The North Dakota Nurse - July 2022

The North Dakota Nurse 

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 3 July, August, September 2022 

INDEX 

Message from the President 

Every Voice Matters 

Page 3 

August is National 

Breastfeeding Month 

Page 8 

NDNA Attends ANA Hill Day and 

Membership Assembly 2022 

Page 12 

Greetings North Dakota Nurses! We are 

advocates in so many ways. We know advocacy 

is defined as the act of pleading for or actively 

supporting a cause or proposal, but what we 

need to think about is what does that mean to 

us as nurses and more importantly to our patients 

we serve. According to Zolnierek, (2012) “The 

American Nurses Association’s Code of Ethics 

for Nurses and Scope and Standards of Nursing 

Practice clearly identifies nurses’ ethical and 

professional responsibility for protecting the safety 

and rights of their patients; State nursing practice 

acts may establish a legal duty for patient 

advocacy as well” (p.1). We all need to consider if 

we are doing our part on a state level to fulfill that 

professional responsibility that we carry. 

Advocacy can mean many things in many 

different ways. Advocacy means using one’s 

position to support, protect, or speak out for the 

rights and interests of another. Nurses have long 

claimed patient advocacy as fundamental 

to their practice. Since we have made this 

commitment to advocacy, others care what we 

have to say and that is why we need to speak 

to be heard. I am happy to report that just last 

week NDNA was able to meet with Congressmen 

in Washington to be advocates for some of the 

current most important health care issues. 

There are many ways that we can speak 

to be heard. One of those ways is to start on a 

local level. There are so many things we can 

do here in our home state in order to be heard. 

One of those ways is by joining NDNA/ANA and 

getting involved. Luckily NDNA has a voice 

at the table with the legislators in our state. By 

becoming a member of your local professional 

organization, you can have the opportunity 

to be heard and support our local platform 

of many nursing issues that arise. We are the 

experts and our legislators want to hear what 

we have to say. Of course, 

we all know that being 

an advocate isn’t always 

easy. It takes dedication, 

passion and love for our 

profession to continue to 

push forward. 

One misconception of 

nurses who do direct patient 

care is that they don’t have 

a voice; this couldn’t be 

more wrong. Direct-care 

Tessa Johnson 

MSN, BSN, RN, 

CDP, NDNA 

President 

nurses are poised especially well to identify and 

speak up about conditions that may result in near 

misses or actual adverse events. Cultures of safety 

promote and encourage staff to raise issues, 

yet most workplace cultures are imperfect, and 

nurses may face challenges in their advocacy 

efforts (Zolnierek, P. 1). This is when we find an 

internal struggle about what has been normal to 

us in some environment and when we know we 

need to speak up and make a change. 

One of the benefits of being involved in a 

group such as a professional association is 

you have support and a unified voice. We all 

know that nurses may fear retaliation and lack 

knowledge about established processes and 

protections for patient advocacy activities. 

Raising a concern disrupts the status quo 

and challenges the organization to confront 

problems. This, my friends, is EXACTLY what we 

need; we must challenge and disrupt the status 

quo to ensure we are always advocating for 

the best possible care for the patients we serve. 

I encourage you all to find a way that works for 

you to get involved. Be well, we need all of you!!! 

Zolnierek, C. (2012). Speak to be Heard. American 

Nurse Today, 7(10), 1-3. Retrieved June 13, 2018, 

from https://www.americannursetoday.com/ 

speak-to-be-heard-effective-nurse-advocacy/. 

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Page 2 The North Dakota Nurse July, August, September 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 

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and of course, well-written. The editors 

look at all promising submissions. 

Deadline for submission for the next issue is 9/6/2022. 

Send your submissions to director@ndna.org 

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2022 

ORTHOPAEDIC AND 

THERAPY UPDATE 

Registration Form 

September 9-10 

Bismarck Event Center 

Upper Level, Prairie Rose Rooms 

METHOD OF PAYMENT (Check one) 

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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 

Staff: 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 

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rates and information, please contact Arthur L. Davis 

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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 

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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 

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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: 

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specific title. 

*Deadline for submission of material for upcoming 

North Dakota Nurse is 9/6/2022! 

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.

July, August, September 2022 The North Dakota Nurse Page 3 

Instilling Hope 

Sheri Gunderson, MS, RN, CNE, 

Assistant Professor of Nursing, 

University of Jamestown 

As a nurse you have seen the dejected look, heard the discouraging 

story, and tasted the bitterness of unfairness. In your heart you felt the 

person’s sadness and mirrored it in your face. Your empathetic and 

supportive touch have been the unspoken words of empathy and 

presence. Depression, grief, or fresh disability put a person’s focus on 

present circumstances and not the future, or if the person considers the 

future it seems bleak without colors of quality and not what the person 

wants to happen. 

Hope is defined as a verb, “to desire with expectation of obtainment 

or fulfillment,” and as a noun, “desire accompanied by expectation of or 

belief in fulfillment” per Merriam-Webster. You may experience a patient 

who either does not have hope, or is not hoping for a future. But to be 

mentally healthy a person needs to stretch their thoughts to hope, so 

here are a few steps to accomplish this: 

1. Provide an environment of openness: don’t deny the person’s 

feelings of sadness, anger, frustration, or grief, but instead encourage 

the person to express those emotions. “The outward expression of 

positive emotion has been repeatedly associated with better health 

outcomes,” (Tuck, Adams, & Consedine, 2017, p. 503) When you hear 

and see emotion your nursing active listening response should be to 

name the emotion(s) and include the story content. If the person denies 

your interpretation, this is beneficial because further clarification and 

explanation will occur. Through these interactions the person will often 

feel validated and more open to continue discussion. For Christians you 

could encourage reading the Psalms which include many emotions 

which the person may relate to while also gaining strength from the 

author’s faith. “Why, my soul, are you downcast? Why so disturbed within 

me? Put your hope in God,“ Psalm 42:11a. Situations may leave your 

patient reeling on a roller coaster of emotions and they need to realize 

this is normal. 

2. Find capabilities and strengths: listen for past interests and look for 

remaining abilities so you can assist the person with imagining a future 

worth living. Hope is found in discussion of plans for the future. Often 

your experience with other patients will assist you in reflecting possibilities 

available. It is important to hear the person’s interests and passions so 

you can help envision use of these, even if in a modified way related to 

disability or loss. When I was a hospice nurse I found that patients would 

sometimes paint an unrealistic future based on prognosis, but instead of 

challenging these plans I would try to ensure that some shorter term or 

modified goals were met. For those with longer futures the realization of 

small goals helps with stretching out the horizons of the mind. Children 

with disabilities and nursing home residents have taught me that new 

accomplishments are to be celebrated no matter the age or speed of 

attainment. 

3. Offer resources: Usually the person without hope feels alone or that 

others don’t understand. “Numerous studies have supported the finding 

that being socially excluded is psychologically and physically aversive,” 

(Hitlan, 2020, p. 309). While no one can feel exactly what the person is 

feeling, often an in-person group or online organization related to the 

diagnosis or loss will provide support and ability to talk/chat/blog on 

frustrations and adaptations. Comradery may be found by chance 

while in the waiting room for medical appointments, but the nurse can 

facilitate friendships with like people by making referrals or providing 

websites. Beyond emotional support, financial and educational supports 

can open doors for using capabilities. You may feel overwhelmed by a 

patient’s dreams combined with limitation, but your communication 

with the healthcare team may start the ball rolling. Social workers and 

physical/occupational therapists have a wealth of knowledge to assist 

with finding resources. One resource example is Make-a-wish that 

you may think of as just one-time trip givers, but some children receive 

adapted equipment to improve quality of life. 

