Missouri Nurse - January 2022

emiller

MISSOURI

NURSING NEWS

Volume 2 • No. 2

January, February, March 2022

The Official Publication of the Missouri Nurses Association with a quarterly circulation of approximately 72,000 to RNs and LPNs

Message from the President

Caryl Goodyear, PhD, RN,

NEA-BC, CCRN-K, FAAN

As I write this letter we

are experiencing yet another

COVID-19 variant that

may prove to be more of a

challenge. All of us has felt the

stress of the pandemic. We are

concerned about ourselves,

our peers and colleagues,

family and friends. A recent

survey, published in the most

recent American Nurse Journal,

Caryl Goodyear

supported that nurses are feeling stressed, frustrated,

exhausted overwhelmed and anxious.(1) Almost half

of the respondents reported having experienced a

traumatic COVID-19 event and not being emotionally

healthy.

So, what can we do for each other? How can we

show support for others? It is hard to show compassion

to others when we are under stress. However, a good

start is asking the question to our peers, “Are you ok?”

And then to suggest that it’s ok not to be ok. The best

thing we can do for each other right now is to listen.

Listening shows our concern, caring and compassion

for others.

Supporting wellbeing by asking the simple question

is a start to show that we care. Being present with

them is also an important aspect of emotional support.

I would suggest that most nurses would admit that

they get support and wellbeing from other staff. Being

present for each other is vital to everyone’s emotional

wellbeing.

The importance of the simple question of “are

you ok?” signifies caring and compassion for others.

Listening is just a first step to ensure wellbeing is being

addressed.

References

1. Hanley, A. Survey findings reveal nurses are struggling.

American Nurse Journal. 2021. 16(11); 44.

Director’s Letter

If you were to write about

2021 like it was a story, what

would it read it like?

Every year I like to take

time to reflect on the past 12

months while looking toward

the year to come. Reflecting

on the year enables us to

acknowledge and honor what

we’ve been through, what

we’ve learned and how we

can take those lessons into

the new year. This allows us

to process what has happened Heidi Lucas

and move forward.

I reached a big milestone birthday this year and for

most of my life, we have been living in “unprecedented

times.” Wars, terrorist attracts, once in a lifetime

weather events that happen yearly, economic booms

and collapse, political division, and now, a worldwide

pandemic with no end in sight.

But we soldier on. Time waits for no one. The sun

keeps rising. The world keeps spinning. We wake up

every day. We laugh. We cry. People continue to fall in

love. Children keep being born.

Nurses get a front row seat on many of these

life events; peoples best and worst days. And the

pandemic has ratcheted that up to a 1000. It takes a

special kind of person to be a caretaker. It requires a lot

of resilience to keep doing what you are doing. That’s

the beauty of the human spirit and life; the getting

back up, the drive to keep going.

So, keep going.

Stay strong.

Take care of yourself.

Advocate for yourself and others.

Tell us at MONA what you need. How we can help.

Lean on each other. Your colleagues. Your friends.

Your family.

We will get through this.

That’s what my 2021 story would read like. It would

be a story of change, strength, the power of friendship

and family, and hope for the future.

The sun will rise tomorrow. And so will we.

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Princeton, MN

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2

Missouri Nursing News January, February, March 2022

Non-Physician Certification in Home

Health Care Blocked by State-Level

Barrier

Existing Missouri law requires orders for home

health services to be written by a physician; however,

many Missourians, particularly those in rural areas,

see an advanced practice registered nurse (APRN) or

physician assistant (PA) for their primary care needs.

For these patients, orders for home health services

must be written by a physician provider regardless of

whether the physician has an existing relationship with

the patient, has not been caring for the patient or has

even met the patient.

This administrative requirement is not necessary

to achieve good clinical outcomes, can disrupt the

continuity of care, and can result in denials or delay of

available care for our seniors.

Thankfully, the ''Coronavirus Aid, Relief, and

Economic Security Act'' or the ''CARES Act,” which

was signed into law on March 27, 2020, permanently

changed federal law so that APRNs and PAs can now

order home health services for their patients. It was a

modernization to the Medicare program!

