North Dakota Nurse - April 2022

The North Dakota Nurse
Celebrate Nurses
Month in May!
NORTH DAKOTA NURSES ASSOCIATION
THE OFFICIAL PUBLICATION OF THE NORTH DAKOTA NURSES ASSOCIATION
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 www.ndna.org and click on “Join.”
Quarterly publication distributed to approximately 20,000 RNs and LPNs in North Dakota
Vol. 91 • Number 2 April, May, June 2022
INDEX
Being Enough
While Still
Getting
Better
Page 4
Medication Safety and Opioid
Risk Screenings Conducted by
Nurses in Patients’ Homes
Page 8
ND Nurse: Resilience
Series 7 of 7
Page 13
Message from the President
It’s Time to Celebrate Nurses!
Greetings nurses of North Dakota. Spring
is here and summer is just around the corner.
As we get ready to welcome May, we get to
celebrate National Nurse’s Week! This is an
exciting time for us to reflect on our career
and the difference we make in the healthcare
industry. Did you ever wonder how many
nurses there are in the world? Well, 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.”
The nursing profession has been maintained
and endorsed by the American Nurses
Association since 1896. Each of ANA's state
and territorial nurses’ associations sponsors the
nursing profession at the state and regional
levels. Each conducts celebration on these
dates to recognize the contributions that nurses
and nursing make to the community. The ANA
supports and encourages National Nurses
Week recognition programs through the state
and district nurses’ associations, other specialty
nursing organizations, educational facilities,
and independent health care companies and
institutions. (ANA, 2019).
As nurses we have so
much to be proud of;
our profession has grown
into a highly respected,
autonomous and highly
trusted profession. When
LIFE featured the profession
on its cover in 1938, the Tessa Johnson
career was in a moment
of transition. “Once almost any girl could be
a nurse,” LIFE explained, “But now, with many
state laws to protect the patient, nursing has
become an exacting profession.” A candidate
needed not only a background in science, but
also a combination of “patience, devotion, tact
and the reassuring charm that comes only from
a fine balance of physical health and adjusted
personality.” (p.1). It is so exciting that we as
a profession have transitioned from “almost
any girl can become a nurse” to any qualified
girl or boy can become a nurse and make a
difference in the workforce. We must make sure
we don’t lose sight of how far we have come
and what an impact we make to our patients.
I believe if we work together to celebrate and
appreciate each other during not only this
time of the year, but all year long, we will help
each other meet this mission. In summary, I am
thankful for all of you, thankful for the nursing
profession and proud to be a nurse! Be well, we
need all of you!
A., A., & A. (2019). National Nurses Week History. ANA
Enterprise. Retrieved March 5, 2019, from https://
www.nursingworld.org/education-events/
national-nurses-week/history/.
Berman, E. (2015, May 6). Celebrate National Nurses
Week With a LIFE Cover Story on Nursing in the
1930s. Time Life, 2. doi:http://time.com/3841878/
national-nurses-week/
current resident or
Presort Standard
US Postage
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Princeton, MN
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Page 2 The North Dakota Nurse April, May, June 2022
How to submit an article for
The North Dakota Nurse!
Nurses are strongly encouraged to contribute to the profession
by publishing evidence-based articles; however, anyone is
welcome to submit content to the North Dakota Nurse.
We review and may publish anything we think is
interesting, relevant, scientifically sound,
and of course, well-written. The editors
look at all promising submissions.
Deadline for submission for the next issue is 6/6/2022.
Send your submissions to director@ndna.org
Welcome New Members
Ma.Irene Rose Verdida
Pomona
Sherry Burg
Grand Forks
Jennifer Rusten
Aneta
Katie Unbehaun
Bismarck
Trisha Jungels
Jamestown
Jacqueline Schwan
Williston
Kimberly Sandvig
Fargo
Nicolette Perrin
Fargo
Editor’s note from the
January 2022
The North Dakota Nurse:
Our apologies to Gail Pederson as
we had incorrectly had her picture
with another piece on the ANA
election from ANA’s Gail Peterson
who is the Nominations and Elections
Committee Chair. Gail Pederson,
SPRN, HN-BC, also had her article,
Medical Marijuana, Legislative
Updates and Education in the issue.
Ann Sears
Minot
Autumn Blair
Fargo
Anabel Ulat
Williston
Wendy Hager
Jamestown
Rebecca Kuss
Jamestown
Paola Lopez
Minot
NDNA at the
Bismarck Tribune
Nurses – The Heart
of Health Care Event
on May 11
The NDNA is excited to again
be a part of the Bismarck
Tribune Nurses “The Heart of
Healthcare” event! Nine top
nominees were selected by a
panel of local judges and one
nurse was selected by Tribune
readers. All ten honorees will
be in the paper on May 6 and be honored at
luncheon on May 11!! NDNA will be there to
draw for two free memberships from among the
honorees. We love this event!
For more information, go to: https://
go.bismarcktribune.com/Nurses2022.
The North Dakota Nurse
Official Publication of:
North Dakota Nurses Association
General Contact Information:
701-335-6376 (NDRN)
director@ndna.org
Board of Directors and Staff
President
Tessa Johnson, MSN, BSN, RN, CDP
President-Elect
Mylynn Tufte, MBA, MSIM, RN
Vice President of Finance
Richelle Johnson, MSN, RN
Director of Membership
Kami Schauer, MSN, RN, CGMT-BC
Director of Education and Practice
Beth Sanford, MSN, RN, ACN, CLC
Director of Advocacy
Penny Briese, PhD, RN
Director at Large
VACANT
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: www.ndna.org
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, sales@aldpub.com. 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 associations.
Want to Make Your Nursing Voice
Heard…Get Published in the
North Dakota Nurse!
The North Dakota Nurse quarterly publication accepts
content on a variety of topics related to nursing. Nurses
are strongly encouraged to contribute to the profession
by publishing evidence-based articles, but we welcome
anyone to submit for publication. If you have an idea,
but don’t know how or where to start, contact one of
the NDNA Board Members.
Please note:
*Send articles to director@ndna.org
*Articles should be in Microsoft Word and be double
spaced.
*All articles should have a title.
*Articles sent should have the words “North Dakota
Nurse Article” in the email subject line, along with the
specific title.
*Deadline for submission of material for upcoming
North Dakota Nurse is 6/6/2022!
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 2022 The North Dakota Nurse Page 3
CAUTI Prevention
Sarah E. Azure, Julia M. Jenny, Alexis R. Waldren
BSN Students, University of Jamestown
Editor: Penny Briese, PhD(c), RN
University of Jamestown
Catheter-associated urinary tract infections (CAUTI) are hospitalacquired
infections that develop from the insertion and maintenance of
Foley catheters. An estimated three-fourths of hospital-acquired urinary
tract infections are a result of Foley catheterization (Scanlon et al., 2017).
Although catheters and other devices may be beneficial to a patient’s
care, they also have great potential for harm. CAUTIs may cause many
complications including gram-negative bacteremia, septic conditions,
mortality, and more. CAUTI-related deaths were reported around 13,000
annually and account for more than $500 million each year (Scanlon
et al., 2017). The increasing number of patients affected by CAUTIs is too
substantial to ignore and needs to be addressed. The aim of this literature
review is to explore CAUTI prevention strategies and programs and how
they can and have been implemented in practice.
CAUTIs in Critical Care Settings
Knowledge of proper catheter insertion and care is essential. In one
study, Chaver et al. (2018) evaluated nursing attitudes and behaviors
toward Foley catheter insertion to address any gaps in knowledge.
Surveys were given to Registered Nurses (RNs) working at the bedside in
emergency rooms and intensive care units. Not surprisingly, the results
of this study revealed the best way to prevent a CAUTI is to avoid the
insertion of a catheter to begin with (2018). This is not always feasible so
this study recommended enhancing documentation for urinary catheter
infections, restricting foley catheter insertion to trained personnel,
and buying new Foley catheter kits that help train and guide the users
through aseptic technique (Shaver et al., 2018). Meddings et al. (2020)
also addressed the need for CAUTI prevention specifically in the Intensive
Care Unit (ICU). These patients commonly require Foley catheters and
often have medical comorbidities that increase their risk for infection. This
knowledge led to the creation of the Agency for Healthcare Research
and Quality (AHRQ) Safety Program for ICUs: Preventing Central-
Line Associated Bloodstream Infections (CLABSI) and CAUTI (2020). It
was later discovered that this project was not used as it was originally
planned. This was correlated with the lack of improvement seen in the
number of CAUTI cases. The finding of this study help to show that even
when resources are available, they are not always used. This is another
problem that needs to be addressed along with more effective nursing
interventions related to proper catheter care.
References
Carr, A. N., Lacambra, V. W., Naessens, J. M., Monteau, R. E., & Park, S. H. (2017).
CAUTI prevention: streaming quality care in a progressive care unit. MedSurg
Nursing, 26(5), 306-308 and 323.
Chaver, B., Eyerly-Webb, S. A., Gibney, Z., Silverman, L., Pineda, C., & Solomon, R.
J. (2018, January-February). Trauma and intensive care nursing knowledge
and attitude of Foley catheter insertion and maintenance. Journal of
Trauma Nursing, 25(1), 66-72. DOI: 10.1097/JTN.0000000000000344
Meddings, J., Greene, T., Ratz, D., Ameling, J., Fowler, K. E., Rolle, A. J., . . . Saint,
S. (2020). Multistate programme to reduce catheter-associated infections in
intensive care units with elevated infection rates. BMJ Qual Saf, 29, 418-429.
DOI: 10.1136/bmjqs-2019-009330
Scanlon, K. A., Wells, C. M., Woolforde, L., Khameraj, A., & Baumgarten, J. (2017,
May-June). Saving lives and reducing harm: A CAUTI reduction program.
Nursing Economics, 35(3), 134-141. https://www.thefreelibrary.com/Saving+li
ves+and+reducing+harm%3a+a+CAUTI+reduction+program.-a0502001258
Siregar, S., Mustafa, A., & Batista, B. (2021). Strategies for preventing catheterassociated
urinary tract infection in pediatric: A systematic review.
International Medical Journal, 28(4), 411-416. https://seronjihou.files.
wordpress.com/2021/08/284411-1.pdf
Wilde, M. H., McMahon, J. M., McDonald, M. V., Tang, W., Wang, W., Brasch,
J.,… & Chen, D.-G. (2015). Self-management intervention for long-term
indwelling urinary catheter users. Nursing Research, 64(1), 24-34. doi: 10.1097/
NNR.0000000000000071.
CAUTIs in Other Healthcare Settings
CAUTIs can occur in any unit in the hospital, not just the ICU. Siregar,
Mustafa, and Batista (2021) performed a systematic review of the
literature and discussed effective interventions to prevent CAUTIs
in children and neonates. Since this is a less commonly discussed
demographic, there were fewer resources that found statistical
evidence that related to CAUTIs and children. It was discovered that
prevention measures in children are very similar to prevention measures
in adults. The most widely used interventions were found to be the use
of aseptic insertion techniques and catheter cares. The authors also
recommended interventions such as continuous evaluation, reporting
the effectiveness of interventions, and providing a doctor to determine
appropriate and necessary indications for catheter placement (Batista,
2021). Finally, the article highlighted the importance of removing Foley
catheters as soon as they are not medically indicated. Wilde et al.
(2015) understood that even though early removal of a catheter is ideal,
many individuals require long-term use. A randomized control trial was
conducted to evaluate the benefit of suggested self-care interventions
in reducing CAUTIs in patients with long-term indwelling urinary catheters.
In this study, education was first provided to participants regarding
catheter insertion skills. A urinary diary was then introduced to track
any abnormalities in urine appearance. Patients were encouraged to
maintain a consistent fluid intake and decrease caffeine. Additionally,
the processes of catheter changing and bag emptying, and draining
were reviewed. Unfortunately, results of this study showed there was
no reduction in CAUTIs even after self-management techniques were
reintroduced (2015).