4. Support faith: Hope may not be in earthly things, but in a heavenly 

future where there won’t be tears or fears. Offering prayer can help a 

person see that God is in control and planning for the future. As a 

hospice nurse I often saw that despite my best efforts during a visit, it was 

not until I offered prayer that I truly saw the person become peaceful as 

if a heavy weight was lifted from their shoulders. Allow and encourage 

chaplain, pastor, priest, or spiritual faith leader visits as an important 

part of holistic health care. Some people will find that an encouraging 

phrase, or motto, becomes the spark for glimmers of hope. If the person 

is Christian, then Bible verses can be a foundation for building hope: “But 

those who hope in the LORD will renew their strength,” Isaiah 40:31a, NIV; 

“For I know the plans I have for you declares the Lord, plans to prosper 

you and not to harm you, plans to give you hope and a future, Jeremiah 

29:11, NIV; “For with God nothing shall be impossible,” Luke 1:37, KJV; and 

“May the God of hope fill you with all joy and peace as you trust in him, 

so that you may overflow with hope by the power of the Holy Spirit,” 

Romans 15:13. 

Whether this article made you think of a patient, colleague, nursing 

student, or acquaintance, I encourage you to be a Hope Builder! 

Hitlan, R. (2020). Social exclusion and health: The buffering effects of perceived 

social support. North American Journal of Psychology, 22(3), 309-330. 

Tuck, N., Adams, K., & Consedine, N. (2017). Does the ability to express different 

emotions predict different indices of physical heath? A skill-based study 

of physical symptoms and health rate variability. British Journal of Health 

Psychology, 22(3), 502-523.


Palliative Care Awareness and Education in North Dakota 

Nancy E. Joyner, MS, CNS-BC, APRN, ACHPN® 

National Palliative Care Definition 

A definition of palliative case was identified 

by the Center to Advance Palliative Care (n.d.) 

as follows: 

Palliative care is specialized medical care 

for people living with a serious illness. 

This type of care is focused on providing 

relief from the symptoms and stress of 

the illness. The goal is to improve quality 

of life for both the patient and the family. 

Palliative care is provided by a specially 

trained team of doctors, nurses and other 

specialists who work together with a 

patient’s other doctors to provide an extra 

layer of support. Palliative care is based 

on the needs of the patient, not on the 

patient’s prognosis. It is appropriate at any 

age and at any stage in a serious illness, 

and it can be provided along with curative 

treatment. (para. 2) 

Background of Palliative Care Awareness in 

North Dakota 

On May 19, 2015, “Quality Care with Palliative 

Care in Cancer” was presented at the North 

Dakota Cancer Coalition annual meeting 

in Bismarck. There was discussion on how 

palliative care could be added to the qualityof-life 

aspect of the ND Cancer Control Plan. 

In October 2015, American Cancer Society/ 

Cancer Action Network’s (ACS/CAN) North 

Dakota Cancer Summit focused on palliative 

care. 

During the 2016 ND Cancer Coalition annual 

meeting, a dedicated breakout time was 

palliative care. Most attendees did not know 

exactly what palliative care is, where palliative 

care services were being provided across the 

state, and what services were provided. To 

understand the status of palliative care in North 

Dakota, it was decided by those attending the 

breakout session to conduct a statewide survey 

of health care facilities and programs to include 

any diseases that could benefit from palliative 

care. To begin the process, a small group of 

individuals convened to develop and deploy 

this survey. Members of this survey workgroup, 

representing state programs, included: 

• Lynette Dickson (ND Center for Rural 

Health) 

• Sally May (Quality Health Associates & 

Honoring Choices® North Dakota) 

• Nancy Joyner (Nancy Joyner Consulting) 

• Sara McGaurvran and Deb Knuth (ACS/ 

CAN) 

• Joyce Sayler (ND Dept. of Health) 

Goals of the survey were to: 

• increase awareness of and access to 

palliative care in North Dakota where 

current gaps exist and 

• develop a baseline for ND palliative care 

services. 

The survey demonstrated more awareness 

and education was needed throughout North 

Dakota. ACS Cancer Action Network sought 

support from the legislature to assemble an 

advisory committee, focused on palliative 

care needs in the state. In 2017, Senator Judy 

Lee reached out to Tracee Capron (Hospice 

of the Red River Valley) and Patricia Moulton 

(ND Center for Nursing) to assist with the 

2017 Resolution 4010. The formation of state 

palliative care legislation would maximize the 

effectiveness of palliative care initiatives in the 

state by: 

• providing substantial cost reduction and 

• improving awareness, education, and 

workforce about palliative care 

The goal of this work was to adapt the 

taskforce into action-oriented workgroups of 

statewide partners, addressing the palliative 

care needs in ND. 

On June 27, 2017, a face-to-face meeting was 

held in Fargo at Hospice of the Red River Valley. 

Presenters were: 

• Nancy Joyner – Palliative Care Survey 

results and finds 

• Donelle Richmond – ANA palliative Care 

paper 

• Deb Knuth – SCR 4010 

• Lynette Dickson – Community needs 

assessment 

• Judy Beck – ND statistics 

North Dakota Palliative Care Taskforce 

The North Dakota Palliative Care Taskforce 

(NDPCTF) (2022) assembled workgroups, 

focused on palliative care access, awareness, 

and needs in the state: 

• Provider Education 

• Access and Reimbursement 

• Definition and Community Awareness 

Provider Education Workgroup Members 

Name 

Donelle Richmond 

Doris Vigen 

Discipline, Representing/ 

Organization 

APRN, Fargo, Sanford 

RN, Mayville, ND Center 

for Nursing/Sanford 

Mayville 

Judy Beck 

Karen Semmens 

Kris Hendrickx 

Nancy Joyner 

Tracee Capron 

Liz Sterling- chair 

Phyllis Heyne- 

Lindholm 

Jesse Tran 

Sara Anderson 

Minot, Quality 

Improvement Program 

Manager 

APRN, Grand Forks, UND 

APRN, Grand Forks, UND 

APRN, Grand Forks, 

Nancy Joyner Consulting 

RN, MAOL, Fargo, 

Hospice of the Red River 

Valley 

RN, Fargo, Hospice of the 

Red River Valley 

PT, DPT, Bismarck, St. 

Alexius 

PhD, Bismarck, NDDOH 

Comprehensive Cancer 

Control Program Director 

ASC Cancer Action 

Network ND 

The Provider Education Work Group’s task 

was to make recommendations to improve 

access to information that will enhance the 

understanding of palliative care by providers 

in all areas of North Dakota. The group also 

hoped to increase opportunities for members 

of academia to disseminate information to 

professionals in the state. The work group 

members met over the past year and would like 

to make the following recommendations to the 

task force. 

Key Topics: 

• Access to educational information: RHIHub, 

Center for Rural Health, was deemed 

necessary. 

• The platform will provide information 

that is current by designating a plan or 

organization to check the site at least 

annually. 

• There is a responsible group to update the 

information–consider the North Dakota 

Hospice Association. 

• The platform has flexibility to house 

relevant education and training 

opportunities 

• Interface with academia needed to be 

considered. 

• UND College of Nursing in this workgroup 

will consider: 

• Develop programming for students 

• Program information in the form of 

posters or other presentations, and 

• Shared at state conferences or 

professional meetings.


The following items also need to be 

considered: 

• Professional training opportunities for 

healthcare 

• End of Life Nursing Education Consortium 

training modules 

• Clinical specialties–individual training 

requirements 

• Directed by national professional 

organizations 

• Center for Rural Health Project ECHO 

• Implement standard education for 

providers 

Access and Reimbursement Workgroup 

Members 

Name 

Tracy Freidt 

Deb Knuth 

Shannon Bacon 

Nick Hillman 

Nancy Joyner 

Tim Blasl 

Jean Roland 

Courtney Vroman 

Tracee Capron 

Sue Heitkampchair 

Lynette Dickson 

Courtney Koebele 


Organization 

RN, Bismarck, Sanford 

ACS Cancer Action 

Network ND 

ACS Cancer Action 

Network ND 

RN, Bismarck, Sanford 



President, Bismarck, 

NDHA 

Minot, Quality 

Improvement Program 

Manager 

Fargo, Hospice of the Red 

River Valley 

RN, MAOL, Fargo, Hospice 

of the Red River Valley 

RN, CHI, Fargo 

MS, RD, LRD, Associate 

Director, State Office of 

Rural Health, CRH, GF 

JD, ND Medical 

Association- Bismarck 

Types of Palliative Care to Access 

• Community-based care includes a variety 

of models of care designed to meet the 

needs of seriously ill individuals and their 

families, outside of the hospital setting: 

• Independent entity 

• Affiliated with health system or hospital 

• Separate Business Line of Hospice or 

Home Health agency 

• Affiliated with physician practice. 