Now that the federal law changed, it is necessary to

update Missouri’s home health law by simply changing

the definition of home health services to include APRNs

and PAs in the list of providers who may order home

health services for their patients. Sounds easy right?

Unfortunately, the answer is NO! Legislation to update

Missouri’s home health statute was filed during the

2021 Missouri legislative session (will be filed again in

the upcoming 2022 session) and was met with strong

opposition from various physician trade organizations.

While the proposed legislation greatly benefits

Missouri’s seniors, it would not expand the scope of

practice for APNS or PAs and does not impact existing

relationships between physicians and their patients,

however, it seems the decades long “turf war”

continues on in Missouri.

In April of 2020, the state of Missouri implemented

a COVID-19 waiver mirroring the new federal law.

During these past 19 months, thousands of patients,

under the sole care of a nurse practitioner or physician

assistant, have been admitted for home health services.

In a recent survey of home health providers, 90%

responded that the process for ordering and approving

home health services under a APRN or PA was more

efficient and allowed the patient a timely admission.

Data from the care provided during the waiver period

clearly demonstrates that this benefits physician

workload and patient outcomes and satisfaction.

COVID-19 continues to present challenges, and

even when we emerge from the pandemic, we face

a permanently changed healthcare market. A 2021

Mercer study, US Healthcare Labor Market, found

that “by 2026, it is estimated that 23,000 primary

care physicians will permanently leave the profession,

leaving a vacuum of demand for primary care

providers. More and more often, physician assistants

(PAs) and nurse practitioners (NPs) will step in to fill

that demand. About 40,000 new PAs and NPs enter

the workforce annually, providing a steady stream of

new entrants who are qualified and ready to fill the

extra demand resulting from retiring physicians.” This

data only reinforces the recent permanent change

in federal law and further highlights the need for

Missouri lawmakers to follow suit. We must take this

opportunity where we can make decisions now that

will help address the coming physician workforce issue

and put a process in place that will not only improve

the continuity of care but will continue and enhance

the home health benefit for patients.

The federal government, through bi-partisan

efforts, recognized APRNs and PAs inability to sign

home health orders as a potential delay in care,

increased risk of poor outcomes and increases in the

cost of care and took the steps to permanently make

the change in federal law. It is time Missouri lawmakers

put patients over politics and allow Missouri’s home

health statute to include APRNs and PAs ability to

certify home health services.

Respectfully Submitted,

Carol Hudspeth, Executive Director

Missouri Alliance for Home Care

MONA’s Mission, Vision, Purpose

Our Mission

Registered Professional Nurses advancing the profession to

improve health for all Missourians

Our Vision

Missouri nurses are a powerful, unified force engaging

consumers and transforming health and health care.

Our Purpose

To act and speak for the nursing profession and Missouri’s

professional nurses and to promote and enhance safe and

accountable professional nursing practice.

MONA’s Official Publication:

The Missouri Nursing News is an official publication of the

Missouri Nurses Association (MONA) (a constituent member

of the American Nurses Association), published quarterly

every January, April, July and October. The MONA provides

education, networking opportunities, publications and

other products and services to its members and extends its

mission to all nurses in Missouri.

Phone: (573) 636-4623

Email: director@missourinursess.org

Web site: www.MissouriNurses.org

Mail: c/o Midwest Multistate Division

3340 American Avenue, Suite F

Jefferson City, MO 65109

Questions about your nursing license?

Contact the Missouri State Board of Nursing at:

(573) 751-0681.

This newsletter is a service of the Missouri Nurses

Association and your receipt of it does not mean

you are automatically a member. Your membership

in support of this work is encouraged; please visit

www.missourinurses.org.

Writer’s Guidelines:

• Any topic related to nursing will be considered for

publication in the Missouri Nursing News.

• Authors are not required to be members of the MONA;

however, when space is limited, preference will be given

to MONA members.

• Photos are welcome, digital is preferred. MONA does not

assume responsibility for lost or damaged photos.

• Use current APA formatting for any article requiring

citation.

• Provide a brief author biography indicating the author’s

nursing experience and/or expertise with the paper’s

content.

o Limit the author’s biography to 4-sentences.

• Submitted material is due by the 10th of the month in

March, June, September and December of each year.