But on a good note, one progressive care unit at Mayo Clinic in
Jacksonville, Florida was able to report zero CAUTIs in 22 months following
the implementation of a prevention project (Carr et al., 2017). The nurse
manager, nurse educator, and two other nurses on the unit implemented
use of a CAUTI Prevention Form (CPF) and a CAUTI bundle audit tool. The
CPF was used for every patient with a newly inserted indwelling catheter
and for every patient admitted with an indwelling catheter already in.
The only nonadherence to these interventions came from float staff (Carr
et al., 2017). The key limitation of this project was long-term sustainability,
as they were the only unit in the hospital using these measures. The
prevention form and audit tool could be more widely implemented and
analyzed to gain further insight on its effectiveness and sustainability.
Conclusion
Proper prevention of CAUTIs must be implemented to promote
patient safety and well-being. This miniature literature review discussed
several studies that have investigated CAUTI prevention strategies and
programs and how they can and have been implemented in practice.
The literature currently available supports that there are multiple
interventions and programs that can be implemented to reduce the
occurrence of CAUTIs. However, studies are ongoing and there is still
much work that needs to be done regarding the prevention of CAUTIs.

Page 4 The North Dakota Nurse April, May, June 2022
Unsettled
Kami Schauer MSN RN CGMT-BC, Director of Membership
The last few years of nursing have been the most challenging, stressful,
and life-altering of my career. Now in 2022, through many changes in
my view and outlook of nursing, my heart yearns for more. More safety,
stability, and security for nurses past, present, and future. I began this
year reflecting on how my nursing practice, experience, and personal
beliefs intertwine and affect my current and future career in nursing.
As the entire realm of health care has faced unprecedented volumes,
complexity, and overall attitude of healthcare has changed. I met the
heartbreaking decision of should I leave nursing, and if I stay, how do I
continue doing my best while balancing my family life?
No one could have anticipated the changes that COVID had on our
society. The constant change in recommendations, safety protocols,
and lack of medical data was overwhelming as a nurse. As the virus
spread worldwide, the US healthcare system was beginning to feel the
strain. Our schools began to shut down, and my manager notified me
that I would be required to shift to inpatient ICU nursing duties from my
outpatient nursing role. This reassignment was the first of three waves that
forever changed my outlook on COVID, being a nurse, and balancing
family life as a one adult household. It was an honor to care for our
patients; I was just not prepared for the ripples stress would have on me.
For the first time in my adult life, I second-guessed my career as a nurse
and my future aspirations in the healthcare field.
The stress of the situation took its toll; I was struggling to stay on time
with my graduate school projects. I was not adjusting to rotating sleeping
schedules. My kids wanted their mom as they were transitioning to online
classes and not seeing their friends. The flipping back and forth to my
regular job and then very short notice flip to mandatory reassignment
put the hard work that I put in to be a good nurse was at risk for
reprimand if I was unable to flip with a few days' notice. I felt the constant
state of unsettled; I couldn't leave my regular job duties unfinished at
the end of the day because I never knew if I would be moved again.
The unknown led to an unhealthy amount of overtime to ensure my work
wasn't overwhelming my remarkable peers in my regular job. I knew
the importance of helping the inpatient unit; I am glad to have done
my small part. The bedside nurses have such tough jobs, and in crisis,
everyone tries to help out. Unfortunately, I got so used to trying to fill in
gaps and fill other cups that I didn't recognize that my cup was empty,
and I wasn't giving my best anywhere.
Burnout among nurses is a significant issue, specifically during the
COVID-19 pandemic. Per the Journal of Advanced nursing article Nurses'
burnout and associated risk factors during the COVID-19 pandemic: A
systematic review and meta-analysis 'There is an urgent need to prepare
nurses to cope better with COVID-19 pandemic. Identification of risk
factors for burnout could be a significant weapon giving nurses and
health care systems the ability to respond in a better way against the
following COVID-19 waves in the near future.' (Galanis et al. 2021)
Although I had a great team and supportive manager, that unsettled
feeling kept coming. I felt that my master's in nursing program may have
been a waste, that I was burnt out of nursing, and that I needed to either
leave nursing or find a role with a better home/life balance. I mourned
the fantastic team I worked with, the important work we did, and the
place I thought I would retire from, and I could not wait any longer. I
knew I had to make a change, and I did. Now, nearly six months into an
incredible career opportunity, I am happy to say I am again settled in a
nursing role and intend to retire as a nurse.
I will support nursing safety, stability, and security for nurses for many
years to come. I highly encourage you to join an organization, volunteer
on a board, and use your voice to express yourself. Let’s help each other
through the stress ripples of the last few years. Please recognize the need
for self-care. North Dakota nurse’s, we need you, all of you. If you are
feeling the stress of burnout please know you are not alone, let’s change
the COVID stress ripples and make positive changes for our profession
together.
References
Galanis P, Vraka I, Fragkou D, Bilali A, Kaitelidou D. Nurses' burnout and
associated risk factors during the COVID-19 pandemic: A systematic review
and meta-analysis. J Adv Nurs. 2021;77(8):3286-3302. doi:10.1111/Jan. 14839
Being Enough While Still
Getting Better
Mylynn Tufte, RN, MBA, MSIM,
NDNA President-Elect
Hi, my name is Mylynn. I want to introduce myself
as the new president-elect for NDNA. You may know
me from my time as the State Health Officer, head
of the North Dakota Department of Health (Feb. 2017
to Jun. 2020). Since then, I’ve returned to healthcare
consulting with Optum. There I lead the Population
Health Practice delivering strategic consulting
services focused on health equity, public health,
health information technology and population
health management for payers, providers, and
Mylynn Tufte
public sector clients across the Country.
I want to thank you for all of your hard work and dedication to our
profession. These past few years have been especially difficult with
the increased demands on nurses, workforce shortage and then the
COVID-19 pandemic. A recent study by the International Council of
Nurses found the burnout rate in nursing was 40 percent before the
pandemic and has since grown to 70 percent (January 2021). Morale has
been low with many professionals questioning their desire to stay in the
workforce. On a brighter note, enrollments at our nursing schools have
been on the rise. When I spoke with some of these future nurse leaders, I
was both inspired and encouraged about the quality and caliber of the
nurses that are graduating from our North Dakota nursing programs.
So how do we manage the demands and pressures of our life and our
profession?
People who know me know that I’m a huge fan of James Clear, Brené
Brown and Mel Robbins. I’ll admit that I often quote them or use a mantra
of theirs to motivate myself or others to get going…5-4-3-2-1! I try to keep
myself in check with a couple of things that I’ve learned from other
nurses, health professionals, and yes even reading those best-selling
authors.
Start with self-care. We’ve all been advised on airplanes to put on our
own oxygen mask first. It makes sense. We have to take care of ourselves
so that we are able to take care of others. I have built exercise into my
morning routine. Healthy habits that are supported by systems of support
will help you and me achieve our goals – one step at a time, one day at
a time. Do what’s best for you but do something to take care of yourself.
Recognize that you are enough. Be kind to yourself. Just show
up. I have a dear friend that has helped reinforce this for me too.
Showing up every day and being present where you are. Truthfully, a
gratitude practice helps me with this, and I’ve been journaling daily.
This has helped me focus and recognize the areas of resilience, grace,
avoidance, and others of reflection. I’d love to hear from you what you
do to help you show up and be present in your work.
Better every day. Curiosity. Humility. Grit. These are just some of the
values that cross my mind at the end of the day. Did I learn something
new today? Did I practice humility? Did I demonstrate my passion and
perseverance for making a difference today? Truthfully, we may answer
“No” to these questions more than we’d like and that’s all right. We will try
again tomorrow.
NDNA advances our practice and profession
As a nurse leader, I’m excited to be a part of the North Dakota
Nurses Association. The NDNA has been advancing the mission being
working on your behalf 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
advocating on health care issues affecting nurses and the public.
My hope is that you’ll engage with NDNA in the manner that best suits
you. Please invite a colleague to come along with you too. I’m looking
forward to getting to know you all better as I serve in this role with NDNA.
I believe we are enough, and we are getting better every day!
ELBOWOODS MEMORIAL
HEALTH CENTER
MANDAN, HIDATSA,
& ARIKARA NATION
NURSING DEPARTMENT
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
• Sign-on bonus & Relocation reimbursement
For more information email EMHC Recruiter
GoodEarthWoman.Perkins@ihs.gov
To Apply: EMHC Employment www.mhanation.com/emhcemployment
or visit us at www.elbowoodshealth.com
Unity Medical Center, located in Grafton is
recruiting for Med Surg/ER Nurses to work
in our new addition that consists of 11 new
patient rooms and a new ED department.
12 hour shifts rotating days and nights
every 3rd weekend and rotating Holidays.
Please contact Jenny, CNO at 701-352-1620
or apply online at
www.unitymedcenter.com
EOE
Visit nursingALD.com today!
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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 6 The North Dakota Nurse April, May, June 2022
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Gaming in Nursing Simulation:
Creating an Escape Room
Amy S. Lee MSN, RN, CNE
Department of Nursing, Minot State University
Abstract
Background
- With nursing shortages in our area and
across the country, creative ways can
be used to increase interest in the nursing
program at Minot State University. We use
simulation to allow students to participate
in medical scenarios in a safe and
controlled environment. Creating games,
like an escape room, can be used as an
education strategy in nursing simulation to
test knowledge and skills in a controlled
setting. It can also be used as a fun way
to introduce learners to the simulation lab
and the high-fidelity simulator capabilities.
Purpose
- An escape room was developed for
high school Certified Nursing Assistant
(CNA) students to allow them to interact
with the simulation center at Minot State
University. The hope is to also to entice
them to investigate nursing as a career.
We have a guaranteed admission policy
for high school students who meet criteria
for admission. Developing this escape
room introduced the high school students
to our simulation center and allowed
the opportunity to provide them with
information regarding the guaranteed
admission program.
Description of Topic
- I created a scenario and clues the students
need to answer to progress in the escape
room and eventually escape. The scenario
includes a high-fidelity simulator. Mr. J
is a 68-year-old man with a history of
hypertension admitted this morning after a
total knee arthroplasty. The students have
to use their skills and knowledge to escape
his room.
- Supplies:
o The escape room was developed using
all supplies on hand in our simulation
center.
References
Backhouse, A., & Malik, M. (2019). Escape into patient
safety: Bringing human factors to life for medical
students. BMJ Open Quality, 8(1), e000548.
https://doi.org/10.1136/bmjoq-2018-000548
Baily, K., Dr. (2020, January 7). Escape rooms in
medical simulation: Downloadable sepsis
scenario & more | healthysimulation.com.
HealthySimulation.com. Retrieved February
14, 2022, from https://www.healthysimulation.
com/22109/escape-room-sepsis-simulation/
How simulation escape rooms can make learning
stick. (n.d.). Laerdal Medical. Retrieved
February 14, 2022, from https://laerdal.com/ca/
information/how-simulation-escape-rooms-canmake-learning-stick/
McLaughlin, J. L., Reed, J. A., Shiveley, J., & Lee,
S. (2020). Escape room blueprint: Central
orientation contagion crisis. Simulation
& Gaming, 52(1), 24–30. https://doi.
org/10.1177/1046878120954493

April, May, June 2022 The North Dakota Nurse Page 7
Viruses Problem-Solve
NDNA Events
Paula J. Grosinger, RN
As a nurse and journalist, it has been hard to watch the confusion and
false promises about Covid-19 and how we can get “back to normal.”
Worse, public health officials and the media have contributed to the
confusion with inaccurate, misleading, or false reports about what works,
what will happen, and how our fight against Covid-19 will end.
I first read about the novel coronavirus on January 9, 2020, in a Wall
Street Journal article. The article detailed the identification of the virus
by Q Li, a doctor in Wuhan, China. I recalled hearing about Wuhan in
a story a couple of months earlier that talked about a doctor who
reported deaths possibly linked to a new pathogen and how he
had “disappeared.” I perked up. I also knew the world was in for a
long battle. There is no doubt now that China tried to suppress early
information about the virus, and it appeared as early as October 2019
(using molecular time clock calculations). Global mobility meant it could
spread rapidly and already had opportunity to do so.