• Hospital-based: 

• Consult services 

• In-patient 

Increase Access (community/providers), using 

GetPalliativeCare.org provider directory tool. 

• The Community HealthCare Association 

of the Dakotas (CHAD) will share where 

current palliative care is offered. 

Reimbursement 

• Many private insurance companies and 

health maintenance organizations (HMOs) 

have some benefit, mostly fee for service 

for providers. 

• In 2017, extra Medicare plan (Part B) 

offered some palliative care benefits. 

• Medicaid coverage of hospice and 

palliative care for people of limited 

incomes varies by state 

• Fee for service, shared savings, or 

capitated payment model 

• Endowments, grants, or fundraising 

• Financial contributions 

• Risk Sharing arrangements 

• Single-Payer 

• Accountable Care Organizations (ACO) 

Definition and Community Awareness 

Workgroup Members 

Name 

Caleb Christiansen 

Trina Kaiser 


Organization 

Hospice of the Red River 

Valley, Fargo 

MD, Bismarck, Primecare 

Rochelle Schaffer 

Shannon Feistchair 

Katie Ambuehl 

Kristi McCarty 

Mary Sahl 

Nancy Joyner 

Tammy Theurer 

Theresa Behrens 

Joyce Sayler 

Tracee Capron 

RN, Bismarck, Hospice 

Sanford 

APRN, Bismarck, Sanford 

LSW, Fargo, Essentia 

-Memory Care of the RR 

Valley 

DON, Jamestown, 

Sisters of Mary of the 

Presentation Health 

System 

Nurse Educator, 

Harwood, Sanford 



Director, Bismarck, CHI 

RN, Fargo, Sanford 

Hospice 

ND DOH, Bismarck 

RN, MAOL, Fargo, Hospice 

of the Red River Valley 

• Standard definitions to define palliative 

care and hospice (Created by the NDPCTF 

Definition Workgroup, posted on the 

Center for Rural Health website, 2020) 

• Comparison table to show the similarities/ 

distinctions 

• Diagram to show the progression of care 

over time 

• A wider range of learning styles 

• Some type of logo for the NDPCTF 

Palliative Care Education in North Dakota 

In 2017, Stratis Health Project (2017-2020), 

originally the North Dakota Rural Community- 

Based Palliative Care project, was chosen 

by Stratis Health for a multi-state effort to 

increase access to palliative care services in 

rural communities. North Dakota, Wisconsin, 

Minnesota, and Washington collaborated in 

this multi-faceted project to increase access to 

palliative care services in rural communities and 

improve quality of life and quality of care for 

those with advanced illness and complex care 

needs. 

• North Dakota Rural Community-Based 

Palliative Care project was chosen by 

Stratis Health (2022) for a multi-state effort 

• Tiered approach: Washington, North 

Dakota and Wisconsin 

• Based on Rural Community-based 

Palliative Care Toolkit being developed 

The following goals were developed: 

• Increase access to palliative care services 

in rural communities 

• Improve quality of life and quality of 

care for those with advanced illness and 

complex care needs. 

In 2018, a new serious illness definition 

emerged with new messaging, which reads, 

“A health condition that carries a high risk 

of mortality and either negatively impacts 

a person’s daily function or quality of life or 

excessively strains their caregiver” (Kelley & 

Bollens-Lund, 2018, para. 7). This is the definition 

of ‘Serious Illness’ that is used in the 4th edition 

of the National Consensus Project Guidelines 

for Quality Palliative Care (NCP) was critical in 

removing prognosis and lessening end-of-life/ 

hospice mindset to defining palliative care. 

During this time, the Center for Rural Health’s 

Flex Program appropriated grant funds through 

August 2022 to promote statewide palliative 

care by: 

Full or Part Time RN or LPN 

Wages depend on experience 

Starting LPN $24.85/hr • RN $31.81/hr 

For More Information Contact 

Kasey Brandenburger, RN DON 

kasey.brandenburger@stgerards.org 

701-242-7891 

St. Gerard’s Community of Care • Hankinson, ND 

Stgerards.org 

• Offering ND POLST CME on demand online, 

• Offering monthly ND POLST CE live virtually, 

• Providing ongoing Project ECHO sessions: 

Organizing Palliative Care for Rural 

Populations TeleECHO, and 

• Expanding rural community-based 

palliative care throughout ND. 

When the COVID pandemic emerged 

in 2020, the NDPCTF efforts were paused. 

However, in November 2021, a renewed 

interest in ND’s Palliative care awareness and 

education emerged. North Dakota’s state 

senator Judy Lee and State Health Officer Dr. 

Nizar Wehbi have joined forces to assist in the 

National Academy for State Health Policy’s 

efforts to build and support Palliative Care. 

Call to Action 

Your help is needed. Please unite the efforts 

in advancing palliative care awareness, 

education, and implementation by joining the 

ND Palliative Care Taskforce and share with 

others. 

Reference 

Kelley, A. S., & Bollens-Lund, E. (2018). Identifying the 

population with serious illness: The "denominator" 

challenge. Journal of Palliative Medicine, 21(S2), 

S7–S16. https://doi.org/10.1089/jpm.2017.0548 

Resource Links 

Center to Advance Palliative Care (CAPC): 

https://www.capc.org/ 

Center for Rural Health: https://ruralhealth. 

und.edu/assets/746-17373/palliative-hospicecare-flyer.pdf 

Get Palliative Care.org: https:// 

getpalliativecare.org/ 

National Academy for State Health Policy/ 

Palliative Care: https://www.nashp.org/ 

palliative-care/ 

North Dakota Palliative Care Taskforce: 

https://www.qualityhealthnd.org/contracts/ 

palliative-care-task-force/ 

Palliative Care or Hospice Care Flyer 

(Created by the NDPCTF): https://ruralhealth. 

und.edu/assets/746-17373/palliative-hospicecare-flyer.pdf 

North Dakota POLST Awareness, Education, 

and Implementation CE: https://www. 

honoringchoicesnd.org/event/polst-awarenesseducation-and-implementation-10/ 

Rural Health Information Hub (RHIHub)/ 

palliative care: https://www.ruralhealthinfo.org/ 

search?q=palliative+care 

UND’s Project ECHO/ Palliative Care: https:// 

ruralhealtAwh.und.edu/projects/project-echo/ 

topics/palliative-care


Telehealth Interventions in the Management of Diabetes 

Appraised by: 

Amanda Papke SN Alyssa Dailey SN, Tayla Gange SN, Tierrany Trudell 

SN, , Wallen Masiasa SN, Jonathan Gallagher SN 

Allison Sadowsky MSN RN Assistant Professor of Practice (Faculty) 

(NDSU School of Nursing at Sanford Health Bismarck) 

Clinical Question: 

In diabetic patients, what is the effect of telehealth interventions on 

patient health outcomes? 

Sources of Evidence: 

Anderson, A., O’Connell, S.S., Thomas, C., & Chimmanamada, R. (2021). 

Telehealth Interventions to Improve Diabetes Management Among Black 

and Hispanic Patients: A Systematic Review and Meta-Analysis. Journal of 

Racial and Ethnic Health Disparities (2022). https://doi.org/10.1007/s40615- 

021-01174-6 

Baron, J. S., Hirani, S., & Newman, S. P. (2016). A randomized, controlled 

trial of the effects of a mobile telehealth intervention on clinical and 

patient-reported outcomes in people with poorly controlled diabetes. 

Journal of Telemedicine and Telecare, 23(2), 207–216. https://doi. 

org/10.1177/1357633x16631628 

Eberle, C., & Stichling, S. (2021). Clinical Improvements by Telemedicine 

Interventions Managing Type 1 and Type 2 Diabetes: Systematic Metareview. 

Journal of medical Internet research, 23(2), 23244. https://doi. 

org/10.2196/23244 

Wild, S. H., Hanley, J., Lewis, S. C., McKnight, J. A., McCloughan, L. B., Padfield, P. 