• The peer-review is blinded; submit the title page

separately from the article

• Submit the title page and article as Word documents to

info@missourinurses.org

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Arthur L. Davis Publishing Agency, Inc. reserve the right to

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advertisement does not imply a product offered for advertising

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this association disapproves of the product or its use. MONA

and the Arthur L. Davis Publishing Agency, Inc. shall not be held

liable for any consequences resulting from purchase or use of

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express the opinions of the authors; they do not necessarily

reflect views of the staff, board, or membership of MONA or

those of the national or local associations.


January, February, March 2022 Missouri Nursing News 3

What is Value-Based Purchasing?

Sarah Oerther, Ph.D., RN, ANEF

Since 2019, in the United States, people older

than 65 years of age have outnumbered those

younger than five years of age, and this trend is true

in Missouri (United States Census Bureau, 2021). As

Missouri residents live longer and age, more of them

will develop multiple chronic conditions, such as heart

disease, dementia. Many also will develop functional

limitations, including difficulty with the activities of

daily living such as managing one’s household due to

a lack of mobility. Researchers have found that patients

who can remain in their home with support services

benefit in multiple ways (Landers et al., 2016; Pozniak

et al., 2021). For example, often they receive more

personalized care, maintain greater independence,

are safer and more comfortable, and have a decrease

in unnecessary trips to the hospital. Collectively, these

benefits may delay or even prevent admission to

assisted living and nursing home facilities, which often

are more expensive forms of care as compared to the

provision of support services in the home. On the

other hand, the provision of support services in the

home may be subject to fewer quality controls because

healthcare providers traveling to homes may have less

support from and supervision from peers as compared

to facility-based care (Landers et al., 2016; Pozniak et

al., 2021).

To help ensure the quality of the provision of

support services in the home, in 2016 several states

began to implement the Home Health Value-Based

Purchasing (HHVBP) Model developed by the Centers

for Medicare & Medicaid Services (CMS) (The Centers

for Medicare & Medicaid Services, 2021). "Valuebased

purchasing," also known as pay for performance

(P4P), is a model of payment that offers financial

incentives to physicians, hospitals, medical groups,

and other healthcare providers for meeting certain

performance measures (Chee et al, 2016; Landers et

al., 2016). Clinical outcomes, such as longer survival,

are difficult to measure. Therefore, pay for performance

systems usually evaluate process quality and efficiency,

such as measuring blood pressure, lowering blood

pressure, or counseling patients to stop smoking. In

addition, this model penalizes health care providers

for poor outcomes, medical errors, or increased

costs. Integrated delivery systems where insurers and

providers share in the cost are intended to help align

incentives for value-based care (Chee et al, 2016; The

Centers for Medicare & Medicaid Services, 2021).

The HHVBP Model was designed to give Medicarecertified

home health organizations incentives to

deliver high quality and efficient care (The Centers

for Medicare & Medicaid Services, 2021). By adjusting

payments based on the quality of care, rather than

the quantity of services provided, the HHVBP Model

enables CMS to tie home health organizations’

payment to their performance. To support the efforts

of the Department of Health and Human Services,

the HHVBP Model helps to spend healthcare dollars

wisely. This includes supporting efforts to deliver better

overall care, which contributes to healthier people and

communities (Landers et al., 2016; The Centers for

Medicare & Medicaid Services, 2021).

In November 2021, the CMS acted to improve home

health care for older adults and people with disabilities

through a final rule, which aims to shift payments from

a volume-based system to a value-based system for

Medicare sponsored home health services. Nationwide,

the HHVBP Model provides a critical update to the

Home Health Prospective Payment System (PPS). This

includes updates to the payments rates for home

infusion therapy services for Calendar Year (2022).

All these changes have been designed to harmonize

with existing statutory and regulatory requirements,

nationwide (The Centers for Medicare & Medicaid

Services, 2021).

One of the greatest health care challenges facing the

State of Missouri is making sure that aging adults with

multiple chronic illnesses can remain as independent

as possible. Nurses need to understand these changes

to reimbursements for the provision of home health

services and respond accordingly. As nursing continues

to meet the challenge of providing affordable health

care to aging adults in their homes, nurse educators

should look to the guidance offered in the Future of

Nursing 2030 Report and expanding the training of

future nurses to continue to work effectively at the

clinical bedside and beyond.

