter in a large pot over medium

heat. Stir in the leeks and onion, and cook

until tender.

Step 2

Pour water into the pot. Mix in potatoes,

carrots, asparagus, and rice. Season with

salt. Bring to a boil, reduce heat, and

simmer 30 minutes, until vegetables and

rice are tender.

Step 3

Stir spinach and heavy cream into the soup

mixture, and continue cooking about 5

minutes before serving.

Nutrition Facts

Per Serving: 194 calories; protein 3.6g;

carbohydrates 16.1g; fat 13.8g; cholesterol

44.8mg; sodium 1014.2mg.






Director of Nursing • Justice Center Nurse

Registered Nurse, LPN and CNA (FT & PT)

• Excellent Benefits

° 401K

° Health, Dental & Vision Insurance

° Bonus/Retention Bonus

• Loan Repayment Program

For more information email EMHC Recruiter

To Apply: EMHC Employment

or visit us at

Grandma's Lemon Meringue Pie


1 cup white sugar

2 tablespoons all-purpose flour

3 tablespoons cornstarch

¼ teaspoon salt

1 ½ cups water

2 lemons, juiced and zested

2 tablespoons butter

4 egg yolks, beaten

1 (9 inch) pie crust, baked

4 egg whites

6 tablespoons white sugar


Step 1

Preheat oven to 350 degrees F (175 degrees


Step 2

To Make Lemon Filling: In a medium

saucepan, whisk together 1 cup sugar,

flour, cornstarch, and salt. Stir in water,

lemon juice and lemon zest. Cook over

medium-high heat, stirring frequently, until

mixture comes to a boil. Stir in butter. Place

egg yolks in a small bowl and gradually

whisk in 1/2 cup of hot sugar mixture. Whisk

egg yolk mixture back into remaining sugar

mixture. Bring to a boil and continue to

cook while stirring constantly until thick.

Remove from heat. Pour filling into baked

pastry shell.

Step 3

To Make Meringue: In a large glass or metal

bowl, whip egg whites until foamy. Add

sugar gradually, and continue to whip until

stiff peaks form. Spread meringue over pie,

sealing the edges at the crust.

Step 4

Bake in preheated oven for 10 minutes, or

until meringue is golden brown.

Nutrition Facts

Per Serving: 298 calories; protein 4.4g;

carbohydrates 49.7g; fat 10.3g; cholesterol

110.1mg; sodium 229.2mg.

Summertime Chicken and Pasta Salad


6 eggs

1 (16 ounce) package farfalle (bow tie) pasta

6 chicken tenders

1 cucumber, sliced

1 bunch radishes, trimmed and sliced

2 carrots, peeled and sliced

3 green onions, thinly sliced

½ red onion, chopped

½ (16 ounce) bottle Italian-style salad dressing

4 romaine lettuce hearts, thinly sliced


Instructions Checklist

Step 1

Hard boil the eggs by placing them into a

saucepan in a single layer. Fill with water

to cover the eggs by 1 inch. Cover the

saucepan and bring the water to a boil

over high heat. Once the water is boiling,

remove from the heat and let the eggs

stand in the hot water for 15 minutes. Pour

out the hot water, then cool the eggs

under cold running water in the sink. Peel

once cold.

Step 2

Fill a large pot with lightly salted water and

bring to a rolling boil over high heat. Once

the water is boiling, stir in the bow tie

pasta and return to a boil. Cook the pasta

uncovered, stirring occasionally, until the

pasta has cooked through, but is still firm to

the bite, about 12 minutes. Drain well in a

colander set in the sink, and rinse with cold


Step 3

Simmer the chicken tenders in about 1/4 cup

of water in a saucepan over medium-low

heat, until no longer pink inside. Remove

the tenders from the water, and set aside

to cool.

Step 4

Cut the tenders into bite-size pieces. Slice

the eggs. Combine the cooked pasta,

chicken, eggs, cucumber, radishes, carrots,

green onions, and red onion in a salad

bowl, and pour the Italian dressing over.

Toss lightly to mix, and refrigerate the salad

for at least 1 hour, or until cold.

Step 5

Place about 3/4 cup of sliced romaine hearts

on each plate, then top with about 1 cup

of pasta-chicken salad to serve.

Nutrition Facts

Per Serving: 542 calories; protein 29.4g;

carbohydrates 67.7g; fat 18.4g; cholesterol

195mg; sodium 732.6mg.