L., Parker, R. A., Paterson, M., Pinnock, H., Sheikh, A., & McKinstry, B. (2016). 

Correction: Supported telemonitoring and glycemic control in people with 

type 2 diabetes: The Telescot diabetes pragmatic multicenter randomized 

controlled trial. PLOS Medicine, 13(10). https://doi.org/10.1371/journal. 

pmed.1002163 

Wong, V. W., Wang, A., & Manoharan, M. (2021). Utilization of telehealth for 

outpatient diabetes management during COVID-19 pandemic: How did 

the patients fare? Internal Medicine Journal, 51(12), 2021–2026. https://doi. 

org/10.1111/imj.15441 

Zhai, Y. K., Zhu, W. J., Cai, Y. L., Sun, D. X., & Zhao, J. (2014). Clinical- and costeffectiveness 

of telemedicine in type 2 diabetes mellitus: a systematic 

review and meta-analysis. Medicine, 93(28), e312. https://doi.org/10.1097/ 

MD.0000000000000312 

Synthesis of Evidence: 

Six articles were reviewed as evidence in this report. The articles 

included three systematic reviews, a quasi-experimental, and two 

single randomized controlled trials. In patients with chronic conditions, 

there are various barriers that inhibit management of their disease. 

Determining these barriers and researching alternative interventions is 

necessary in improving clinical and patient-reported outcomes. 

Baron and Newman (2016) conducted a randomized controlled trial 

to examine the effects of mobile telehealth on a range of clinical and 

patient reported outcomes. The study included 81 participants who 

were patients diagnosed with type 1 or type 2 diabetes. The participants 

exchanged medical information daily, including blood glucose and 

blood pressure, with the telehealth nurse using a mobile device that 

transmitted the data to a web server where it was accessed and 

reviewed by the telehealth nurse. Feedback was provided to the patient 

based on the transmitted data. Variables such as hemoglobin A1c, 

blood pressure, daily insulin doses, and patient-reported outcomes were 

studied. The results conclude that participants who received access to 

the mobile telehealth intervention reported a significant increase in 

quality of life, improvement in hemoglobin A1c and a decrease in both 

systolic and diastolic blood pressures. Hemoglobin A1c decreased in the 

intervention group from an average of 9.07 at baseline to 8.56 at nine 

months. Average hemoglobin A1c increased in the control group from 

8.88 at baseline to 8.93 at nine months. 

Eberle and Stichling (2021) conducted a systematic meta-review of 

31 studies. Including 21 SR & MA, 8 RCT, 1 non-RCT, and one qualitative 

study. These studies used the intervention of telehealth in various ways 

such as text messaging, telephone calls, video conferences, to email. 

Patients with type 1 and type 2 diabetes were studied with these clinical 

outcomes in mind: HbA1C, FBG (fasting blood glucose), BP, body weight, 

BMI, health-related quality of life (HRQoL), diabetes-related quality of 

life (DRQoL), cost effectiveness, and time saving. The results concluded 

a significant improvement in HbA1C. There were also noted positive 

effects on BP, FBG, body weight, BMI, DRQoL, HRQoL, time saving, and 

cost effectiveness using an intervention of telemedicine to find these 

outcomes. 

Wild & Hanley (2016) conducted a randomized, parallel, investigatorblind 

controlled trial with centralized randomization of 321 people 

diagnosed with type 2 diabetes and glycated hemoglobin (HbA1c) 

greater than 58 mmol/mol. Patients self-monitored and transmitted their 

blood sugar levels to a secure website twice weekly during the morning 

and evening. Individuals in the intervention group had a decrease in 

HbA1c and Blood Pressure compared to the control group. The results 

showed that the monitored group HbA1c decreased by 5.60 mmol/mol / 

0.51% lower compared with the control group. The systolic BP decreased 

by 3.06 mmHg & diastolic BP decreased by 2.17 mmHg in the 

interventional group compared to the control group. This study showed 

that telemonitoring and supported self-management of blood glucose 

can result in clinically meaningful improvements in blood glucose among 

people with poorly controlled type 2 diabetes. 

Anderson, O’Connell, Thomas, and Chimmanamada (2021) 

conducted a systematic review and meta-analysis of randomized 

controlled trials including nine studies. The review and analysis of the 

nine studies were used to evaluate the effectiveness of telehealth 

interventions aimed at improving HbA1c values among Black and 

Hispanic patients with type 2 diabetes connected to primary care. 

Telehealth interventions were health care, health education, and health 

information services by remote technologies. The clinical effectiveness 

was aimed at evaluating the hemoglobin A1c pre- and post-telehealth 

intervention. The major findings indicated a net change decreased by 

-0.47%, this is a significant change in this case. These findings suggest 

telehealth interventions can be effective at improving glycemic control 

among Black and Hispanic diabetes patients. 

Zhai, Zhu, Cai, Sun, & Zhao (2014) conducted a systemic Review and 

Meta-analysis of 35 randomized controlled studies tied to patients with 

type 2 diabetes who were 18 years or older and receiving insulin or oral 

diabetic drugs. The sample size ranged from 13-844 individuals from 

various health care settings. The purpose of the study was to evaluate 

the clinical effectiveness and cost effectiveness of telemedicine 

approaches on glycemic control in patients with type 2 diabetes mellitus. 

After implementing the telehealth interventions which included virtual 

visits, telephone calls, and website check ins, A1C improved from 6.4- 

11.2 to 6.4-8.7. The intervention also revealed institute for clinical and 

economic review (ICER) of $491 and $29,869 per capita for each unit 

reduction in HbA1c, for the telephone and internet base interventions. 

Wong, Wang, and Manoharan (2021) conducted a quasiexperimental, 

retrospective review of electronic medical records (EMRs) 

of 629 outpatient diabetic patients from two major hospitals in Sydney, 

Australia for a five-month period. Years reviewed were 2019 and 2020. 

Methods used for telehealth consultations consisted of voice calls, 

video calls, and sending blood glucose level results electronically. The 

review found that the attendance rate improved from 85.2% to 88.9%, 

HbA1c improved from 8.2 to 7.8. There was no statistical significance in 

unplanned admissions from 75 readmissions to 58 admissions after the 

telehealth interventions were implemented, albeit it improved. HbA1c 

was collected one year prior to 2019, one visit prior to the COVID-19 

pandemic, and one visit a year after their pre-virtual management 

period. 

Conclusion: 

All six articles supported the use of mobile telehealth interventions in the 

care management of patients with diabetes. Five of the six articles showed 

clinically significant changes in the hemoglobin A1c (HbA1c), while one 

article showed a marginal change in the HbA1c. Across the studies, the 

most commonly used modes of telehealth include video conferencing, 

telephone calls, texting, and internet programs. The evidence suggests 

these interventions lead to effective management of diabetes. 

Implications for Nursing Practice: 

Diabetes is a chronic condition that can have long-lasting effects 

on patients. The effects the interventions have on diabetic patients 

would be beneficial in effectively improving hemoglobin A1c. Care 

surrounding the management of diabetes should aim to implement 

mobile telehealth interventions as adjunct means to managing diabetes. 

Patients should also be encouraged to follow-up with their diabetes 

providers for optimal outcomes.


Staffing Effect on Hospital Acquired Infections 

Appraised by: 

Kiana Schatz SN, Chelsie Shook SN, Dominic 

Sieve SN, Jada Kjonaas SN, Kathryn Dragseth SN, 

Kylee Utter SN 

Allison Sadowsky MSN RN Assistant Professor 

of Practice (Faculty) (NDSU School of Nursing at 

Sanford Bismarck) 


In hospitalized patients, does staffing on the 

unit affect hospital acquired infections? 


Daud-Gallotti, R. M., Costa, S. F., Guimarães, T., Padilha, 

K. G., Inoue, E. N., Vasconcelos, T. N., da Silva 

Cunha Rodrigues, F., Barbosa, E. V., Figueiredo, W. 