As the virus spread around the globe and lockdowns went into effect,
there was the hope that science and public health agencies could
engineer an end to the pandemic and to the virus. Two years later, we
are still being falsely promised that if we do what public health and
political leaders say, the virus will “Go Away.” Covid-19 is not going away
–probably EVER. Here’s why:
Like many microorganisms, viruses do not “think,” but they do solve
problems. Among those problems are survival and replication in the face
of an immune response by a host.
SARS-CoV-2, also known as Covid-19, is from a group of viruses that are
especially adept at solving those problems, and they do so by rapidly
mutating.
A recent opinion in my local newspaper blamed mutations in Covid-19
on people not getting vaccinated. In their defense, they were repeating
a line that has come from some in public health.
Corona viruses are going to mutate regardless of vaccination status
in humans. In fact, the virus may be MORE likely to mutate, the more
people get vaccinated. It will solve the problem of vaccinated hosts.
That is why there is no cure for your cold, another coronavirus. Our
hope is that as Covid-19 mutates it will become less virulent, causing
less damage from physical illness. We are seeing this with the Omicron
variant.
Testing also caused a lot of chaos. Back in 2020, officials raved about
the accuracy of PCR (polymerase chain reaction) testing. I am familiar
with these tests, but many providers were not when PCR testing for Covid
rolled out.
The tests are extremely sensitive, but they also result in lots of false
positives. Some public health officials stated, “False positives are a good
thing.”
False positives can be a dangerous thing.
People who tested positive but were asymptomatic often assumed
they had the virus. For most of the “non-essential” folks this meant a
quarantine and then return to activity as usual. Some of these people
ended up getting Covid-19 later and did not immediately act on their
symptoms because they thought they were Covid clear. They exposed
everyone with whom they had contact.
Some blame the unvaccinated for our current Covid problems. Some
want to impose sanctions on the unvaccinated. There is even talk of not
insuring the unvaccinated and withholding care.
In early 2021, I chose to get the two-dose vaccine and in December
2021 I got the booster based on information at the time. I believe it is
safe for an older person like me and may reduce disease severity, but I
understand vaccine reluctance. It is ridiculous to force people to get a
vaccine that is no longer effective against the dominant variant. Worse,
getting unlimited boosters could do long-term harm to individuals and
society. T-cell depletion is one possibility with overvaccination.
Long term effects are unknown. Reproductive effects are unknown.
Efficacy is minimal. Trust, for many, has been broken.
NDNA will be including upcoming events in our The North Dakota
Nurse publication that may be of interest to nurses! If you would like to list
your event, please contact director@ndna.org. We will continue to have
a calendar of ANA/NDNA meetings and others in our NDNA Monthly
eNews as well.
Late April/May/June 2022
**April 18 NDNA Spring Conference 2022 – Focused Efforts on Health
Equity – Online Webinar REGISTER AT ndna.org*
April 20 Dr. Andrea Edlow Presentation – Online Webinar
April 25 YWCA Women of the Year 2022 – Delta Hotels by Marriott,
Fargo
April 29 National Evidence-Based Practice (EBP) Conference – Virtual
April 20-21
May 3-6 North Dakota Long Term Care Association Annual Convention
and Expo – Bismarck Event Center
May 5 Cannabis 101: What Medical Professionals Need to Know –
AmericInn, Valley City
May 7 Missouri Valley Oncology Nursing Society Symposium – Ramkota,
Bismarck
May 12 Rising Out of Hatred – Sanctuary Events Center, Fargo
May 15 “The Hormone Connection” – Common Does Not Mean
Normal – Hampton Inn, Williston
June 7 Redefining Memory Loss Caregiver Conference – Holiday Inn,
Fargo
June 8-9 North Dakota Nonprofit Leadership Conference - Minot
June 8-10 Dakota Conference on Rural and Public Health – Alerus
Center, Grand Forks
June 21-22 North Dakota Department of Health Immunization
Conference - Bismarck
June 21-26 2022 AANP National Conference – Orlando, Florida
June 23 The Bakken Human Trafficking Summit – Rough Rider Center,
Watford City
Along with ANA, NDNA is
Recognizing Nurses in May!
The American Nurses Association is excited to commemorate the
annual National Nurses Month. We are all indebted to nurses for their
unwavering commitment to patients, their communities, and our health
care systems. The Nurses Month theme, “You Make A Difference,” was
selected to encourage nurses, individuals, employers, other health care
professionals and community leaders to recognize and promote the vast
contributions and positive impact of America’s nurses.
Celebrating and honoring nurses during the month of May provides
an added opportunity to promote the value of nursing, advocate for the
profession, conduct media outreach, and host virtual events.
Connect your activities to the official Nurses Month tagline — You
Make a Difference — recognizing nurses’ unparalleled impact on health
and health care.
Watch our website and social media for Nurses Week and Month posts
and activities!
An abbreviated version of this article appears in the Turtle Mountain
Star, 24 January 2022
Wall Street Journal 1/8/20 Natasha Khan
https://www.wsj.com/articles/new-virus-discovered-by-chinese-scientistsinvestigating-pneumonia-outbreak-11578485668
Science 1/9/20 Jon Cohen, Dennis Normile
https://www.science.org/content/article/scientists-urge-china-quickly-sharedata-virus-linked-pneumonia-outbreak
Science 1/14/20 Jon Cohen, Dennis Normile
World on Alert for Potential Spread of SARS-like virus
https://www.science.org/content/article/world-alert-potential-spread-new-sarsvirus-found-china
Paula J. Grosinger, RN, BNSc is the owner of Crain Grosinger Publishing
in Rolla,
Contact information not for publication:
701-202-1293, pgrosin@gmail.com
P.O. Box 11, Rolla, ND 58367

Page 8 The North Dakota Nurse April, May, June 2022
Medication Safety and Opioid Risk Screenings Conducted by
Nurses in Patients’ Homes
Brianna O’Gary, PharmD student and
Heidi Eukel, PharmD
The opioid crisis has continued to have
negative mortality, morbidity, and financial
impact on the United States over the past 20
years. Throughout a 12-month period ending
in April 2021, there were 100,306 drug overdose
deaths, a 28.5% increase from the same period
the year prior. 1 The National Institute on Drug
Abuse estimates that approximately 25% of
patients prescribed opioids for chronic pain
will misuse their medication and about 10% will
develop opioid use disorder (OUD).
There have been a multitude of public health
and healthcare initiatives across the United
States to help curb the opioid epidemic. In
2016, the CDC developed the Guidelines for
Prescribing Opioids for Chronic Pain. 3 These
guidelines include the recommendation
for preventative approaches and upstream
interventions targeted to patients at risk of OUD
and/or overdose.
In North Dakota, programs aimed at
curbing the opioid crisis include free MedSafe
medication disposal at local pharmacies, the
“Lock. Monitor. Take Back.” prevention effort,
and the availability of free 2-dose Narcan kits
through Recovery Reinvented. 4
To help further address the opioid harm
reduction efforts, pharmacy faculty at North
Dakota State University created the Opioid
and Naloxone Education (ONE) Program
in 2018. This program moves opioid misuse
prevention upstream. Pharmacists screen
patients receiving an opioid prescription for risk
of opioid misuse and also for risk of overdose
and provide interventions based on risk score.
Results from the ONE Program show that 20%
of the patients screened at participating
pharmacies in North Dakota were identified as
at-risk of opioid misuse or accidental overdose. 5
After three years of focusing on prevention in
the pharmacy sphere, the founders of the ONE
Program wanted to apply The ONE Program’s
core principles and continue to expand
opioid safety to other fields of healthcare and
vulnerable populations.
One particularly vulnerable patient
population is those receiving home healthcare.
In 2015, 4.5 million patients across the United
States received home healthcare services. 6
These patients are often homebound receiving
their medications via mail or delivery services
from the pharmacy. This can lead to difficulty
for pharmacy personnel to provide adequate
education and follow-up leading to potential
medication safety issues, especially with
opioids. Home health clinicians, such as nurses,
are well positioned as the most accessible
healthcare provider for this population to
provide risk assessments and medication safety
education. 7
Currently, there is minimal literature on opioid
and medication safety initiatives in the home
healthcare setting. A medication disposal
survey and intervention was created for a
small number of home healthcare patients by
University of Pennsylvania nursing students.
The survey found that 53% of respondents had
unused medication in their household, 93% of
respondents have never been educated how
to properly dispose of medications, and 60% of
respondents disposed of their medications in
the trash, sink, or toilet. 8 Based on these findings,
the ONE Program partnered with local public
health units and CHI Health at Home to create
a medication safety and opioid risk assessment
initiative.
Through this initiative, nurses conduct
a medication safety screening to assess
medication storage, disposal, and adherence.
If the patient is taking an opioid, an opioid risk
assessment is also completed. Interventions
provided by the nurse are based on patient
risk level and include 1. Education about
medication storage, disposal, adherence, and
opioid safety; 2. Deterra drug disposal bag;
3. Daily pill organizer, 4. Medication lock box;
and 5. Narcan. The supplies are provided by a
grant through the North Dakota Department
of Human Services and program development
and support is provided by the ONE Program.
More than 1,400 screenings have been
conducted to date. The ONE Program’s home
health initiative has helped address gaps in
medication safety research and has provided
critical safety information to a vulnerable
population in North Dakota. For more
information or to discuss initiating these services
with your patients, contact Heidi.Eukel@ndsu.
edu
Bottineau, ND
Full-Time RN/LPN
Also hiring CNAs and
CS/ER Technicians
NEW competitive salary &
excellent benefit package
ND licensure/certification required.
SIGN-ON
BONUS
1. Overview | Drug Overdose | CDC Injury Center.
Published June 23, 2021. Accessed January
17, 2022. https://www.cdc.gov/drugoverdose/
deaths/prescription/overview.html
2. Abuse NI on D. Opioid Overdose Crisis. National
Institute on Drug Abuse. Published March 11,
2021. Accessed January 17, 2022. https://www.
drugabuse.gov/drug-topics/opioids/opioidoverdose-crisis
3. CDC Guideline for Prescribing Opioids for
Chronic Pain — United States, 2016. MMWR
Recomm Rep. 2016;65. doi:10.15585/mmwr.
rr6501e1er
4. Lock. Monitor. Take Back. | North Dakota PRMC.
Accessed January 31, 2022. https://prevention.
nd.gov/takeback
5. About – ONE Program. Accessed January 18,
2022. https://one-program.org/about-us/
6. FastStats. Published May 20, 2020. Accessed
January 31, 2022. https://www.cdc.gov/nchs/
fastats/home-health-care.htm
7. Cotton BP, Lohman MC, Brooks J, et al.
Prevalence of and Factors Related to
Prescription Opioids, Benzodiazepines, and
Hypnotics among Medicare Home Health
Recipients. Home Healthc Now. 2017;35(6):304.
doi:10.1097/NHH.0000000000000553
8. Haughey CW, Lawson D, Roberts K, Santos M,
Spinosa S. Safe Medication Disposal. Home
Healthc Now. 2019;37(2):106-110. doi:10.1097/
NHH.0000000000000719
For more information or an application, please contact Human
Resources at 228-9314 or visit our website at
www.smphealth.org/standrews

April, May, June 2022 The North Dakota Nurse Page 9
Solutions to the Nursing Shortage
Brianna Regner, Melissa Haas, Maggy Russek
BSN Students, University of Jamestown
Editor: Penny Briese, PhD(c), RN
University of Jamestown
The nursing shortage in the United States has
been an ongoing problem for many years. It is
assumed that the only contributing factor to
this shortage is the lack of interest in the field.