April, May, June 2021 The North Dakota Nurse Page 13

Breastfeeding and Postpartum Depression

Appraised by:

Olivia Dietrich SN, Shayla Heger SN, Elisa Johnson SN, Sierra Peters SN,

and Shanae Wentz SN (NDSU School of Nursing at Sanford Bismarck)

Allison Sadowsky MSN, RN Assistant Professor of Practice (Faculty)

Clinical Question:

In postpartum women, what is the effect of breastfeeding on

postpartum depression compared with not breastfeeding?

Sources of Evidence:

Brown, A., Rance, J., & Bennett, P. (2016). Understanding the relationship

between breastfeeding and postnatal depression: the role of pain and

physical difficulties. Journal of Advanced Nursing (John Wiley & Sons, Inc.),

72(2), 273–282.

Borra, C., Iacovou, M., & Sevilla, A. (2015). New Evidence on Breastfeeding

and Postpartum Depression: The Importance of Understanding Women’s

Intentions. Maternal & Child Health Journal, 19(4), 897–907.

Farías-Antúnez, S., Santos, I. S., Matijasevich, A., & Barros, A. J. (2020). Maternal

mood symptoms in pregnancy and postpartum depression: Association

with exclusive breastfeeding in a population-based birth cohort. Social

Psychiatry and Psychiatric Epidemiology, 55(5), 635-643. doi:10.1007/s00127-


Haga, S. M., Lisøy, C., Drozd, F., Valla, L., & Slinning, K. (2018). A population-based

study of the relationship between perinatal depressive symptoms and

breastfeeding: a cross-lagged panel study. Archives of Women’s Mental

Health, 21(2), 235–242.

Hahn-Holbrook, J., Haselton, M., Dunkel Schetter, C., & Glynn, L. (2013).

Does breastfeeding offer protection against maternal depressive

symptomatology? Archives of Women’s Mental Health, 16(5), 411–422

Synthesis of Evidence:

To answer our PICO question, we searched for high quality research

articles that studied the effects of breastfeeding on postpartum

depression. We selected five articles to review as evidence in this report:

a cross-sectional self-report survey, correlational study, two quantitative

longitudinal studies, a cohort study, and a cross-lagged panel study. Our

main findings from these articles will be summarized below.

Brown, Rance and Bennet (2016) was a cross-sectional self-report

survey correlation study done to examine the relationship between

specific reasons for stopping breastfeeding and depressive symptoms

in the postnatal period. The study was done on 217 of 502 mothers in

South West Wales, UK who had initiated breastfeeding at birth, but

were no longer breastfeeding at the time of the survey. The survey

examined many reasons for stopping breastfeeding. The mothers also

used the Edinburgh postnatal depression scale. The findings showed that

breastfeeding duration and multiple reasons for stopping breastfeeding

were associated with a high depression score. There was a strong

negative correlation with longer breastfeeding durations and lower EPDS

scores. There was also a significant negative correlation seen between

age of stopping breastfeeding and reports of physical difficulty, pain,

lack of support, embarrassment, and pressure from others to stop.

However in regression analysis only the specific reasons of stopping

breastfeeding for physical difficulty and pain remained predictive of

depression score.

Borra, Iacovou, and Sevilla (2013) conducted a longitudinal

quantitative study. The study was conducted to examine the effects

of breastfeeding on postpartum depression (PPD) using data from

the Avon Longitudinal Study of Parents and Children. Mothers were

recruited into the survey by doctors, at the point when the pregnancy

was first reported. This study included 14,541 pregnancies which resulted

in 14,676 known fetuses, 14,062 live births, and 13,988 babies surviving to

one year. They assessed mother’s intentions on breastfeeding along with

depression screenings at 18 and 32 weeks' gestation and postnatally at 8

months, 18 months, and 33 months. The results of the study conclude that

in mothers that were not depressed during pregnancy and planned on

breastfeeding and went on to do so, the risk of postpartum depression

was decreased. However, if mothers were not able to breastfeed as

planned, the risks of PPD increased.

Farías-Antúnez, Santos, Matijasevich, and Barros (2020) conducted

a cohort study that aimed to evaluate the association between mood

symptoms during pregnancy and exclusive breastfeeding at three

months, as well as the association between exclusive breastfeeding at

three months and maternal depression at 12 months. The study included

4231 mothers with babies born in 2004 who were choosing to breastfeed

or not breastfeed. The mothers filled out questionnaires with information

about their demographics, socioeconomic status, and obstetric history.