B., & Levin, A. S. (2012). Nursing workload as a risk 

factor for healthcare associated infections in ICU: 

A prospective study. PLoS ONE, 7(12). https://doi. 

org/10.1371/journal.pone.0052342 

Kaier, K., Mutters, N. T., & Frank, U. (2014, December 

13). Bed occupancy rates and hospital-acquired 

infections-should beds be kept empty? Clinical 

Microbiology and Infection. Retrieved March 

20, 2022, from https://www.sciencedirect.com/ 

science/article/pii/S1198743X14610909 

Kouatly, I. A., Nassar, N., Nizam, M., & Badr, L. K. (2018). 

Evidence on Nurse Staffing Ratios and Patient 

Outcomes in a Low-Income Country: Implications 

for Future Research and Practice. Worldviews on 

Evidence-Based Nursing, 353-360. 

Mitchell, B. G., Gardner, A., Stone, P. W., Hall, L., & 

Pogorzelska-Maziarz, M. (2018). Hospital staffing 

and health care–associated infections: A 

systematic review of the literature. The Joint 

Commission Journal on Quality and Patient 

Safety, 44(10), 613–622. https://doi.org/10.1016/j. 

jcjq.2018.02.002 

Shang, J., Needleman, J., Liu, J., Larson, E., & Stone, 

P. W. (2019). Nurse Staffing and Healthcare- 

Associated Infection, Unit-Level Analysis. The 

Journal of nursing administration, 49(5), 260–265. 

https://doi.org/10.1097/NNA.0000000000000748 

Tawfik, D., Profit, J., Lake, E., Liu, J., Sanders, L., & Phibbs, 

C. (2020). Development and use of an adjusted 

nurse staffing metric in the neonatal intensive care 

unit. Health Services Research, 190-200. 


Six articles were reviewed as evidence in this 

report including a prospective cross-sectional 

study, a prospective cohort study, a repeated 

measures observational study, two systematic 

reviews, and a quantitative study with cross 

sectional data analysis. The articles are reviews of 

studies conducted to determine the relationship 

between the occurrence of hospital acquired 

infections or patient outcomes, and how they are 

related to nurse workload and staffing ratios. 

The first article by Kouatly, Nassar, Nizam, & 

Badr (2018) was a prospective cross-sectional 

study. This study was conducted to describe 

the relationship between nurse staffing and 

nurse sensitive outcomes (NSOs) at a Magnet 

designated university hospital in a low-income 

country. This study included 68,000 patients 

who had a fall, an injury fall, hospital-acquired 

pressure injury (HAPI), catheter-associated urinary 

tract infection (CAUTI), central line bloodstream 

infection (CLABSI), and ventilator-associated 

pneumonia (VAP) after admission during July 

2011 to June 2013. The results concluded that in 

the critical care unit (CCU), high nurse hours per 

patient days (NHPPD) compared to low NHPPD 

it reduced total patient falls by 79%, injury falls 

by 77%, HAPIs by 74%, CAUTIs by 23%, CLABSIs by 

62%, and VAP by 38%. In the medical-surgical 

unit, the results concluded that when there was 

high NHPPD compared to low NHPPD it reduced 

falls by 84%, injury falls by 75%, HAPI by 74%, CAUTIs 

by 39%, CLABSIs by 79%, and VAP by 20%. These 

results imply that when more nurses are available, 

the likelihood of adverse NSOs decreases. 

The second article by Daud-Gallotti, Costa, 

Guimarães, Padilha, Inoue, Vasconcelos, da Silva 

Cunha Rodrigues, Barbosa, Figueiredo, & Levin 

(2012) was a prospective cohort study. The aim 

of the study was to evaluate the role of nursing 

workload in the occurrence of HAIs (hospital 

acquired infection) in medical ICUs (intensive care 

unit) using a nursing activities score (NAS). The 

study included 195 patient’s ages 12+ who were 

admitted to three medical ICUs and a step-down 

unit. The results concluded that out of the 195 

patients’ being evaluated, 43 of them developed 

HAI and data analysis showed that excessive 

nursing workload was found to be the biggest 

contributing factor to these HAI. It was also found 

that of the 195 patients, 79 of them suffered from 

adverse effects during their stay in the ICU. 

The third article by Tawfik, Profit, Lake, Liu, 

Sanders, & Phibbs (2020) was a repeated 

measures observational study. The purpose of 

the study was to determine whether adjusted 

nurse staffing in hospitals contributed to patient 

outcomes. The study took place in 99 California 

neonatal intensive care units (NICUs) where they 

studied 276,054 infants born between January 

2008-May 2016. The study aimed to evaluate 

staffing effects on HAIs, infant mortality, and 

length of stay (LOS). The results concluded that 

increased nurse staffing may result in reductions 

of patient-related events. Although the results 

showed there was no impact on staffing related 

to infant mortality and LOS, there was great 

evidence regarding staffing impacts on lower 

odds of HAIs. There was a total of 25,744 infants 

that fell into the California Perinatal Quality Care 

Collaborative (CPQCC) test cohort and of those 

infants, 52% fell into the low birth weight and 7.2% 

experienced a HAI. These numbers corresponded 

to lower odds of HAI with each additional nursing 

hours per patient-day (NHPPD). The results 

supported the idea that staffing on a hospital unit 

does indeed affect the rates of hospital acquired 

infections. 

The fourth article by Kaier, Mutters, and 

Frank (2014) was a systematic review. The study 

was conducted to look at the correlation 

of bed occupancy rates and the effects of 

overcrowding and understaffing on hospitalacquired 

infections. The study included 12 studies 

that were reviewed for analysis. These studies 

included various hospital settings which were 

composed of general wards, surgical wards, 

ICU’s, and NICU’s. The results concluded that high 

bed occupancy rates and understaffing directly 

impacted the incidence and spread of hospitalacquired 

infections. This was evidenced by nine 

of the twelve studies finding a positive correlation, 

whereas three of the studies found no correlation 

or a negative correlation. Therefore, hospitalacquired 

infections are at risk of increasing if 

overcrowding of beds and understaffing continue 

to be issues within the hospital setting. 

The fifth article by Mitchell, Gardner, Stone, 

Hall, Pogozelska-Maziarz (2018) conducted a 

systematic review. The systematic review included 

Appraised by: 

Leah Nelson, RN, Danica Calderon, RN, Vanessa 

Poitra, RN, and Mikayla Kitsch, RN: students at 

Mayville State University RN-to-BSN Program 


Within staff in a medical-surgical unit, does 

bedside hand-off report compared to traditional 

report impact the number of errors made on a 

given shift? 

Articles: 

Becker, Sherry, MSN-Ed, RN-BC, Hagle, Mary, PhD, 

RN-BC, Amrhein, Andra, BSN, RN, et al. (2021). 

Implementing and sustaining bedside shift 

report for quality patient-centered care. Journal 

of Nursing Care Quality, 36, 125-131. 

Gettis, M. A., Dye, B., Williams, C., Frankish, B., & 

Alvarez, B. (2019). Bedside report: Nursing 

handoffs impact outcomes for caregivers, 

healthcare providers, and organizations. 

Worldviews on Evidence-Based Nursing, 16(6), 

495–497. https://doi.org/10.1111/wvn.12404 

McAllen, E., Stephens, K., Swanson-Biearman, B., Kerr, 

K., & Whiteman, K. (2018). Moving shift report 

to the bedside: An evidence-based quality 

improvement project. OJIN: The Online Journal 

of Issues in Nursing, 23(2). https://doi.org/10.3912/ 

ojin.vol23no02ppt22 

Small, D. and Fitzpatrick, J. (2017). Nurse perceptions 

of traditional and bedside shift report. Nursing 

Management, 48, 44-49. 


This synthesis includes four studies that provide 

evidence supported to the research question. The 

Bedside Reporting 

54 studies. Study designs included cohort, case 

control, cross-sectional, randomized controlled or 

case reports. The aim of the study was to examine 

the association between hospital staffing and 

patients’ risk of developing HAIs in hospital 

settings. The studies were further categorized 

into studies examining nurse staffing and single 

site-specific infection; studies examining nurse 

staffing and multiple HAI’s; studies examining 

nurse staffing and organism-specific HAI’s; studies 

examining nurse staffing and HAI’s (unspecified 

infection type; and lastly, studies examining nonnurse 

staffing and HAI’s. Major findings of this 

systematic review find that 42/54 of the studies, 

suggest that staffing levels are associated with 

HAI’s. Increased levels of staffing seem to be 

connected to a decrease in the risk of patients 

acquiring HAI’s. 