References

Chee, T. T., Ryan, A. M., Wasfy, J. H., & Borden, W. B.

(2016). Current state of value-based purchasing

programs. Circulation, 133(22), 2197–2205. https://doi.

org/10.1161/CIRCULATIONAHA.115.010268

Landers, S., Madigan, E., Leff, B., Rosati, R. J., McCann, B.

A., Hornbake, R., MacMillan, R., Jones, K., Bowles, K.,

Dowding, D., Lee, T., Moorhead, T., Rodriguez, S., &

Breese, E. (2016). The future of home health care. Home

Health Care Management & Practice, 28(4), 262–278.

https://doi.org/10.1177/1084822316666368

Pozniak, A., Lammers, E., Mukhopadhyay, P., Cogan, C.,

Ding, Z., Hanslits, K., Ji, N., Jin, Y., Repeck, K., Schrager,

J., & Turenne, M. (2021). Impacts of the home health

value-based purchasing ( HHVBP ) model after the first

payment adjustment year. Health Services Research,

56(S2), 72–72. https://doi.org/10.1111/1475-6773.13799

The Centers for Medicare & Medicaid Services. (2021). Home

health value-based purchasing model: CMS Innovation

Center. Innovation Center. Retrieved from https://

innovation.cms.gov/innovation-models/home-healthvalue-based-purchasing-model.

United States Census Bureau. (2021). U.S. Census Bureau

quickfacts: Missouri. Retrieved from https://www.

census.gov/quickfacts/MO.


4

Missouri Nursing News January, February, March 2022

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January, February, March 2022 Missouri Nursing News 5

Think like an expert witness to avoid falls liability

An 88-year-old patient slips on the floor, falling and

breaking his hip. Your immediate concern is getting

him the help he needs, but you also wonder if you

could be legally liable for what happened. By thinking

like an expert witness, you can help determine if this

concern is valid and whether you could have taken

steps to avoid the situation in the first place. But first,

you need to understand some background information.

Elements of malpractice

To be successful in a malpractice lawsuit, plaintiffs

must prove four elements:

1. Duty. A duty existed between the patient and

the nurse: The nurse had a responsibility to care

for the patient.

2. Breach. The duty to care was breached. To

determine if negligence occurred, the expert

witness would consider whether the nurse met

the standard of care, which refers to what a

reasonable clinician with similar training and

experience would do in a particular situation.

3. Injury. The patient suffered an injury. Keep in

mind that an injury can be defined as not only

physical injury, but also psychological injury or

economic loss.

4. Causation. The breach of duty caused the

injury: Did the act or omission cause the negative

outcome?

Expert witnesses will consider these four elements as

they review the case, and they’ll ask multiple questions

(see Was there liability?). The questions primarily

address prevention and what was done after the fall

occurred.

Prevention

The following steps can help prevent falls and,

if documented correctly, prove that the nurse took

reasonable steps to protect the patient from injury:

Take a team approach. Registered nurses, licensed

practical/vocational nurses, and certified nursing

assistants are ideal members for a team dedicated to

creating a falls reduction plan for each patient.

Assess the risk. A comprehensive assessment

is essential to identify—and then mitigate—falls

hazards. This starts with assessing the patient for risk

factors such as history of a previous fall; gait instability

and lower-limb weakness; incontinence/urinary

frequency; agitation, confusion, or impaired judgment;

medications; and comorbid conditions such as postural

hypotension and visual impairment. Keep in mind that

assessment should be ongoing during the patient’s care

because conditions may change. It’s also important

to consider the environment, particularly in the home

setting.

An excellent resource for assessing communitydwelling

adults age 65 and older is the CDC’s STEADI

(Stopping Elderly Accidents, Deaths & Injuries) initiative.

Develop a plan. Once the assessment is complete,

the patient care team, including the patient and their

family, can develop a falls-reduction plan based on the

patient’s individual risk factors. The plan should address

locations that are at greatest risk, such as bedside,

bathrooms, and hallways, and detail action steps.

Communicate. It’s not enough to create a plan;

communication is essential for optimal execution.