Additionally, they had mothers complete the Edinburgh Postnatal

Depression Scale (EPDS) which is a questionnaire that assessed the

intensity of mother’s depressive symptoms in the preceding seven days

which was filled out at 12 months. The results found that mothers who

exclusively breastfed until three months had a 19% decrease in the risk of

depression at 12 months postpartum, compared to those that stopped

exclusively breastfeeding before three months postpartum.

Haga et al (2018) is a cross-lagged panel study based on a Norwegian

population based prospective study. This study was conducted to test

the relationship between depressive symptoms and breastfeeding over

time, from pregnancy throughout the first year postpartum. There were

1,396 pregnant women who participated in this study. These women

were receiving prenatal and/or postpartum care at nine well-baby

clinics in different Norwegian municipalities. The main finding from this

study was that breastfeeding did not have an influence on postpartum

depressive symptoms Thus, more research is needed to determine what

influences postpartum depressive symptoms.

Hahn-Holbrook et. al. (2013) conducted a longitudinal quantitative

study to explore the relationship between breastfeeding and

depression. 205 pregnant/postpartum women participated in this

study. They assessed depressive symptomatology using the Center

for Epidemiological Studies Depression Scale five times during their

pregnancy and at 3, 6, 12, and 24 months after birth using the Edinburgh

Postnatal Depression Scale. The study found that women who breastfeed

more frequently at three months postpartum showed less symptoms of

depression than women who breastfeed less frequently at three months.


Of the five articles reviewed, four of them found that breastfeeding

does reduce postpartum depression. However, the article from Haga et.

al (2018) found that there is no correlation between breastfeeding and

postpartum depression, but suggested that further research is needed.

All of the articles support breastfeeding as the preferred method of

feeding as there are many benefits to both mom and baby.

Implications for Nursing Practice:

As nurses we always try to promote breastfeeding because we know

that it is best for the baby and also benefits the mom. Knowing that there

is an increased risk for depression when mothers stop breastfeeding,

we need to assess and encourage mothers to continue and help in

times of difficulties. Specific support needs to be directed towards

helping mothers experiencing pain and/or physical difficulties. By

providing education on outside support groups, lactation consultants,

and breastfeeding experts, it encourages prolonged breastfeeding

experience. Outcomes can differ depending on the mother's mental

health status before, during, and after pregnancy. Research also

suggests that the duration and frequency of breastfeeding can affect

the outcomes of postpartum depression.

Page 14 The North Dakota Nurse April, May, June 2021

Catheter Associated Urinary Tract

Infection Rates and Nurse Compliance

Appraised by:

Jamie Bishop SN, Mason Borud SN, McKenzie

Klipfel SN, Allie Kulish SN, and Lexus LaMotte SN

(NDSU School of Nursing at Sanford Bismarck)

Allison Sadowsky MSN, RN Assistant Professor

of Practice (Faculty)

Clinical Question:

In patients with an indwelling urinary

catheter, what is the effect on catheter

associated urinary tract infections when nurses

comply with prevention procedures and

guidelines compared to nurses that are noncompliant?

Sources of Evidence:

Boneva, D., Puyana, S., Bernal, E., Hai, S., &

McKenney, M. (2018). Targeting Catheter-

Associated Urinary Tract Infections in a Trauma

Population: A 5-S Bundle Preventive Approach.

Journal of Trauma Nursing, 25(6), 366-373 https://


Ferguson, A. (2018). Implementing a CAUTI Prevention

Program in an Acute Care Hospital Setting.

Urologic Nursing, 38(6), 273. doi:10.7257/1053-


Gesmundo, M. (2016). Enhancing Nurses’ Knowledge

on Catheter Associated Urinary Tract Infection

(Cauti) Prevention. Kai Tiaki Nursing Research,

7(1), 32–40

Hernandez, M., King, A., & Stewart, L. (2019).

Catheter-associated urinary tract infection

(CAUTI) prevention and nurses’ checklist

documentation of their indwelling catheter

management practices. Nursing Praxis in New

Zealand, 35(1), 29–42. https://doi-org.ezproxy.lib.

McCoy, C., Paredea, M., Allen, S., Blackey, J., Nielsen,

C., Paluzzi, A., Jonas, B., & Radovich, P. (2017).