The sixth article by Shang, Needleman, Liu, 

Larson, and Stone (2019) was a quantitative study 

with cross sectional data analysis. The study was 

done between 2007-2012 to examine whether 

healthcare associated infections (HAIs) and nurse 

staffing are associated using unit-level staffing 

data. It included 100,264 patients in the ICU, 

medical, med/surg, and step-down units in three 

hospitals in a large metropolitan area. The results 

concluded the hazard rate of HAIs in patients on 

units with nursing staff (NS) understaffing on both 

shifts two days before infection onset were 11% 

higher than for those staying in units with both day 

and night shifts adequately staffed with NS. 

Conclusion: 

All six articles indicated that staffing on a 

nursing unit plays a role in the prevalence of 

hospital acquired infections. These articles 

support the same idea that either increasing staff 

on a hospital unit contributes to a decreased 

rate of infection, or in the same way, that by 

decreasing staff on a hospital unit it contributes to 

an increased rate of infection. 


Findings suggest that staffing is directly related 

to the rate of hospital acquired infections. By 

increasing nurse staffing, increasing nurse hours 

per patient day, eliminating excessive nurse 

workloads, and eliminating overcrowding, it leads 

to a decreased rate of adverse effects, with the 

main one being HAIs. Staffing nurses properly will 

allow for more compliance to care plans and 

adherence to infection control prevention. 

first study completed by S. Becker et al., (2021), 

identified the lack of bedside report increased 

the number of errors from miscommunication. 

The second study by Gettis et al., (2019), 

using the situation, background, assessment, 

recommendation (SBAR) method was used less 

inconsistent when report is given at the bedside. 

The third study by McAllen et al., (2018), identified 

less falls and improved satisfaction from the 

nurse and patient. The fourth study by Small 

and Fitzpatrick (2017), found that bedside report 

improves nurse accountability, decrease patient 

errors, and increase patient involvement. 

Bottom Line: 

Based on current research, there is evidence 

to show improvement in patient safety outcomes 

when using bedside report to help reduce the 

number of errors on shift. Bedside report can 

reduce errors by making sure drips, lines, and 

wounds are in order before the off-going nurse 

leaves. This bedside report helps reduce the 

patient’s hospital anxiety by providing them a 

better understanding of their plan of care and 

allow them to participate in the decision-making 

process. Bedside report can also reduce the risk of 

out of bed falls by making sure the patient is safe 

with visual observation until the new nurse comes in 

to complete the new shift assessment. 

Bedside Reporting continued on page 9


August is National 

Breastfeeding Month 

Richelle Johnson, MSN, RN, NDNA VP of Finance 

Nursing Needs a Mental 

Health Makeover 

Easy access to resources and erasing stigma are key. 

Since 2011, the United States Breastfeeding Committee (USBC) has 

claimed August as National Breastfeeding Month. Breastfeeding, more 

commonly known as nursing, is a means to feed a child human breast 

milk. It has been proven to be an excellent prevention strategy that 

ultimately builds a foundation for health and wellness in infants and 

parents (USBC, n.d.). 

The American Academy of Pediatrics recommends that infants be 

exclusively breastfed for the first six months of life and then continue to 

be breastfed up until twelve months or older while solid foods are being 

introduced. 

Current research still supports the many health benefits for both 

mother and baby as well as potential environmental and economic 

benefits for communities. According to the Centers for Disease Control 

and Prevention ([CDC], 2021), these benefits include but are not limited 

to: 

1) Breast milk is the best source of nutrition for most babies. 

2) Breastfeeding can help protect babies against some short- and 

long-term illnesses and diseases. 

3) Breast milk shares antibodies from the mother with her baby that 

formula cannot provide. 

4) Mothers can breastfeed anytime and anywhere. 

5) Breastfeeding can reduce the mother’s risk of breast and ovarian 

cancer, type 2 diabetes, and high blood pressure. 

As natural as the breastfeeding process may seem, problems can 

occasionally arise. When problems arise, they may interfere with the 

mother's milk production and the baby's ability to get the nutrients they 

need. For this reason, it is imperative that mothers seek help if they have 

trouble with breastfeeding or observe a change in their baby's behavior 

such as short (or long) nursing sessions, baby seeming hungry after 

feedings, baby not gaining weight, breast engorgement, etc. 

Lastly, breastfeeding may not be possible for all women and for many, 

the decision is solely based on their comfort level, lifestyle, and even 

certain medical situations. For mothers who decide not to or cannot 

breastfeed, infant formula is a healthy alternative as it does provide 

babies with the proper nutrients to thrive and grow. 

The decision to breastfeed is a very personal one. Encourage mothers 

to weigh the pros and cons of breastfeeding as well as talk to their 

doctor and/or a lactation consultant. These health care providers can 

give mothers more information about their options and help them make 

the best decision for their family. 

References 

Centers for Disease Control and Prevention. (2021). Breastfeeding benefits 

both baby and mom. Retrieved May 9, 2022 from https://www. 

cdc.gov/nccdphp/dnpao/features/breastfeeding-benefits/index. 

html#:~:text=Breastfeeding%20can%20help%20protect%20babies,ear%20 

infections%20and%20stomach%20bugs. 

U.S. Breastfeeding Committee (USBC). (n.d.). State and territory breastfeeding 

reports. Retrieved May 9, 2022 from http://www.usbreastfeeding.org/p/cm/ 

ld/fid=257 

Belcourt, ND 

Multiple Nursing Opportunities 

in OB, Clinic, Med/Surg & ER 

The Quentin N. Burdick Memorial Health Care Facility is an Indian 

Health Service unit located on the Turtle Mountain Reservation 

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 

and sick leave, health/dental/vision benefits, life insurance, and retirement. 

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. 

Holly Carpenter, BSN, RN; Dawn Webb, MSN, RN, PMH-BC; and 

Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC 

For too long, nurses have struggled quietly with mental health issues, 

fearing stigma or negative consequences associated with getting 

help. Even before the COVID-19 pandemic, nurses had higher rates of 

depression and suicide than the general population. Suffering in silence 

can’t be a part of our profession. 

Survey results from Healthy Nurse, Healthy Nation (HNHN), the 

American Nurses Association nurse wellness community, show that 

nurses’ mental well-being has worsened during the pandemic. The 

Healthy Nurse® Survey found that, during the pandemic, respondents 

had statistically higher instances of anxiety and depression disorders 

than before. In addition, 34% of nurses reported feeling sad, down, 

or depressed for two weeks or more over the past 30 days during the 

pandemic, compared to 29% pre-pandemic. 

Mood and anxiety disorders commonly coexist with substance use 

disorders (SUD). Increases in substance use and drug overdoses in the 

United States during the pandemic, along with higher rates of depression 

and suicide among nurses, make it clear that nurses are at high risk 

for SUD and mental health conditions due to the stressors of simply 

being a nurse. Nurses have worked on self-care and resilience building 

interventions. Now, we need healthcare employers, nursing associations, 

schools of nursing, legislators, and other interested parties to invest in 

nurses’ mental health. 

Recently, HNHN expanded its focus by adding mental health to its 

existing domains of rest, physical activity, nutrition, quality of life, and 

safety. HNHN’s Advisory Committee endorsed this change and formed a 

subcommittee to address nurses’ mental health, specifically confronting 

mental health stigma, identifying nursing leadership and employer 

responsibilities and planning strategies for improved mental health. For 

more information, visit www.hnhn.org. 

Many mental health and well-being resources support nurses. 