However, there are multiple issues contributing
to the overwhelming need for nurses. Some
of these issues include declines in the number
of nursing faculty, pandemic complications,
and inadequate staffing ratios. In this miniliterature
review, we will discuss how these issues
contribute directly to the nursing shortage and
recommend possible solutions these problems.
Nursing Faculty Shortage
According to Brown (2015), 68,938 qualified
nursing applicants were denied entry into
programs in 2014 due to faculty shortages.
Lack of nurse educators has complicated
the national nursing shortage significantly. To
better understand the faculty shortage, is it
important to recognize why it is taking place.
One problem for nurse educators involves
a lack of incentives and failure to have
competitive salary. For example, practicing
nurse practitioners earn nearly $20,000 more
than nurse educators (Brown, 2015). The author
of this study goes on to discuss specific pay
differentials between the two and how clinical
settings offer higher salaries to nurses with the
same doctoral level of education. Without
nurse educators, however, there will be no new
nurses. To combat this specific shortage, nurse
educators must be considered an essential
component of the nursing profession. Not
only will significant increases in recognition
and compensation help maintain the current
number of educators, it may also attract more
individuals to the field (Brown, 2015). Attracting
more individuals to the field with initiatives,
incentives, and recognition will hopefully
help combat the current nursing shortage by
reducing the number of potential students
being turned away (Brown, 2015).
Pandemic Complications
The COVID-19 pandemic has escalated the
nursing shortage to a new level. According to
Caruso (2020), one of the main complications
related to the pandemic is the intense infection
control protocols that have been put into place
and the stress of adhering to best practices
regarding infection control. The shortage of
personal protective equipment (PPE) has also
put additional strain on nurses, both mentally
and physically. Every day, nurses have to deal
with feeling inadequate to properly care for
multiple patients while maintaining such strict
infection control protocols, as well consider
the risk of infecting themselves and their loved
ones (Caruso, 2020). Not only has the pandemic
caused complications for those already
practicing in the field, but it also put strain on
the nursing students. In 2020, nursing students’
education was interrupted during the nation’s
shutdown. This forced students to switch over to
virtual learning and practice social distancing
to prevent the spread of the pandemic
(AHC Media, 2021b). Learning virtually was
challenging for many nursing students and it
was difficult for some colleges to provide their
students with hands-on experiences and inperson
clinicals (AHC Media, 2021a). This has led
to nursing students entering into practice feeling
less prepared.
COVID-19 has caused extra strain on all
healthcare workers. They are experiencing
elevated anxiety, depression, burnout, and
work overload rates. According to AHC Media
(2021b), “burnout affected 49% of healthcare
workers, while 43% reported work overload.
Also, 61% of workers reported fear of exposure
or transmission of COVID-19” (p. 2). Healthcare
facilities failed to increase their staffing numbers
during the pandemic, further burdening their
workers and nursing burnout was a result
(AHC Media, 2021a). Because of this, nursing
has experienced the highest amount of
burnout than any other occupation during the
pandemic (Hospital Employee Health, 2021).
Inadequate Staffing Ratios
The nursing shortage can be associated
with low job satisfaction, work-related stress,
bullying and harassment among colleagues,
and the challenges of difficult patients (Africa,
2017). Along with this, new nurses may not feel
confident coming off orientation due to lack of
training. Thus, transition to practice programs
are being implemented to help new nurses
become comfortable at work. The goal of
these programs is to improve communication,
preceptorship, mentoring, time management,
and outcomes for new nurses (Africa, 2017).
Hospitals should also be required to follow safe
nursing staffing standards. By doing so, nurse
burnout could possibly be decreased.
Conclusion
Although the nursing shortage is nothing
new to the United States, it is important that
developing and implementing plans on how
to manage this ongoing issue be recognized
by those outside of the profession. As we have
outlined, there are several issues contributing
to the severe nursing shortage, but there is
hope. Institutes of higher education could
begin by increasing recognition, incentives and
compensation for nursing faculty. With more
faculty, schools of nursing have the ability to
train more nurses. Another strategy is ensuring
that nurses have enough PPE. And providing
support for new nurses by means of transition to
practice programs that mentor new nurses as
they make the move to professional nursing has
been shown to be a very effective way to keep
nurses in practice. Federally mandating safe
staffing ratios is another way to ensure nurses do
not get burned out and leave practice. These
may sound like simple solutions, but they will
take a lot of hard work. The nursing shortage is
not going to get any better until we nurses unite
our voices and work together for both our sake
and the safety of our patients.
References
Africa, L. M. (2017). Transition to practice programs:
Effective solutions to achieving strategic
staffing in today’s healthcare systems. Nursing
Economic$, 35(4), 178-183. https://www.
proquest.com/docview/1929673638?pq-origsite=
gscholar&fromopenview=true
AHC Media. (2021a). COVID-19 pandemic
exacerbated perioperative nursing shortage.
Same-Day Surgery, 45(7). 1-3. https://www.
reliasmedia.com/articles/148150-covid-19-
pandemic-exacerbated-perioperative-nursingshortage
AHC Media. (2021b). Pandemic stress, burnout
contribute to nursing pipeline shortage.
Contraceptive Technology Update, 42(7), 1-3.
https://www.reliasmedia.com/articles/148193-
pandemic-stress-burnout-contribute-to-nursingpipeline-shortage
Brown, O. (2015). Nursing Faculty Shortage: A
Piece of the Nursing Shortage Puzzle. The
Free Library. https://www.thefreelibrary.com/
Nursing+faculty+shortage%3a +a+piece+of+the+nur
sing+shortage+puzzle.- a0471383397
Caruso, M. (2020). Outlook for nurse supply
and demand shifting amid COVID-19.
Modern Healthcare, 50(15), 14. https://www.
modernhealthcare.com/labor/outlook-nursesupply-and-demand-shifting-amid-covid-19
Hospital Employee Health (2021). Inadequate staffing
caused nurse burnout before pandemic.
Hospital Employee Health, 40(10). 1-3. https://
www.reliasmedia.com/articles/148508-
inadequate-staffing-caused-nurse-burnoutbefore-pandemic
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Page 10 The North Dakota Nurse April, May, June 2022
Jessica Allen, BA (NDDOH) and
Lauren Dybsand, MPH (NDSU)
Immunizations, including the COVID-19 vaccine, are an important
part of routine personal, prenatal and postpartum care. The Centers
for Disease Control and Prevention (CDC), the Society for Maternal
Fetal Medicine (SMFM), and the American College of Obstetricians and
Gynecologists (ACOG) strongly recommend that pregnant individuals
be vaccinated against COVID-19, in addition to influenza and pertussis.
All health care providers who see patients who are pregnant or who
may become pregnant in North Dakota should be recommending and
administering staying up to date on COVID-19 vaccines.
COVID-19 Vaccine and Pregnancy
Staying up to date on COVID-19 vaccination is recommended for
all people five years and older, including people who are pregnant,
breastfeeding, trying to get pregnant now or might become pregnant in
the future. Throughout the COVID-19 pandemic, pregnant and recently
pregnant persons have been shown to be at increased risk for severe
illness from COVID-19. One study conducted by the National Institutes
of Health (NIH), found moderate to severe COVID-19 infection while
pregnant to be associated with higher rates of pregnancy complications
including cesarean section delivery, preterm delivery and postpartum
hemorrhaging. As of February 14th, 2022, there have been 2,376
pregnant persons infected with COVID-19 in North Dakota. Eighty-three
of those cases have been hospitalized and one individual has passed
away. Seventy-eight (94%) of these severe cases were unvaccinated.
However, only 20% of pregnant persons in 2021 in the state of North
Dakota were vaccinated with at least one dose of COVID-19 vaccine.
Nationally, about one third of pregnant adults in the US still remain
unvaccinated as of February 2022.
By mid-February 2022, more than 201,075 pregnant people have
reported COVID-19 vaccination in the United States, and the evidence
regarding the safety and effectiveness of COVID-19 vaccination
during pregnancy continues to grow. COVID-19 vaccines are effective
NDC3 is improving health
and wellness in communities
across North Dakota
“NDC3.org has allowed our clients in North Dakota to connect with free
evidence based programs to support their health. With options ranging from in
person to online programs, caregiver support options and workshops promoting
self-management of chronic conditions, NDC3 truly is a one-stop shop for anyone
in our communities. By getting this information out to the public, we have been
able to enrich the lives of all North Dakotans,
regardless of their physical location.”
Wendy Schmidt MBA, BAN, RN
Answering Your Questions on Vaccines
Pregnancy, Fertility and COVID-19 Vaccines:
What you Need to Know
at reducing the rates of severe COVID-19 in pregnant and recently
pregnant persons. Additionally, there is not an increased rate of adverse
events affecting both mother and baby from COVID-19 vaccines,
including no association with preterm birth or miscarriages. Regarding
effectiveness, a pregnant woman’s primary COVID-19 vaccine series has
been shown to be 61% effective against COVID-19 hospitalization among
infants aged

April, May, June 2022 The North Dakota Nurse Page 11
EARN YOUR
RN TO BSN
(Source: https://www.cdc.gov/mmwr)
100% ONLINE
Admit Fall, Spring, and
Summer Semesters
Want to Learn More?
Resources and Articles Related to COVID-19
Vaccines, Pregnancy and Fertility:
• COVID-19_Vaccine_and_Pregnancy.pdf
(nd.gov)
• COVID-19_Vaccine_Fertility.pdf (nd.gov)
• COVID-19 Vaccines While Pregnant or
Breastfeeding (CDC)
• COVID-19 Vaccines for People Who Would
Like to Have a Baby (CDC)
• North Dakota Department of Health |
Department of Health (nd.gov)
• NDSU Center for Immunization Research
and Education (CIRE)
• Why Pregnant People Were Left Behind
While Vaccines Moved at “Warp Speed” to
the Masses (KHN)
• Widespread Misinformation About Infertility
Continues to Create COVID-19 Vaccine
Hesitancy (JAMA)
Health Literacy and Misinformation Toolkits:
• Tackling COVID-19 Misinformation: A Social
Media Toolkit for Healthcare Practitioners
(uk.gov)
• A Community Toolkit for Addressing Health
Misinformation (US Public Health Service)
Nurses Make Change Happen: COVID-19
Vaccine Toolkit (National Nurse-Led Care
Consortium)
Key program features:
• Study at your own pace
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• Earn college credit for current NCLEX-RN licensure
• Affordable tuition and scholarships available
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Melissa.Fettig@MinotStateU.edu
MinotStateU.edu/nursing
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Flexibility
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your goals!
We are a COVID-19 help line and resource center for healthcare
professionals - created by healthcare workers. This effort is funded by the
Substance Abuse and Mental Health Services Administration (SAMHSA),
administered through the North Dakota Department of Human Services.

Page 12 The North Dakota Nurse April, May, June 2022
Catheter-Associated Urinary Tract Infection Prevention:
A Review of Literature
Bailee Finch, Coralea Fuss, Abbey Neumiller
BSN Students, University of Jamestown
Editor: Penny Briese, PhD(c), RN
University of Jamestown
Best practices to prevent Catheter-Associated
Urinary Tract Infections (CAUTIs):
A mini-literature review
A catheter-associated urinary tract infection
(CAUTI) is defined as a urinary tract infection
that occurs in a patient with an indwelling
catheter whose symptoms occur within 48
hours of catheter insertion (Ferguson, 2018).
CAUTIs can increase patient discomfort, length
of hospital stay, mortality and cost. Shaver
et al. (2018) state that CAUTIs can “generate
$300 million in potentially avoidable health
care costs per year” (p. 66-67); CAUTIs are
“never events” and all resulting patient care
must be covered by the treating facility. Thus,
it is important for nurses to be aware of ways
in which to decrease the rate of CAUTIs within
the hospital setting. The six articles utilized in
this review were all published within the past
five years and retrieved from CINAHL. We
will discuss their findings, significance and
recommendations for preventing CAUTIs.
Findings from the Literature
To begin with, nursing knowledge is key.