Catheter-Associated Urinary Tract Infections:

Implementing a protocol to decrease incidence

in oncology populations. Clinical Journal of

Oncology Nursing, 21(4), 460–465. https://doi.


Synthesis of Evidence:

Evidence has shown that catheter-associated

urinary tract infections (CAUTI) are the most

common type of healthcare-associated

infection. Five articles were reviewed to

determine the effects of nurse compliance

on CAUTI rates. The articles reviewed included

three quasi-experimental studies and two multiphased

mixed-method approach studies. These

studies all show a similarity throughout while

examining the importance of nurse compliance

and care.

To access electronic copies of the

North Dakota Nurse, please visit

Ferguson (2018) conducted a quasiexperimental

non-randomized control trial that

implemented a quality improvement project

with an educational program of interactive

CAUTI prevention in two units of an acute

care hospital, selected based on having

experienced the highest CAUTI rates among

all hospital units. Specifically, this project

aimed to enhance nurses’ knowledge with

pre and post surveys of appropriate indwelling

urinary catheter care and reduction of CAUTI

incidences on the units. There were 67 nurses

that worked on the two units that were selected

for this study, but only 59 completed the quality

improvement program education. Of those that

participated, the survey scores from the nurse’s

knowledge from pre-educational to posteducational

program significantly increased,

which indicated better knowledge from the

nurses regarding catheter indications, cares

and infection prevention. The greatest change

from pre to post knowledge was correct

indications for Foley catheter placement by

the nurses. CAUTI rates were also measured pre

and post-educational program and declines in

infection rates were observed in both units.

The second study by Elkibuli et al. (2018)

was a quasi-experimental controlled trial. This

study was performed to determine whether

implemented measures would reduce CAUTI

rates in trauma patients. This study was

completed at Regional Medical Center trauma

service on 12,962 patients who were 16 years

of age or older. The intervention included was

the implementation of a 5-S CAUTI bundle. The

5-S CAUTI bundle included staff education,

bladder catheter stabilization, patient and

caregiver education, keeping the collection

bag below the bladder and above the floor,

and daily evaluations for discontinuation. The

study prospectively measured CAUTI rates

by collecting data from the Trauma Registry.

Execution of the 5-S bundle, responsible

utilization of resources, and a multidisciplinary

approach led to a significant reduction in CAUTI


The third study by Gesmundo, M. (2016), was

a multi-phased mixed-method approach that

was collected over 17 weeks with three phases

of interventions. The study was conducted in

Auckland, New Zealand in two postoperative

wards of a surgery center. They evaluated

the impact CAUTI education package on

nurses’ knowledge of indwelling catheter


They focused on four components of catheter

care: avoid unnecessary use of catheters, insert

catheters using aseptic technique, maintain

catheters based on recommended guidelines,

and review catheter necessity daily to ensure

prompt removal. Through both a quantitative

and qualitative study and design, the results

showed that through the introduction of a CAUTI

education package, a nurse’s knowledge

on indwelling catheter management and

prevention can not only improve gaps in the

nurses knowledge, but their nursing practice as


In the fourth study by Hernandez, M.,

King, A., & Stewart, L. (2019), they performed

a quantitative research in part of a mixed

methods study. This study was done at two

surgical wards within one public hospital

in Auckland, New Zealand. They included

checklists to document the nurse’s compliance

of CAUTI prevention techniques. Of the 175

checklists obtained, 54 of the total had

complete documentation of appropriate

catheter indications such as; hand hygiene,

catheter insertion, maintenance, removal, and

signed/dated. This indicates that the nurses

did not maintain proper documentation of

the checklists. In conclusion, this further shows

the regular use of the checklists should be

continued to document the care that is being

provided with CAUTI prevention measures.

The last study is a pre-post quasiexperimental

done by McCoy (2017). They

conducted their own research on bestevidence

based practice to find the most

efficient way to prevent CAUTIs. Once

they found a protocol that they liked they

implemented it on two 26 bed med surg

oncology units. They measured success by

looking at CAUTI rates, numbers of days a

patient has an indwelling urinary catheter,

nursing adherence with an audit tool, and

nursing adherence with a protocol using

that same audit tool. It was found that the

evaluation of infections per 1,000 catheter

days from 2013 through the third quarter of

2016 demonstrated a reduction in CAUTIs

from 14.32 (pre implementation) to 11.79 (post



In conclusion, all five articles indicated a

decrease in CAUTI rates and costs. Through the

use of education programs for CAUTI prevention

and implementation of nurse compliance, all

articles revealed a significant drop in infection

rates and an increase in nurse involvement.