Several—such as HNHN—are free of charge and readily accessible: 

• 2022 Healthcare Workforce Rescue Package. A one-pager from the 

National Academy of Medicine’s Action Collaborative on Clinician 

Well-Being and Resilience. (bit.ly/35FyQKG) 

• Nurse Suicide Prevention/Resilience. ANA site dedicated to 

promoting mental health and suicide prevention. (bit.ly/3jeLcg1) 

• Substance Use Disorder in Nursing. Substance use disorder 

resources from the National Council of State Boards of Nursing. (bit. 

ly/3NHQPS5) 

• The Well-Being Initiative. Launched by the American Nurses 

Foundation, this site offers free tools and apps to support nurses’ 

mental health and well-being. (bit.ly/3jcBb2T) 

Many employers offer support through employee assistance programs, 

peer support, mental health screenings and services, healthcare 

insurance, and wellness officers. Helpful resources are accessible, 

anonymous, and affordable or free. Every organization must instill an “It’s 

ok not to be ok” culture. 

The Dr. Lorna Breen Health Care Provider Protection Act (S. 610/H.R. 

1667) will supply millions in funding to train healthcare professionals 

about suicide prevention, burnout, and SUD. An awareness campaign for 

healthcare professionals will promote assistance with mental health and 

substance use issues and resiliency. 

Nurses need to be the CEOs of their own mental health. Please don’t 

wait until you are in crisis. All nurses should advocate and educate for the 

underserved—in this case, ourselves. 

Holly Carpenter is a senior policy advisor at ANA. Dawn Webb is 

director of nursing practice at Texas Nurses Association. Katie Boston- 

Leary is director of nursing programs at ANA. 

JOIN US AT UMC 

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 701-379-3002 or 

apply online at www.unitymedcenter.com.


Violence in the Healthcare Industry: 

What is Being Done to Protect Healthcare Workers? 

Penny Briese, PhD (c), RN, North Dakota Nurses 

Association, Director of Advocacy 

On Wednesday, June 1, 2022, a man walked 

into The Warren Clinic, a specialty care office 

within Saint Francis Hospital in Tulsa, Oklahoma, 

with a gun he had purchased that very day 

and opened fire. Michael Louis murdered 

four people; a receptionist, a patient, and 

two doctors including Dr. Preston Phillips, an 

orthopedic surgeon who had recently operated 

on Mr. Louis’ back. According to sources, Mr. 

Louis was dissatisfied with the level of pain 

following his surgery. He had sought medical 

help several times in the days leading up to 

the shooting and blamed Dr. Phillips for not 

receiving adequate pain relief. Mr. Louis took 

his own life at the scene; a letter found on his 

body confirmed his intent and motive (Hanna & 

Watts, 2022, June 3). 

Workplace violence is not uncommon, 

however it is five times more prevalent in 

the healthcare industry. “According to the 

American College of Emergency Physicians 

and the Emergency Nurses Association, almost 

half of emergency physicians and 70% of 

emergency nurses reported being physically 

assaulted on the job” (Skog, 2022, para. 1). In a 

recent 2022 survey of 2,500 hospital nurses, 48% 

reported having experienced violence in the 

workplace, a 31% increase since just last year. 

According to testimony given on Capitol Hill 

by Todd Haines, a member of the Emergency 

Nurses Association, nurses have been “bitten, 

punched, knocked unconscious and strangled 

with stethoscopes, all while just trying to provide 

basic care to patients” (Mensik, 2022, May 5, 

para. 1). 

So what is being done? 

Legal protections for healthcare workers are 

already in place in many states. According 

to the Emergency Nurses Association, 31 out 

of 50 states have made it a felony to assault a 

healthcare worker and they are lobbying for 

it to become a felony nationwide. Wisconsin 

state law already makes battery against a 

healthcare worker a felony, however in March 

2022 they passed a law making it a felony to 

even threaten a healthcare worker. In May of 

2020, Oklahoma Governor Kevin Stitt signed The 

Medical Care Provider Protection Act (Senate 

Bill 1290) increasing penalties from one year to 

a mandatory two to five year sentence and 

requiring that assaults on healthcare workers 

be reported to the state health department. 

(Rowland, 2020, May 20). 

At the federal level, The Workplace Violence 

Prevention for Health Care and Social Service 

Workers Act (H.R. 1195) was introduced in 

February, 2021 with strong bipartisan support. 

The bill was passed in the US House of 

Representatives in April of 2021 and sponsors 

of the bill are pushing to have it brought to 

the forefront in the US Senate. This bill would 

require that healthcare facilities receiving 

Medicare funds “develop and implement 

a comprehensive workplace violence 

prevention plan and carry out other activities or 

requirements…to protect health care workers, 

social service workers, and other personnel 

from workplace violence” (Congress.gov, 2022, 

p. 10). The bill has met with some opposition 

with regard to cost to healthcare facilities and 

questions as to the actual outcome of such 

programs. 

And here in North Dakota? 

In 2015, legislation was introduced in North 

Dakota that would make it a felony to assault 

a healthcare worker, including by putting 

excrement or bodily fluids on them. It did not 

pass. In 2017, legislators in North Dakota tried 

again, introducing Senate Bill 2216 which 

called for an amendment and reenactment of 

sections 12.1-17-01.1 (Assault), and subsection 

1 of section 12.1-17-11 (Contact by bodily fluids 

or excrement) of the North Dakota Century 

Code. This Bill discussed assault of health care 

facility providers, specifically via contact by 

bodily fluids or excrement. Peace officers 

and correctional institution officers working at 

the North Dakota state hospital were already 

covered under this section and it was, and 

remains, a Class C felony to assault them while 

they are acting in the course and scope of 

their employment. Senate Bill 2216 called for 

intentionally making contact of bodily fluids 

(blood, emesis, excrement, mucus, saliva, 

semen, vaginal fluid or urine) with a healthcare 

provider a Class A misdemeanor “…if the victim 

is employed or contracted by a health care 

facility, which the actor knows to be a fact, and 

the assault occurs on the health care facility 

property” (Dever et al., 2017). This time, the bill 

was successfully passed. 

In 2021, S.B. 2268 was introduced to once 

again try to amend and reenact section 12.1 

17 01 of the North Dakota Century Code, 

making it a felony to assault a healthcare 

Face Shields and Face Coverings 

worker in North Dakota (Roers et al., 2021). 

Despite strong support from the North Dakota 

Medical Association, this bill failed to pass. But 

healthcare provider advocates and supporters 

are not giving up just yet. The 68th legislative 

session is due to begin in January, 2023 so don’t 

be surprised if this issue is once again brought 

forward. As a healthcare provider, you can be a 

part of the action by lending your voice. Like so 

many doctors and nurses in other states across 

the nation, healthcare workers in North Dakota 

deserve to be protected. 

References 

Congress.gov. (2022). H. report 117-14-workplace 

violence prevention for health care and social 

services workers act. Retrieved from https:// 

www.congress.gov/congressional-report/117thcongress/house-report/14/1?overview=closed 

Dever, D., Burkhard, R., Nelson, C., Karls, J., Nelson, 

M., & Westlind, G. (2017). Senate bill no. 2216. 

Retrieved from https://trackbill.com/bill/northdakota-senate-bill-2216-an-act-to-create-andenact-a-new-subsection-to-section-12-1-17-11-ofthe-north-dakota-century-code-relating-to-thedefinition-of-a-health-care-facility-to-amendand-reenact-subsection-1-of-section-12-1-17-11- 

of-the-north-dakota-century-code-relating-tocontact-by-bodily-fluids-or-excrement-and-toprovide-a-penalty/1339077/ 

Hanna, J. & Watts, A. (2022, June 2). Gunman 

who killed at Oklahoma medical building 

had been a patient of a victim, police chief 

says. CNN. Retrieved from https://amp.cnn. 

com/2022/06/02/us/tulsa-hospital-shotingthursday/index.html 

Mensik, H. (2022, May 5). ER providers push for federal 

protection against rising health worker violence. 

HEALTHCAREDIVE. Retrieved from https:// 

www.healthcaredive.com/news/workplaceviolence-prevention-healthcare-workers-billpandemic/623244/ 

Roers, K., Dever, D., Heinert, J., Nelson, M., & Westlind, 

G. (2021). Senate bill no. 2268. Retrieved from 

https://www.ndlegis.gov/assembly/67-2021/ 

documents/21-0918-02000.pdf 

Rowland, R. (2020, May 20). Okla. Governor signs law 

to protect EMS, hospital personnel from violence. 