Shaver et al. (2018) discussed the importance
of nursing knowledge and attitudes toward
foley catheter insertion and the benefits
of addressing gaps in knowledge and
inconsistencies in attitudes through education
to prevent CAUTIs. Through skill training stations,
bedside nurses were educated on “appropriate
Foley catheter insertion and maintenance
techniques” (Shaver et al., 2018, p. 67).
Ferguson (2018) also described the impact
that additional education had on enhancing
nurses’ knowledge and decreasing CAUTI
rates. The results of both studies concluded that
an increase in nursing knowledge regarding
catheter insertion and maintenance led to a
reduction in CAUTIs.
Implementing preventive policies and
procedures is also important. Ballard et al. (2018)
recognized the importance of implementing
nurse-driven processes for insertion and removal
of urinary catheters. This study discussed the
results of implementing the “HOUDINI-based
checklist” within a hospital facility (Ballard et
al., 2018, p. 185). HOUDINI is an acronym that
stands for hematuria, obstruction, urologic
surgery, decubitus ulcer, intake and output,
no code/comfort care, and immobility. If the
patient’s condition does not include one of
these seven conditions, the checklist states
that the nurse is allowed to remove a urinary
catheter without a physician’s order. The results
of this quality improvement project were not
statistically significant, however there was an
overall decrease in catheter days and CAUTIs
throughout the facility (Ballard et al., 2018).
The literature also discussed the use of
CAUTI prevention care bundles. Shadle et al.,
(2021) utilized a CAUTI bundle that included
interventions such as staff education, an
electronic daily checklist, and a nursedriven
removal protocol for indwelling urinary
catheters. The nursing staff were also required
to participate in hands-on education that
focused on “CAUTI definition and related
information, appropriate urine specimen
testing and collection techniques, and carebased
education” (Shadle et al., 2021, p. 65).
The study found that adhering to the CAUTI
bundle protocol decreased the incidence of
CAUTIs. Leontie and Delawder (2021) discussed
a maintenance bundle called “Fight the Foley,”
to decrease the incidence of CAUTIs. The plan
for the study was to develop a daily huddle for
unit leaders, implement a STOP huddle prior to
insertion, and increase available alternative
devices such as condom catheters, male
pouches, female urinary incontinence devices,
and intermittent catheterization kits. This study
found that the use of the bundle decreased
CAUTI rates and ultimately reduced the cost of
treatment. Elkbuli et al. (2018) described a 5-S
CAUTI bundle that was implemented to reduce
CAUTI rates in the trauma population. The 5-S
CAUTI bundle consisted of staff education on
correct aseptic insertion and maintenance,
bladder catheter stabilization to prevent
movement and urethral traction, patient and
caregiver education about the need for the
catheter, keeping the collection bag below
the bladder and above the floor to keep a
sterile and continuously closed drainage system
to avoid backflow, and daily evaluations for
discontinuation. This bundle was continued
over a four-year period and resulted in an 80%
reduction in CAUTI rate among the trauma
population along with an 81.5% decrease in
cost attributable to CAUTI.
Implications for Nursing Practice
This mini-literature review revealed
several different ways in which CAUTIs can
be prevented. Multiple methods, including
continuing staff education, nurse-driven
processes for insertion and removal of
catheters and the utilization of CAUTI care
bundles showed that these interventions work;
patients ultimately benefited from decreased
incidences in CATUIs. This decrease benefits
healthcare facilities financially as well, as CAUTIs
are “never events” and must be paid for by the
treating facility.
There is always room for improvement and, as
nurses, we all must pay special attention to the
care we provide and advocate for our patients
who have indwelling urinary catheters. Their
lives are in our hands.
References
Ballard, J. P., Parsons, S., Rodgers, J., Mosack, V., &
Starks, B. (2018). HOUDINI impacts on utilization
and infection rates – A retrospective quality
improvement initiative. Urologic Nursing, 38(4),
184-191. doi:10.7257/1053-816X.2018.38.4.184
Elkbuli, A., Miller, A., Boneva, D., Puyana, S., Bernal,
E., Hai, S., & McKenney, Mark. (2018). Targeting
catheter-associated urinary tract infections in a
trauma population: A 5-s bundle preventative
approach. Journal of Trauma Nursing, 25(6), 366-
373. doi: 10.1097/JTN.0000000000000403
Ferguson, A. (2018). Implementing a CAUTI
prevention program in an acute care hospital
setting. Academy of Medical Surgical Nurses,
29(2), 4-12.
Leontie, S.L., & Delawder, J.M. (2021). Utilizing a ‘fight
the foley’ bundle to reduce device utilization
rates and catheter-associated urinary tract
infections. Urologic Nursing, 41(4), 208-213.
Shadle, H.N., Sabol, V., Smith, A., Stafford, H.,
Thompson, J.A., & Bowers, M. (2021). A bundlebased
approach to prevent catheter-associated
urinary tract infections in the intensive care unit.
Critical Care Nurse, 41(2), 62-71. doi: 10.4037/
ccn2021934
Shaver, B., Everly-Webb, S.A., Gibney, Z., Silverman, L.,
Pineda, C., & Solomon, R. J. (2018). Trauma and
intensive care nursing knowledge and attitude
of foley catheter insertion and maintenance.
Journal of Trauma Nursing, 25(1), 66-72. doi:
10.1097/JTN.0000000000000344
Belcourt, ND
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in OB, Clinic, Med/Surg & ER
The Quentin N. Burdick Memorial Health Care Facility is an Indian
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in Belcourt, ND. The Facility provides comprehensive primary
care and preventive care and hosts a medical clinic, dental clinic,
optometry clinic, pharmacy, radiology services, mental
health services, outpatient surgical services, labor
and delivery services, emergency room and inpatient/
acute care unit.
The site qualifies as a student loan payback site and offers benefits including annual
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For more information, please visit www.usajobs.gov
or call Lynelle Hunt, DON (701) 477-6111 ext. 8260.
All RNs encouraged to apply or call for more information.

April, May, June 2022 The North Dakota Nurse Page 13
ND Nurse: Resilience Series 7 of 7
Melanie Schock, DNP, RN, CNE
Associate Professor of Nursing, Dakota Nursing
Program, Bismarck State College
In part one of this series, an introduction to
resilience was presented, setting the stage for its
extensive impacts on the nursing profession and
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
covered.
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 particular settings. Special nursing
populations were highlighted in the article
with hopes of tailoring to resilience needs.
Indeed, 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) were addressed and how resilience
plays a role in their wellness, illness, and
recovery trajectories.
For part six, resilience was investigated
through a personal lens. Now, in the final part
of this series, how to increase and strengthen
our levels of resilience will be shared. Further,
strategies that you can use in personal and
professional sectors will be shared.
Resilience is viewed as a skill that can be
developed. Exploring coping behaviors,
teaching self-care strategies, and fostering
social networking can help individuals develop
a resistance to stressors (Skalski et al., 2006).
Indirectly, these strategies would undoubtedly
contribute to resiliency as well. The basis of
resilience-building strategies should be focused
on leveraging one’s internal and external
resources (Delgado et al., 2017). Internal factors
include optimism, a sense of purpose, faith/
belief, self-care, and emotional intelligence.
External (environmental) factors include social
networks, workplace supports, and role models.
Press Ganey (2018b) reinforces the need to
address external stressors. Improving the
function of teams and developing a positive
organizational culture is strongly encouraged.
Streamlining work to reduce burdens is
also beneficial. Additionally, Press Ganey
emphasizes the value of meeting patient needs
and relieving suffering while bolstering nurses’
pride in doing such arduous work (2018b).
Less than best levels of wellness result from
the stressful nature of nurses’ work (Craigie
et al., 2016). Several studies focused on the
psychosocial aspects of self-care to support
resilience. As part of a pilot study, Craigie et al.
(2016) supplied a one-day compassion fatigue
workshop, followed by weekly mindfulness
seminars. Post-intervention, significant
improvements were discovered in the study
group for compassion satisfaction, burnout,
trait-negative affect, and stress scores. A
second pilot study by Tarantino et al. (2013)
investigated the effectiveness of an eight-week
program entitled “Healing Pathways.” Guided
imagery, yoga, meditation, creative expression,
and mentorship were among the course
components to foster more empowered and
resilient healthcare professionals. Participants
reported lower levels of stress and significantly
increased confidence in their ability to cope
at treatment conclusion. This was also true at
12-month long-term follow-up (Tarantino et al.,
2013).
McDonald et al. (2012) tested another
multimodal approach to develop and
strengthen personal resilience. Six-monthly
workshops included collaborative, creative, and
therapeutic learning activities. Post-intervention,
the nurses and midwives in the study reported
effective learning about personal resilience's
key characteristics and strategies. Finally,
Sullivan et al. (2012) supplied stress inoculation,
management of compassion fatigue, and
positive psychology concepts to staff, including
registered nurses. The program goals were
met as healthcare staff could perform more
effectively in stressful situations. This translated
as “…improved patient care outcomes, staff
satisfaction, and the healthcare environment.”
(p.2).
Special nursing populations were highlighted
in the evidence with hopes of tailoring to
resilience needs. A randomized and controlled
12-week intervention study was conducted
for intensive care unit nurses. The intervention
was a multimodal resilience training program
including written exposure sessions, eventtriggered
counseling sessions, stress-reduction
exercises, and a protocolized aerobic-exercise
regimen (Mealer et al., 2014). As a workable
intervention for intensive care nurses, there was
a significant decrease in post-traumatic stress
disorder symptom scores after the program. A
second population of focus was burn center
nurses. Christiansen et al. (2017) developed a
standardized staff development program to
improve nurse satisfaction, increase resiliency,
build unit cohesion, and enhance morale
and unit performance. Following the eighthour
training day, the program successfully
supported teamwork and resiliency among the
staff.
Press Ganey (2018a) echoed these strategies
when examples of resilience-fortifying
approaches were outlined. Meaningful
recognition was suggested to drive nurse
activation, and interventions should target the
specific needs of different nursing segments.
Formal resilience training is also recommended
for nurses, not just new nursing graduates.
Finally, enhancing nurse social support via
relationship-building activities and burnoutprevention
strategies can be justified to support
the culture of nurse wellness (Press Ganey,
2018a).
SMP Health-St Raphael
in beautiful Valley City, ND,
is looking for you!
LPN’s starting at $24 per hr. & RN’s starting at $31 per hr.
Great Benefits!
PTO, CAT, Health, Dental, Vision, Life, AD&D, HSA, FSA, 401(k),
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For more information, call 701-845-8222 or
visit our website at
www.smphealth.org/straphael/
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Here’s your chance to become part of the premier nursing program in the
area. The NDSCS Nursing Dept is seeking innovative and student focused
faculty for a FT, 9 month, tenure-track position beginning Fall 2022.
Requires a Bachelor’s degree in Nursing and willingness to obtain Master’s in
Nursing; an unencumbered ND registered nurse license (or the ability to attain);
and two years recent clinical or related experience. Master’s Degree is preferred.
Salary is DOE. Screening begins immediately – open until filled.
Interested candidates must complete the online application.
For more information, go to: WWW.NDSCS.EDU/JOIN-OUR-TEAM
EOE
In closing, embrace the spirit of resiliency,
stay well, support one another, and treasure
being a North Dakota nurse.
References
Christiansen, M. F., Wallace, A., Newton, J. M.,
Caldwell, N., & Mann-Salinas, E. A. (2017).
Improving teamwork and resiliency of burn
center nurses through a standardized staff
development program. Journal of Burn Care
& Research, 38(4), e708-e714. https://doi.
org/10.1097/bcr.0000000000000461
Craigie, M., Slatyer, S., Hegney, D., Osseiran-Moisson,
R., Gentry, E., Davis, S., Dolan, T., & Rees, C.
(2016). A pilot evaluation of a mindful self-care
and resiliency (MSCR) intervention for nurses.