All care team members, including patients and their

families, need to be aware of the patient’s fall risk and

the falls reduction plan. The STEADI initiative has falls

prevention brochures for patients and family caregivers

at www.cdc.gov/steadi/patient.html. The falls risk

reduction plan, communication with others, and

education provided should all be documented in the

patient’s health record.

If a fall occurs

Despite nurses’ best efforts, a patient may fall. An

expert witness will scrutinize how the nurse responded

to the event. The following steps will help to reduce

the risk of a lawsuit or the chances that a lawsuit is

successful:

Assess the patient. Examine the patient for any

obvious physical or mental injuries. Do not move

the patient if a spinal injury is suspected until a full

evaluation can be made. Be particularly alert for

possible bleeding if the patient is taking anticoagulants.

When appropriate, ask patients why they think they fell

and continue monitoring at regular intervals.

Communicate assessment results. Notify

the patient’s provider of the fall and results of the

assessment. The provider may order X-rays for further

evaluation. Remember to mention if the patient is

taking anticoagulants, particularly in the case of a

potential head injury, so the appropriate scans can be

ordered.

Revise the plan. As soon as possible after the fall,

work with the team to reassess risk factors, revisit the

falls reduction plan, and revise the plan as needed. It’s

important that actions are taken to prevent future falls,

and that those actions are documented.

Document. Each step should be documented in the

patient’s health record, especially all assessment results

and provider notifications.

Reducing risk

Unfortunately, patient falls are not completely

avoidable. However, developing a well-conceived

prevention plan can help reduce the risk, and taking

Think like an expert witness to avoid...continued on page 6


6

Missouri Nursing News January, February, March 2022

Think like an expert witness to avoid...continued from page 5

appropriate actions after a fall can help mitigate further

injury. Both prevention and post-fall follow up not only

benefits patients, but also reduces the risk of a lawsuit.

Was there liability?

If a patient falls, an expert witness will likely want

to know the answers to the following questions

(developed by Patricia Iyers) when deciding if liability

may exist:

• Was the patient identified as being at risk for

falls? How was that risk communicated to

others?

• Were measures implemented to prevent falls?

• Approximately how soon was the individual

found after he had sustained a fall?

• What was done at the time of the fall?

• Was the patient appropriately monitored after

the fall to detect injuries?

• What did the assessment (including vital signs)

reveal?

• Did the nurse communicate the findings to the

patient’s provider?

• Were X-rays ordered and performed?

• Was there an injury? If so, how soon was it

treated?

• If the patient hit their head, was the chart

reviewed to determine if mediations included

an anticoagulant? If on anticoagulant, was this

information communicated to the provider so

head scans could be performed to check for

cranial bleeding?

• Was there a change in mental status after the

fall?

• Were additional assessments and monitoring

done as follow up?

• Was the patient’s risk for falls reassessed after

the fall and the plan of care revised to minimize

the risk of future falls?

Article by: Georgia Reiner, MS, CPHRM, Senior Risk

Specialist, Nurses Service Organization (NSO)

RESOURCES

Bono MJ, Wermuth HR, Hipskind JE. Medical malpractice.

StatPearls. 2020. www.ncbi.nlm.nih.gov/books/

NBK470573.

Centers for Disease Control and Prevention. Important facts

about falls. www.cdc.gov/homeandrecreationalsafety/

falls/adultfalls.html.

Centers for Disease Control and Prevention. STEADI:

Materials for healthcare providers. 2020. www.cdc.gov/

steadi/materials.html.

CNA, NSO. Nurse Professional Liability Exposure

Claim Report: 4th Edition. 2020. www.nso.com/

nurseclaimreport.

Dykes PC, Adelman J, Adkison L, et al. Preventing falls in

hospitalized patients. Am Nurs Today. 2018;13(9):8-13.

https://www.myamericannurse.com/preventing-fallshospitalized-patients.

Iyer P. Legal aspects of documentation. In: KG Ferrell, ed.

Nurse’s Legal Handbook. 6th ed. Wolters Kluwer; 2015.

Van Voast Moncada L, Mire GL. Preventing falls in older

persons. Am Fam Physician. 2017;96(4):240-247. https://

www.aafp.org/afp/2017/0815/p240.html.