Implications for Nursing Practice:

There is significant evidence to suggest that

implementing education programs on CAUTI

prevention, having nurses follow checklists for

continued compliance, regulating updated

practices, and providing constant education

to patients and their families reduces infection

rates. It also significantly decreases required

cares and costs that would follow. Overall, the

effects on CAUTI rates would result in a shorter

hospital stay for patients, prevent poor patient

outcomes, and save the hospital money.

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April, May, June 2021 The North Dakota Nurse Page 15

An Angel of Bataan

In the darkness of

defeat immediately

following the

Japanese attack

on Pearl Harbor,

7 December 1941,

shining beacons

of hope and

indominable will

glowed bright in

the formidable

jungles and ragged

mountains of

Bataan Peninsula

and Corregidor

Island in the

Philippine Islands.

These were the

Angels of Bataan:

the sixty-six U.S.

Army nurses,

evacuated to the

harshness of Bataan

By Edward E. (Ed) Saunders

LTC, U.S. Army (retired)

Billings, MT

Mina A. Aasen

Columbus Hospital

Great Falls, MT

and Corregidor and later captured as prisonersof-war

by the Japanese.

One of the sixty-six was a “lifer”: a career

Army nurse on her second tour-of-duty in the

Philippines, Second Lieutenant Mina Andy

Aasen, Great Falls, Montana. Born 19 Apr 1894 in

Willmar, Minnesota, Aasen spent her formative

years on her father’s farm north of Minot, North

Dakota. As a young woman Aasen followed

her sister to work as cooks for grain harvesters

in Montana’s golden triangle near Great Falls.

Aasen later said she wasn’t meant to be a cook.

Mina then began nurse training at Columbus

Hospital, Great Falls.

World War I came and she entered the Army

Nurse Corps at Great Falls, 11 July 1918. She was

a career officer and nurse, serving in World

Wars I and II. (As Aasen entered the Army from

Montana, her military service is attributed to


In June 1941 the Army assigned Aasen to

Sternberg Army Hospital, Manila, Philippine

Islands. At age forty-seven Aasen was one of

the “old gals.” The Japanese invaded 8 Dec

1941. The U.S. Army, Philippines, ordered her and

others to Bataan and Corregidor. The Army later

surrendered. The Japanese held Aasen and the

nurses as prisoners-of-war in brutal conditions

for nearly three years. Aasen and the nurses

were liberated from captivity 3 Feb 1945. Each

nurse, including Aasen, received the Bronze Star

Medal and the Presidential Unit Citation.

After her liberation, (now) Captain Aasen

recuperated at Letterman Army Hospital, San

Francisco, California. She retired from activeduty

19 Jan 1947: serving in uniform for almost

twenty-nine years. She lived in San Francisco

until 1967, then returned to Minot to be near

extended family. Aasen never married. She

died in Minot 2 Apr 1974, and is buried in Minot’s

Rosehill Cemetery. At her burial, an early spring

blizzard struck Minot. Aasen, a courageous

nurse and distinguished Army officer,

regrettably, was not afforded military honors at

her gravesite.

Source: Saunders, Edward E., Knapsacks

and Roses, Montana’s Women Veterans of

WWI. Laurel, MT: Saunders, 2018. Available at

Editor’s Note: The above is part of a narrative

non-fiction book on Montana's women veterans

of WWI. Most were nurses in the Army Nurse

Corps. Aasen was one of but three Montana

women who made the Army a career

beginning in WWI. Mina's story is in a chapter of

his book, the chapter titled "The Great Falls Six."

Mina's captivity weakened her severely. She

had contended with many tropical diseases

and internal pestilence. She was a patient at

Letterman Army Hospital for a few years before

her retirement from active duty.

“Those sixty-six Army Angels of Bataan were

the single largest group of American military

women captured in war. They were remarkable

and courageous. None survive as of today.

May they all rest in peace.” ~ Edward E. (Ed)

Saunders, LTC, U.S. Army (retired), Billings, MT

Photo courtesy

Rosehill Cemetery. Minot, ND

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