Mindfulness, 7(3), 764-774. https://doi.org/10.1007/
s12671-016-0516-x
Delgado, C., Upton, D., Ranse, K., Furness, T., &
Foster, K. (2017). Nurses’ resilience and the
emotional labour of nursing work: An integrative
review of empirical literature. International
Journal of Nursing Studies, 70, 71-88. https://doi.
org/10.1016/j.ijnurst u.2017.02.008
McDonald, G., Jackson, D., Wilkes, L., & Vickers, M. H.
(2012). A work-based educational intervention to
support the development of personal resilience
in nurses and midwives. Nurse Education
Today, 32(4), 378-384. https://doi.org/10.1016/j.
nedt.2011.04.012
Mealer, M., Conrad, D., Evans, J., Jooste, K., Solyntjes,
J., Rothbaum, B., & Moss, M. (2014). Feasibility
and acceptability of a resilience training
program for intensive care unit nurses. American
Journal of Critical Care, 23(6), e97-e105. https://
doi.org/10.4037/ajcc2014747
Press Ganey. (2018a). Performance insights:
Resilience for a multigenerational nursing
workforce [White paper]. https://www.
pressganey.com/resources/white-papers/
performance-insights-resilience-for-amultigenerational-nursing-workforce
Press Ganey. (2018b). Burnout and resilience: A
framework for data analysis and a positive path
forward [White paper]. https://www.pressganey.
com/resources/white-papers/burnout-andresilience-a-framework-for-data-analysis
Skalski, C. A., DiGerolamo, L., & Gigliotti, E. (2006).
Stressors in five client populations: Neuman
systems model-based literature review. Journal
of Advanced Nursing, 56(1), 69-78. https://doi.
org/10.1111/j.1365-2648.2006.03981.x
Sullivan, P., Bissett, K., Cooper, M., Dearholt, S.,
Mammen, K., Parks, J., & Pulia, K. (2012). Grace
under fire: Surviving and thriving in nursing by
cultivating resilience. American Nurse Today,
7(12), 1-6. https://www.americannursetoday.
com/grace-under-fire-surviving-and-thriving-innursing-by-cultivating-resilience/
Tarantino, B., Earley, M., Audia, D., D’Adamo, C., &
Berman, B. (2013). Qualitative and quantitative
evaluation of a pilot integrative coping and
resiliency program for healthcare professionals.
EXPLORE, 9(1), 44-47. https://doi.org/10.1016/j.
explore.2012.10.002

Page 14 The North Dakota Nurse April, May, June 2022
It's Official: Vitamin D Reduces the Incidence of Autoimmunity
And a brief review of the growing body of knowledge of vitamin D
Michael Passwater
This article may be reprinted free of charge provided 1) that there is
clear attribution to the Orthomolecular Medicine News Service, and 2)
that both the OMNS free subscription link http://orthomolecular.org/
subscribe.html and also the OMNS archive link http://orthomolecular.org/
resources/omns/index.shtml are included.
OMNS (Feb. 17, 2022) The Harvard led Vitamin D and Omega 3 trial
(VITAL), recently published findings showing a meaningful (22%) and
statistically significant (p = 0.05, Hazard ratio = 0.78 95% CI = 0.61 - 0.99)
reduction in the incidence of autoimmune disease in older adults taking
2000 IU (50 mcg) per day for five years. [1]
This was a large nationwide study involving 12,786 men 50 years or
older and 13,085 women 55 years or older. It was a randomized double
blind, placebo-controlled trial. The British Medical Journal notes, "The
clinical importance of this trial is high because these are well tolerated,
non-toxic supplements, and other effective treatments to reduce the
incidence of autoimmune diseases are lacking." In 2017, the National
Institutes of Health (NIH) estimated that 23.5 million Americans, >7% of the
population, suffered from an autoimmune disease. The NIH noted that
the prevalence appeared to be rising. [2]
Illustrating the high prevalence of vitamin D deficiency and
insufficiency in the USA, 13% of participants in the VITAL trial had vitamin
D levels < 20 ng/mL (50 nmol/L) at the start of the trial, and 45% had levels
< 30 ng/mL(75 nmol/L). A subgroup of participants (1,644 people) had
vitamin D levels tested one year into the study. In aggregate, participants
taking 2000 IU vitamin D had an increase of 40% in vitamin D levels to
41.8 ng/mL(104.5 nmol/L), while participants in the soybean oil placebo
group remained similar to baseline (30.7 ng/mL,77.1 nmol/L). Strengths
of this study include its size and diversity; its design as a prospective,
placebo controlled, randomized trial – the "gold standard" for medical
drug studies; its baseline measurement of blood levels of vitamin D and
follow-up testing of a sample of participants, rather than relying on
intake estimates; the use of a meaningful, safe dose more than double
the US RDA for vitamin D, and its duration with a median follow-uptime of
5.3 years.
"P values" are an expression of the degree of probability that the results
of an experimenttesting a hypothesis are due to chance. Generally
speaking, the lower the P value, thehigher the reliability of the data.
But nutrient studies require different approaches than drug studies. [3,4,5]
A weakness of the VITAL trial was the absence of evaluation of synergistic
nutrients. Additionally, with appreciation for Roger Williams' principle of
biochemical individuality, [6] it would have been interesting and helpful
to compare the outcomes for each range of vitamin D levels achieved
after the fixed dose intervention (e.g. stratifying participants by vitamin D
levels achieved < 20, 20 - 29, 30-39, 40-49, 50-59). However, this would have
required more measurements, thus increasing the expense of the trial.
The 3 Ds for vitamin D (and any nutrient) assessments:
Dose - how much of the nutrient reached the blood/tissue; whether
the individual achieved and maintained sufficient or therapeutic levels.
US RDA (2010)
0 - 12
months
1 - 70
years
400 IU /
day
600 IU /
day
71+ years 800 IU /
day
Pregnant
or Breast
Feeding
600 IU /
day
Recommendation
of 220 vitamin D
experts [7]
2000 - 4000 IU/day
Personal D3
supplementation of
193 vitamin D experts [7]
*excludes professor taking
200,000 IU/day for autoimmune
disease
Range = 0 - 50,000 IU/day
29 take ≥ 10,000 IU/day
Average = 5,175 IU/day
Median = 4000 IU/days
Mode = 4000 IU/day
People with kidney disease should monitor vitamin D levels closely
Adjusting sunlight exposure, D3 intake, and co-factors to maintain
vitamin D levels in the 40-60 ng/mL range is associated with lower risk of
autoimmunity, respiratory disease, and other illnesses. Blood levels up to
100ng/mL are generally safe with adequate vitamin K2.
Daily intake necessary from all sources (sunlight, food, and/or
supplementation) of vitamin D for 97.5% of people to reach: 20 ng/mL =
3,875 IU D3 (97 mcg); 30 ng/mL = 6200 D3 (155 mcg) [7]
Duration - how long sufficient or therapeutic levels were maintained.
Vitamin D has extensive epigenetic effects, impacting over 3,000 genes.
It has been estimated that as much as 3-4% of the genome may be
influenced by vitamin D. These genetic influences may be especially
important during fetal development. [8]
The half-life of the active form of vitamin D is about four hours, and
the half-life of the pre-hormone form of vitamin D is two to three weeks.
However, it may take even longer for the effects of proteins from genes
up regulated and down regulated by vitamin D to make their biological
impact. Bruce Ames' concept of "longevity proteins" applies. [9]
With saturation of a full set of nutrients, cell metabolism is able to
expand from production of only survival proteins to producing additional
proteins he called "longevity proteins." For these reasons, it is important
to maintain vitamin D in the healthy range on an ongoing basis rather
than waiting until illness occurs. When rescue therapyis needed,
calcifediol (25OHD) increases active vitamin D levels more rapidly than
cholecalciferol (D3). [10-12] (see http://www.orthomolecular.org/resources/
omns/v17n17.shtml and http://www.orthomolecular.org/resources/omns/
v16n55.shtml for discussions of nutritional support in criticalillness).
Dynamic interactions - were sufficient levels of synergistic cofactors
maintained? Magnesium is necessary in eight steps of vitamin D
metabolism. [13,14] Intracellular selenocysteine can also be a rate limiting
factor in vitamin D production and function. Increasing glutathione and
cysteine can increase production of vitamin D even without vitamin
D intake or sunlight exposure. In turn, vitamin D increases production
of several seleno proteins. [15-17] Vitamin C and zinc also assist actions
of vitamin D, and it is important to balance vitamin D with vitamin K2
to ensure mobilized calcium gets where it is needed rather than being
deposited in arteries.100 mcg K2 for every 5000 IU D3 is a good ratio for
wellness. [18,19]
In research, controls matter too. This same VITAL study also looked at
the effects of supplementing 1000 mg/day of omega-3 vs. placebo.
A 15% reduction in the incidence of autoimmune disease was
seen compared to the control group. However, this did not reach
statistical significance. Interestingly, olive oil, which is known to be antiinflammatory
and a source of vitamin K, was used as the placebo for
comparison. It is possible that the choice of a non-inert placebo blunted
the signal of true benefit from the omega-3 intervention.
Vitamin D: influence on the immune system
The VITAL study adds important support on the benefits of vitamin D
for the immune system. Vitamin D regulates calcium and phosphate
homeostasis in the body. Calcium is important for much more than strong
bones. [20-23] Mobilized ionized calcium is essential for muscle contractions,
nerve impulses, cell signalling, blood clotting, immune function, and
catalyzing hundreds of enzymatic reactions throughout the body. Nearly
all cells in the body have vitamin D receptors (VDRs). Intestine, bone,
kidney, parathyroid glands, and immune cells (T cells, B cells, Dendritic
Cells, Macrophages) have high levels of VDRs. The CYP27B1 enzyme
which produces the active form of vitamin D and the ligand for VDR is
also widely expressed in many cells throughout the body. The liver and
kidney produce much of the active vitamin D in the body, however
activated immune cells will also produce 1,25(OD)2D when the 25OHD
substrate is present for conversion into the active hormone. Parathyroid
Hormone (PTH) regulates the production of the active form of vitamin
D in non-immune cells. Active vitamin D production in immune cells
is not influenced by PTH, but is instead regulated by cytokines and the
availability of the prehormone 25OHD in the local cellular environment.
Vitamin D has important influences on many phases in the innate
branch of the immune system (cellular, complement, antimicrobial
peptides, lectins, non-antibody producing aspects of immunity), and
also in the adaptive branch of the immune system (antibody-producing
aspects of immunity). The adaptive branch of the immune system has
two major phases. The effector phase involves antibody production while
the regulatory phase involves removal of B cells producing antibodies
that cross-react with self-cells. The antibody-antigen lock and key fit isn't
always exact. Even healthy people have self-reactive B cell clones. [24]
Similarity between a"foreign" antigen and a host cell membrane
element may exist or an antibody may overlap the membrane portion
of a neoantigen-membrane complex. When B cells with these selfreacting
or self-cross-reacting antibodies are stimulated to mass divide
and produce their antibodies, they must be destroyed by the regulatory
immune cells (Tregs) to minimize self-injury. Imbalance or dysfunction
in the regulatory phase of the adaptive immune response is the major
mechanism of autoimmune diseases in humans. [25] Interestingly, several
sensitive areas of the body, the brain, anterior chamber of the eyes, and
testes, are devoid of adaptive immune responses. The risk of collateral
damage from antibody production in these areas is too great.
The active form of vitamin D: [26,27]
• Increases production of cathelicidin and defensins
• Decreases the maturation of dendritic cells, the expression of HLA
DR antigen presenting molecules, and expression of co-stimulation
molecules such as CD40, CD80, and CD86
• Decreases Th1, Th9, Th17 lymphocytes, decreasing IL-2, IL-6, IFNgamma,
IL-12, IL-17, IL-23
• Increases Treg production and production of the cytokine IL-10
• Increases production and maintenance of immune memory cells
The overall effect is a stronger innate immune response, and a safer
adaptive immune response.