Disclaimer: The information offered within this article

reflects general principles only and does not constitute legal

advice by Nurses Service Organization (NSO) or establish

appropriate or acceptable standards of professional conduct.

Readers should consult with an attorney if they have specific

concerns. Neither Affinity Insurance Services, Inc. nor NSO

assumes any liability for how this information is applied in

practice or for the accuracy of this information.

This risk management information was provided by

Nurses Service Organization (NSO), the nation's largest

provider of nurses’ professional liability insurance coverage

for over 550,000 nurses since 1976. The individual

professional liability insurance policy administered through

NSO is underwritten by American Casualty Company of

Reading, Pennsylvania, a CNA company. Reproduction

without permission of the publisher is prohibited. For

questions, send an e-mail to service@nso.com or call 1-800-

247-1500. www.nso.com.

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January, February, March 2022 Missouri Nursing News 7

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Missouri Nursing News January, February, March 2022

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January, February, March 2022 Missouri Nursing News 9

In his seminal work, Diffusion of Innovations,

Everett Rogers found that for a new idea to be widely

adopted, it has to meet four basic criteria:

1. It has to be innovative.

2. It has to be communicated through certain

channels.

3. It has to occur over time.

4. It has to happen among the members of a social

system.

Victor Hugo is credited with the observation that

there is nothing so powerful as an idea whose time

has come. Unfortunately, until their time arrives, the

best ideas can repeatedly fail to launch for decades.

You may be familiar with the case of James Lancaster,

an English sea captain who suspected that citrus juices

prevented scurvy in his sailors (this idea occurred to him

at a time when scurvy killed more sailors than warfare

or sea accidents). Today, we know he was correct. As

early as 1601, he proved his theory with real sailors and

a control group. Even so, his innovation failed to catch

on.

Finally, in 1747 (150 years later), a British Navy

physician, James Lind, read about Lancaster’s

experiments & began some of his own. Lind’s

experiments also proved the theory. It was so

undeniable, the British Navy ultimately required

oranges, lemons & limes for sailors on its entire fleet

of ships, to prevent scurvy among its sailors… in

1795, nearly 50 years after this re-discovery of James

Lancaster’s original experiments.

You may wonder why, in the face of so many

deaths, when the answer was so simple, it took two

centuries for this medical innovation to catch on. In

short, bureaucratic inertia was a major barrier. There

was evidence that citrus prevented scurvy, but not

everyone agreed it was a cure. Further, Dr. Lind may

have been correct, but he was not a prominent figure

in Navy medicine, so his message was slow to gain

traction. One thing we know for sure: During the

intervening 200 years, the Navy adopted numerous

innovations in shipbuilding & weaponry. It was simply

not the case that the Navy was averse to innovation in

general.

One of the most important roles of the Missouri

Nurses Association is our promotion of innovation in

the field of Nursing. One way we do this is by offering

an Early Career Nurse Innovator Award – an annual

cash prize for a creative new nurse, who looks at the

profession with fresh eyes, whose innovative approach

accomplishes something noteworthy & respectable that

advances the profession of Nursing & the health of

Missourians.

This year, we are using a somewhat innovative

approach to fundraising for the grant. We are asking

100 people to donate $100 to support the Early Career

Nurse Innovator Award. As leaders in the social system

of Nursing, we believe that by communicating these

innovative acts to & through our members & our

colleagues over time, we’re well-positioned to help

these innovations diffuse in the time-tested manner

supported by research. We are asking you to visit our

website & make a $100 donation to our effort, and to

send this letter to a couple of your friends, encouraging

them to consider doing the same.

To give, please visit: https://missourinurses

foundation.org/100for100/

With your help, as always, we hope to connect the

past, improve the present & anticipate the future of

Nursing in Missouri.

Thank you,

Matt Younger, M.S., LNHA

President, Missouri Nurses Foundation


10

Missouri Nursing News January, February, March 2022

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January, February, March 2022 Missouri Nursing News 11

EOE/M/F/D/V

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responsible for delivering academic instruction for clinical and/or theory components of the Practical Nursing program.

Qualifications we’re looking for include:

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As a nurse, your time is precious.

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