A short history of clinical observations about vitamin D
• In 1903, Niels Ryberg Finsen received the Nobel Prize in Physiology
and Medicine "in recognition of his contribution to the treatment
of diseases...with concentrated light radiation, whereby he has
opened a new avenue for medical science." [28]
• Sanatoriums and cod liver oil were common treatments for
tuberculosis and other infections for many decades. [29]
• Two studies in South Carolina in the past decade showed significant
reductions in preterm births (57% fewer 95% CI RR = 0.22 - 0.83, and

April, May, June 2022 The North Dakota Nurse Page 15
62% fewer p = 0.002) in women with vitamin
D levels ≥ 40 ng/mL compared to women
with vitamin D levels < 20 ng/mL. [30,31]
• A pooled analysis of over 2300 women
≥ 55 years of age from a randomized
controlled trial and a prospective cohort
study showed participants with a vitamin
D level ≥ 40 ng/mL had a 67% lower risk of
invasive cancer compared to participants
with a vitamin D level < 20 ng/mL. [32] Similar
results were seen with breast cancer when
people with vitamin D levels >60 ng/mL
were compared to people with vitamin D
levels < 20 ng/mL. [33]
• In 2018, the VITAL trial research group
published a conclusion that 2000 IU of
supplemental vitamin D per day had no
impact on cancer risk. [34] However, their
data show a 25% reduction in cancer risk
after the first two years of the study. [35]
• A meta-analysis of 32 studies was
published in 2014 showing a greater risk of
all-cause mortality in people with a vitamin
D level = 30 ng/mL compared to those with
a vitamin D level > 30 ng/mL (Hazard Ratio
= 1.9, 95% CI = 1.6 - 2.2, p=0.001). [36]
• From Tuberculosis to COVID
- Two recent Spanish studies on treatment
of acute Covid-19 showed the efficacy
of calcifediol for reducing ICU admission
and mortality. [11-12]
- In February 2022, a retrospective study
in Israel of 253 consecutive adults
admitted to the hospital for treatment
of SARS-CoV-2 infection with a vitamin
D measurement available 14 - 730 days
prior to admission showed a greater
risk of severe illness (48.1% vs. 10%)
and death (25.6%vs. 5%) in those with
vitamin D levels < 20 ng / mL vs. ≥ 20 ng
/ mL.[33] This was a follow up study to
a large retrospective case-controlled
population study associating vitamin D
deficiency with a higher risk of Covid-19
infection. [37,38] Studies in three different
countries showed an association
between selenium deficiency and
severe SARS-CoV-2 disease. [39-41] Even
though relationships between vitamin D
and selenoproteins are now established,
no studies measuring both selenium and
vitamin D in SARS-CoV-2 patients have
been published.
- A study published in February 2022 from
Mexico showed improved survival of
high risk SARS-CoV-2 patients admitted
to the hospital when given extra
nutritional support. [42] Seven (17.5%) of 40
patients given standard of care died,
while one (2.5%) of 40 patients given
special nutritional support died. The
extra nutritional support consisted of:
• B-complex: 10 mg of cyanocobalamin,
100 mg of thiamin, and 100
mg of pyridoxine administered
intramuscularly every 24 h for the first
five days.
• One envelope package taken orally
after morning meals and another
after evening meals, diluted in 400
mL of water each, during the whole
intervention for a maximum of 21
days. Each envelope contained:
Spirulina Maxima 2.5 g, folic acid 5
mg, glutamine 5 g, vegetable protein
10 g, brewer's yeast, amaranth,
ascorbic acid 1 g, zinc 20 mg,
selenium 100 mcg, cholecalciferol
(D3) 2000 IU, resveratrol 200 mg,
Omega-3 fatty acids 1 g, L-Arginine
750 mg, inulin 20 g, and magnesium
400 mg.
• Probiotics: Saccharomyces boulardii
500 mg daily for six days orally
- A robust series of publications from
2021 showed the benefits of vitamin D
for Covid-19 and other major diseases.
See "Top Vitamin D Papers in 2021:
Benefits ignored at a time they are most
needed" by William B. Grant, PhD http://
orthomolecular.org/resources/omns/
v18n02.shtml
Summary
Vitamin D is important for a wide range of
functions in human biology from conception
onward. We now have more evidence pointing
towards the importance of maintaining a
vitamin D level in the 40-60 ng/mL range,along
with maintaining adequate levels of synergistic
nutrients to fight infections, sustain helpful
immunity, and also to prevent harmful
autoimmune reactions.
References
1. Hahn J, Cook NR, Alexander EK, et al. (2022)
Vitamin D and marine omega 3 fatty acid
supplementation andincident autoimmune
disease: VITAL randomized controlled trial. BMJ
376:e066452. https://pubmed.ncbi.nlm.nih.
gov/35082139
2. NIH Autoimmune Diseases Coordinating
Committee: Autoimmune Diseases Research
Plan, March 2005. https://www.niaid.nih.gov/
sites/default/files/adccfinal.pdf
3. Heaney RP. (2014) Guidelines for optimizing
design and analysis of clinical studies of nutrient
effects. NutrRev 72:48-54. https://pubmed.ncbi.
nlm.nih.gov/24330136
4. Smith RG. (2022) Vitamins and Minerals for
Lowering Risk of Disease: Adding to the
Evidence.Orthomolecular Medicine News
Service. http://orthomolecular.org/resources/
omns/v17n10.shtml
5. Cheng RZ. (2020) Covid-19 Highlights the
Shortcomings of Evidence-based Medicine. J
Orthomol Med. 35:1-7. https://isom.ca/article/
covid-19-highlights-the-shortcomings-ofevidence-based-medicine
6. Williams RJ (1998) Biochemical Individuality.
McGraw Hill; 1st edition (September 11, 1998)
ISBN-13: 978-0879838935
7. Over 200 Scientists, Doctors, & Leading
Authorities Call For Increased Vitamin D Use To
Combat COVID-19 Scientific evidence indicates
vitamin D reduces infections & deaths. Open
Letter #VitaminDforAll, October 2020. https://
vitamind4all.org/letter.html
8. Wagner CL and Hollis BW (2018) The Implications
of Vitamin D Status During Pregnancy on
Mother and her Developing Child. Front
Endocrinol. 9:500. https://pubmed.ncbi.nlm.nih.
gov/30233496
9. Ames BN (2018) Prolonging healthy aging:
Longevity vitamins and proteins. Proc Nat Acad
Sci USA115:10835-10844. https://pubmed.ncbi.
nlm.nih.gov/30322941
10. Bouillon R, Quesada-Gomez JM (2021) Vitamin
D Endocrine System and COVID-19. JBMR
Plus. 5:e10576. https://pubmed.ncbi.nlm.nih.
gov/34950831
11. Entrenas Castillo M, Entrenas Costa LM, Vaquero
Barrios JM, et al. (2020) Effect of calcifediol
treatment and best available therapy versus
best available therapy on intensive care unit
admission and mortality among patients
hospitalized for COVID-19: A pilot randomized
clinical study. J Steroid Biochem Mol Biol.
203:105751. https://pubmed.ncbi.nlm.nih.
gov/32871238
12. Nogues X, Ovejero D, Pineda-Moncusí M, et al.
(2021) Calcifediol Treatment and COVID-19-
Related Outcomes. J Clin Endocrinol Metab.
106:e4017-e4027. https://pubmed.ncbi.nlm.nih.
gov/34097036
13. Dean C (2017) The Magnesium Miracle, 2nd Ed.
Ballantine Books. ISBN-13 : 978-0399594441
14. Deng X, Song Y, Manson JE, et al. (2013)
Magnesium, vitamin D status and mortality:
results from US National Health and Nutrition
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NHANES III. BMC Med 11:187. https://pubmed.
ncbi.nlm.nih.gov/23981518
15. Jain SK, Parsanathan R, Achari AE, et al. (2018)
Glutathione Stimulates Vitamin D Regulatory
and GlucoseMetabolism Genes, Lowers
Oxidative Stress and Inflammation, and
Increases 25-Hydroxy-Vitamin D Levels inBlood:
A Novel Approach to Treat 25-Hydroxyvitamin D
Deficiency. Antioxid Redox Signal. 29:1792-1897.
https://pubmed.ncbi.nlm.nih.gov/30160165
16. Alvarez JA, Chowdhury R, Jones DP, et al. (2014)
Vitamin D status is independently associated
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disulphide redox status in adults. Clin Endocrinol
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gov/24628365
17. Parsanathan R, Jain SK. (2019) Glutathione
deficiency induces epigenetic alterations of
vitamin D metabolism genes in the livers of highfat
diet-fed obese mice. Sci Rep. 9:14784. https://
pubmed.ncbi.nlm.nih.gov/31616013
18. Flore R, Ponziani FR, Di Rienzo TA, et al. (2013)
Something more to say about calcium
homeostasis: the role of vitamin K2 in vascular
calcification and osteoporosis. Eur Rev Med
Pharmacol Sci. 17:2433-2440. https://pubmed.
ncbi.nlm.nih.gov/24089220
19. Schwalfenberg GK. (2017) Vitamins K1 and K2:
The Emerging Group of Vitamins Required for
HumanHealth. J Nutr Metab. 2017:6254836.
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20. Bikle DD. (2016) Extraskeletal actions of vitamin
D. Ann N Y Acad Sci. 1376:29-52. https://pubmed.
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21. Aranow C (2011) Vitamin D and the Immune
System. J Investig Med. 59:881-886. https://
pubmed.ncbi.nlm.nih.gov/21527855
22. Fan YG, Pang ZQ, Wu TY, et al. (2020) Vitamin
D deficiency exacerbates Alzheimer-like
pathologies byreducing antioxidant capacity.
Free Radic Biol Med. 161:139-149. https://pubmed.
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Rapid and Effective Vitamin D Supplementation
MayPresent Better Clinical Outcomes in
COVID-19 (SARS-CoV-2) Patients by Altering
It’s Official: Vitamin D Reduces...continued on page 16

Page 16 The North Dakota Nurse April, May, June 2022
It’s Official: Vitamin D Reduces...continued from page 15
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PA: Mosby Elsevier.
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gov/25893595
26. Cantorna MT, Snyder L, Lin Y0D, Yang L. (2015) Vitamin D and 1,25(OH)2D
Regulation of T-cells. Nutrients7:3011-3021. https://pubmed.ncbi.nlm.nih.
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27. Looman KIM, Jansen MAE, Voortman T, et al. (2017) The role of vitamin D on
circulating memory T cells inchildren: The generation R Study. Pediatr Allergy
Immunol. 28:579-587. https://pubmed.ncbi.nlm.nih.gov/28686349
28. The Nobel Prize in Physiology or Medicine 1903. NobelPrize.org. Nobel Media
AB 2020. https://www.nobelprize.org/prizes/medicine/1903/summary
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30. Wagner CL, Baggerly C, McDonnell S, et al. (2016) Post-hoc Analysis
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nih.gov/26554936
31. McDonnell SL, Baggerly KA, Baggerly CA, et al. (2017) Maternal 25(OH)
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among general obstetricalpatients at an urban medical center. PLoSOne
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32. McDonnell SL, Baggerly C, French CB, et al. (2016) Serum 25-Hydroxyvitamin
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33. McDonnell SL, Baggerly CA, French CB, et al. (2018) Breast cancer risk
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20 ng/mL (150 vs. 50 nmol/L); Pooled analysis of two randomizedtrials and
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gov/29906273
34. Manson JE, Cook NR, Manson I-ML, et al. (2019) Vitamin D Supplements and
Prevention of Cancer andCardiovascular Disease. N Engl J Med. 380:33-44.
https://pubmed.ncbi.nlm.nih.gov/30415629
35. GrassRoots Health Nutrient Research Institute. Risk Reduction with Vitamin
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document/risk-reduction-vitamin-d-omega-3-vital-trial-results-2018
36. Garland CF, Kim JJ, Mohr SB, et al. (2014) Meta-analysis of All-cause Mortality
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https://pubmed.ncbi.nlm.nih.gov/24922127
37. Dror AA, Morozov N, Daoud A, et al. (2022) Pre-infection 25-hydroxyvitamin
D3 levels and association withseverity of COVID-19 illness. PLoS One
17:e0263069. https://pubmed.ncbi.nlm.nih.gov/35113901
38. Israel A, Cicurel A, Feldhamer I, et al. (2022) Vitamin D deficiency is
associated with higher risks for SARS-CoV-2 infection and COVID-19 severity:
a retrospective case-control study. Intern Emerg Med. 2022 Jan 9; 1-11.
https://pubmed.ncbi.nlm.nih.gov/35000118
39. Heller RA, Sun Q, Hackler J et al. (2021) Prediction of survival odds in
COVID-19 by zinc, age, andselenoprotein P as composite biomarker. Redox
Biology 38:101764. https://pubmed.ncbi.nlm.nih.gov/33126054
40. Moghaddam A, Heller RA, Sun Q, et al. (2020) Selenium deficiency is
associated with mortality risk fromCOVID-19. Nutrients 12:2098. https://
pubmed.ncbi.nlm.nih.gov/32708526
41. Zhang J, Taylor EW, Bennett K, et al. (2020) Association between regional
selenium status and reportedoutcome of COVID-19 cases in China. Am J
Clin Nutr. 111:1297-1299. https://pubmed.ncbi.nlm.nih.gov/32342979
42. Leal-Martínez F, Abarca-Bernal L, García-Pírez A, et al. (2022) Effect of a
Nutritional Support System toIncrease Survival and Reduce Mortality in
Patients with COVID-19 in Stage III and Comorbidities: A BlindedRandomized
Controlled Clinical Trial. Int J Environ Res Public Health 19:1172. https://doi.
org/10.3390/ijerph19031172
Nutritional Medicine is Orthomolecular Medicine
Orthomolecular medicine uses safe, effective nutritional therapy to
fight illness. For more information: http://www.orthomolecular.org
Find a Doctor
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orthomolecular.org/resources/omns/v06n09.shtml
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Click here to see a web copy of this news release

April, May, June 2022 The North Dakota Nurse Page 17
COVID-19 and
Vaccine in
Pregnancy
WEDNESDAY, APRIL 20, 2022
CIRE Speaker Series featuring Andrea
Edlow, MD, MSc from the Vincent
Center for Reproductive Biology:
Edlow Laboratory at Harvard Medical
School and a Maternal-Fetal Medicine
specialist at Massachusetts General
Hospital.
WHEN: Live on Wednesday, April 20th from
12:00-1:00 pm CT (this session will be recorded).
WHAT: Andrea Edlow, MD, MSc will be
discussing COVID-19 and the COVID-19 vaccine
in pregnancy and lactation.
WHO'S INVITED: Everyone is welcome! NDSU
is pursuing continuing education credits for this
presentation. More information to follow!
To read more about Dr. Edlow, please click
here.
Everyone is welcome! NDSU is pursuing
continuing education credits for this
presentation. More information to follow!
NDNA’s Advocacy
Platform – Vitamin D
NDNA has Vitamin D as a part of our 2021-
2022 Advocacy Platform. It states that nurses
take research to practice, but cannot properly
educate on the value of vitamin D if it is not
ordered by providers and not covered by
insurance. ‘In the absence of vitamin D, none
of our body systems can work at their optimal
potential. Thus, it becomes clear that low
vitamin D status would inevitably be involved
in a wide range of dysfunctions and diseases.’
(Baggerly, 2015).
As our organization continues to collaborate
with other groups on vitamin D, we will be
supporting the passionate efforts of our newest
board member, Beth Sanford, as she works to
complete her DNP. The project is looking to
improve patients’ outcomes and increasing
nursing knowledge of vitamin D deficiency.
It will include access to an accompanying
sustainability toolkit with tools and strategies for
patients, providers, community members, and
organizations, employers, organizational and
public health policy moving current vitamin D
research into practice. This research is exciting!

Page 18 The North Dakota Nurse April, May, June 2022
Meeting the nurse staffing challenge, part one: Recruitment tips
Georgia Reiner, MS, CPHRM,
Risk Specialist, NSO
The COVID-19 pandemic has prompted
nurses to rethink their careers and reinforced
the need for healthcare and nursing leaders
to shift their approach to nurse recruitment
and retention. A 2021 survey by the American
Nurses Foundation found that 18 percent of
22,316 respondents planned to leave their
current position in the next 6 months. When
the data are sorted by nurses working in
hospitals (8,524), that percentage rises to 21
percent. These pandemic-related staffing
problems are intensified by factors that
existed before COVID-19 and that still plague
leaders. For example, hospitals in rural areas
continue to struggle more with nurse staffing
than those in urban locations. Generational
differences also exist, with Generation Zers
and Millennials more likely to leave positions
compared to Generation Xers and Baby
Boomers. The exodus of bedside nurses takes
its toll on remaining staff and, in some cases,
quality of care.
Too often, organizations have viewed
nurses primarily as an expense, failing to
understand that investing in this workforce
yields financial rewards. High-quality nursing
care helps to reduce the likelihood of patient
safety events and costly medical malpractice
lawsuits related to missed errors. Savvy
leaders know that ensuring appropriate
staffing levels is key to the financial health of
the organization, which means engaging in
effective recruitment and retention strategies.
This article, the first in a two-part series
on nursing recruitment and retention, will
address recruitment strategies that leaders
can utilize to help attract new nurses to their
organization.
Recruitment
Nursing and other organizational leaders
need to work closely with human resources
staff to ensure recruitment processes are
efficient and effective:
Craft ads that work. First impressions count.
Everyone is your competitor for a limited pool
Nursing Faculty position
Beginning August 2022
Teaching Mental Health and
Medical Surgical Nursing
For more details,
visit www.uj.edu/employment.
Camp Nurses
Needed
of nursing talent, so do what you can to make
your organization stand out as an attractive
place to work. Be sure images in recruitment
ads reflect the organization, particularly when
it comes to diversity. Many organizations
feature their own nurses in ads, which has the
additional benefit of employee recognition.
Try to make your messaging as personalized
as possible, emphasizing your organization’s
culture and authentically communicating
why nurses should want to be a part of your
organization.
Reach out early. Ask staff who work
with students completing clinical rotations
to identify those who might make good
employees when they graduate. Then get
to know the students and encourage them
to apply when the time comes. If you lead
a specialty unit, invite students to attend
meetings (onsite or virtual) of local chapters
of the national specialty nursing association
so they can learn more about the role. You
also may want to partner with local schools
to teach a class or workshop so you can
connect with students.
Promote digital efforts. Organizations’
websites often miss the opportunity to feature
nurses. Your facility’s website should have a
special section highlighting nursing, including
stories that feature individual nurses. You
can ask staff to record video testimonials
that highlight what they enjoy about working
for your organization. In addition, your
organization’s job portal and job application
process should not be so cumbersome that
potential employees give up in frustration.
Individualize benefits. Avoid a “one size
fits all” approach to benefits. Instead, offer
a menu that nurses can choose from. For
example, a late-career nurse may be more
interested in retirement-matching funds, but
a newer-to-practice nurse may be attracted
to a flexible schedule, tuition or student loan
assistance, or child-care benefits.
Obtain Magnet® status. Becoming
a Magnet®-designated facility can
be expensive, but many nurses prefer
organizations with this designation, so it can
be well worth the investment. Magnet® status
also may help reduce turnover and decrease
patient morbidity and mortality.
Provide optimal onboarding. This is often
discussed as a retention tool, but it also falls
under the recruitment category, as potential
employees want to know how supported they
will be in their new role. This is particularly
true of new graduate nurses, who have seen
their recently graduated colleagues rushed
into practice as a result of the pandemic.
Many organizations are being shortsighted in
cutting back on nurse residency programs,
which not only attract staff, but also promote
a smoother transition into practice, thus
increasing retention.
International Music Camp
International Music Camp
located on the North Dakota and Manitoba border at the International Peace Garden
Camp Nurses needed for one-week
sessions in June and July
For more info, contact us at 701.838.8472
or info@internationalmusiccamp.com
Christine Baumann and Tim Baumann,
Camp Directors
Work while your child attends IMC!
Preceptors should be chosen based not
only on their level of expertise, but their
effectiveness as educators. Orientees (and
preceptors) should know that they can speak
up if the match isn’t working.
Be sure staff feel warmly welcomed.
For example, some organizations send a
signed welcome card to the employee’s
home before their start date. Others post
the employee’s name and photo in a visible
location on the unit.
Check in regularly with new staff to see
how they are adjusting, such as weekly for a
month, then every other month or so, and
then after 6 months.
Meeting the challenge
Finding creative solutions to recruit nurses
is more important than ever. However, it is
only the first piece of the puzzle to building
a robust nursing team. Creating a safe,
supportive work environment that recognizes
nurses’ meaningful contributions is essential
to encourage nurses to want to keep working
for your organization. Part two will discuss
retention strategies that healthcare and
nursing leaders can employ to help increase
the likelihood that they retain current nursing
staff.
References
American Nurses Credentialing Center. Magnet
benefits. n.d. https://www.nursingworld.org/
organizational-programs/magnet/aboutmagnet/why-become-magnet/benefits/
American Nurses Foundation. COVID-19 impact
assessment survey – the first year. 2021. https://
www.nursingworld.org/practice-policy/
work-environment/health-safety/disasterpreparedness/coronavirus/what-you-need-toknow/year-one-covid-19-impact-assessmentsurvey/
CNA & NSO. Nurse Professional Liability Exposure
Claim Report: 4th Edition: Minimizing Risk,
Achieving Excellence. 2020. https://www.
nso.com/Learning/Artifacts/Claim-Reports/
Minimizing-Risk-Achieving-Excellence
Malliaris AP, Phillips J, Bakerjian, D. Nursing
and Patient Safety. Agency for Healthcare
Research and Quality. 2021. https://psnet.ahrq.
gov/primer/nursing-and-patient-safety
Pink D. When: The Scientific Secrets of Perfect
Timing. Riverhead Books; 2019.
Reitz O, Anderson M, Hill PD. Job embeddedness
and nurse retention. Nurs Admin Q.
2010;34(3):190-200.
Sherman RO. The Nuts and Bolts of Nursing
Leadership: Your Toolkit for Success. Rose. O.
Sherman; 2021.
Wolters Kluwer. Ten recruiting strategies to attract
nurses. 2019. https://www.wolterskluwer.com/
en/expert-insights/ten-recruiting-strategies-toattract-nurses
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.

April, May, June 2022 The North Dakota Nurse Page 19
Cannabis 101:
What Medical
Professionals Need
to Know
Gail Pederson, SPRN, HN-BC,
Be Well Healing Arts
About this event:
This education event is a comprehensive
review of cannabis (marijuana) as medicine,
and is currently accredited through the ND
Board of Nursing and the North Dakota Board of
Social Work Examiners for 1.0 CEU
Date and time:
Thu, May 5, 2022
7:30 PM – 9:00 PM CDT
Location:
AmericInn by Wyndham Valley City
Conference Center
280 Winter Show Road Southwest
Valley City, ND 58072
Topics:
• History of marijuana as medicine
• National Counsel for State Boards of
Nursing National Nursing Guidelines for
Medical Marijuana
• The endocannabinoid system - What it
is and how to maintain and optimize its
function
• The Wild West of CBD products - How to
find and evaluate a good product,
• Legal, political, and ethical considerations
and institutional policies.
6” Ad
OPEN
6” Ad
OPEN
Please watch for presentations in major cities
across ND in the coming months. If you would
like to schedule a presentation for your facility/
office, please contact Gail.
Register: https://www.eventbrite.es/e/
cannabis-101what-medical-professionals-needto-know-valley-city-tickets-294764597847?aff=eb
dsoporgprofile&keep_tld=1
Contact Gail: https://www.eventbrite.com/o/
gail-pederson-sprn-hn-bc-be-well-healingarts-29917048595