EMS1 by Lexipol. Retrieved from https://www. 

ems1.com/ems-assaults/articles/okla-governorsigns-law-to-protect-EMS-hospital-personnelfrom-violence-6OB6YzG6rspiLISv/ 

Skog, A. (2022, March 3). Other views: HB 4142 

could reduce assaults on health care workers. 

Retrieved from https://www.lagrandeobserver. 

com/opinion/columns/other-views-hb-4142- 

could-reduce-assaults-on-health-care-workers/ 

article_2205d5ea-98e1-11ec-959c-3bb7762060c7. 

html 

Appraised by: 

Natalie Hadrava, Rachel Hill 


Are face shields more effective than face 

coverings and between the two options, which 

face protection had a higher success rate in 

preventing the spread of Covid-19? 

Articles References: 

Coclite, D., Napoletano, A., Gianola, S., Del Monaco, 

A., D'Angelo, D., Fauci, A., & Iannone, P. (2021). 

Face mask use in the community for reducing 

the spread of COVID-19: a systematic review. 

Frontiers in medicine, 1060. 

Lindsley, W. G., Blachere, F. M., Law, B. F., Beezhold, 

D. H., & Noti, J. D. (2021). Efficacy of face masks, 

neck gaiters, and face shields for reducing 

the expulsion of simulated cough-generated 

aerosols. Aerosol Science and Technology, 55(4), 

449-457. 

Pooja, A., Kabir, S., & Surabhi, S. (2022, December). 

Real-world assessment, relevance, and 

problems in the use of personal protective 

equipment in a clinical dermatology practice 

in a COVID referral tertiary hospital. EBSCOhost. 

Retrieved April 13, 2022. 

Wendling, J.-M., Fabacher, T., Pébaÿ, P.-P., Cosperec, 

I., & Rochoy, M. (2021, February 17). Experimental 

efficacy of the face shield and the mask against 

emitted and potentially received particles. 

International journal of environmental research 

and public health. Retrieved April 12, 2022. 


In the review of literature, we used keywords 

such as “face mask,” “face covering,” “face 

shields,” and “Covid-19 prevention” in our 

search engines (google scholar, Mayville State 

University online library databases). To narrow 

the search even further, we looked at articles 

and studies that have only been conducted 

in the last five years, as well as only looking at 

scientific articles and studies from reputable 

sources. We, as partners, chose the best articles 

that we both found and used them to create an 

answer to our question. 

Bottom Line: 

The evidence found that face coverings 

are better for the prevention of the spread of 

Covid-19. In all four articles, face coverings 

were found to be more effective than face 

shields. The best face covering to prevent the 

spread of Covid-19 is the N95 respirator mask, 

and face shields were ineffective when used by 

themselves to prevent the spread of Covid-19. 

The studies that were used had different ways 

of showing how face coverings were effective, 

different experiments to show the efficacy of 

face coverings vs. face shields, and flaws of 

wearing a face covering and a face shield. 

Implications for Nursing: 

Knowing this information, all healthcare 

facilities should be using face coverings rather 

than face shields within their facilities. If some 

facilities prefer to do both, that will also work 

because the face shield could stop a few 

particles before they reach the face covering. 

However, face shields should not be used on 

their own because of their ineffectiveness. The 

N95 respirator mask would be the most ideal 

face covering to have due to the mask’s ability 

to stop the greatest number of particles. 

Bedside Reporting continued from page 7 


Implications for nursing practice include to use 

bedside report rather than traditional report to 

help reduce the number of errors on a shift (Small 

& Fitzpatrick, 2017). Using the SBAR method will 

help make sure all information is provided about 

the patient (Becker et. al, 2021). During bedside 

report the nurses can observe the lines, drips, 

and wounds in the patient room and note if any 

changes. The research including the patient in 

bedside report is an effective nursing intervention 

that provides better shift outcomes for patients, 

allowing the patient to be a part of their care and 

ask questions if needed.


Acute Hepatitis in Children: Where are We Now 

Joylyn Anderson, APRN, MSN, RN 

In the last few months, there has been 

worldwide concern regarding an increase in 

the number of cases of acute hepatitis among 

children. According to the World Health 

Organization (WHO), 650 children in 33 countries 

have been diagnosed with acute hepatitis 

between April 5 and May 28 (WHO, 2022). Of 

these 650 cases, approximately 38 children (6%) 

have required liver transplants, and nine deaths 

have been reported (WHO, 2022). Europe has 

had the most significant impact, with 305 cases 

reported since April of this year (ECDC, 2022). 

Since April, the United States has reported 216 

acute hepatitis in children (WHO, 2022). 

A particular increase in acute hepatitis 

in children was noted earlier this year in 

Alabama between October 2021 and 

February 2022, according to the Morbidity 

and Mortality Weekly Report (Baker et al., 

2022). Nine pediatric patients were found to 

have adenovirus and concomitant acute 

hepatitis (Baker et al., p.638). The World Health 

Organization was alerted of concerns of an 

increase in pediatric hepatitis cases when 

169 confirmed cases of acute hepatitis were 

noted in the United Kingdom by April of 

this year. Researcher Robert de Kleine and 

colleagues evaluated the number of pediatric 

hepatitis cases across the United Kingdom 

by sending a web-based public survey to 

pediatric healthcare centers in the United 

Kingdom addressing pediatric diagnoses of 

acute hepatitis over the preceding year. Of 

the 34 participating centers, there were 64 

children diagnosed with severe hepatitis (p. 

2). A previously known cause was noted in 16 

of the 64 children. Thirteen of these children 

were diagnosed with virus-like symptoms, 

with adenovirus being diagnosed in four 

patients. Five of the sixty-four children have 

been previously vaccinated for COVID-19. Four 

children received liver transplants due to severe 

infection (p. 2). 

According to the European Center for 

Disease Prevention and Control (May 31, 2022), 

the following data is the most recent reported 

findings regarding acute pediatric hepatitis 

diagnosis: 

• 76.1% of acute hepatitis cases are five years 

or younger 

• Of the 305 probable cases, 180 have 

recovered while 31 remain under medical 

care 

• 13.6% of patients were admitted to ICU 

• 10.7% received liver transplants 

• One death has been reported 

• Of the 199 tested for adenovirus, 118 (59.3%) 

tested positive 

• Of 204 PCR tested for SARS-C-V-2, 24 (11.8%) 

tested positive. Serology results for SARS- 

C-V-2 were only available for 34 cases, with 

23 (67.6%) testing positive. 

• Of the 72 cases with data on 

COVID-19 vaccination, 61 (84.7%) were 

unvaccinated. 

(European Centre for Disease Prevention and 

Control. May 31, 2022) 

The World Health Organization and Centers 

for Disease Control continue to work together 

to identify the cause of this increase in acute 

hepatitis in pediatric clients. Adenovirus has 

been noted in several cases of severe acute 

hepatitis in both Europe and the U.S. (ECDC, 

2022; CDC, 2022); however, further surveillance 

is necessary to determine the cause correctly. 

New Series! 

The Future of Nursing 

A cause must be identified before proper 

management, care, and preventative measures 

can begin. Continue to follow the Center for 

Disease Control and World Health Organization 

for updates. 

References: 

Baker, J.M., Buchfellner, M., Britt, W., (2022). 

Morbidity and Mortality Weekly Report. Acute 

hepatitis and adenovirus infection among 

children—Alabama, October 21- February 

2022. 71(18), 638-640. MMWR, Acute Hepatitis, 

and Adenovirus Infection Among Children — 

Alabama, October 2021–February 2022 (cdc. 

gov) 

Center for Disease Control and Prevention. (2022). 

CDC alerts providers to hepatitis cases of 

unknown origin. https://www.cdc.gov/media/ 

releases/2022/s0421-hepatitis-alert.html 

De Kleine, R.H., Lexmond, W.S., Buescher, G., Sturm, 

E., Kelly, D., Lohse, A.W., Lenz, D. & Jorgensen, 

M.H. (2022). Severe acute hepatitis and acute 

liver failure of unknown origin in children: a 

questionnaire-based study within 34 pediatric 

liver centers in 22 European countries and 

Israel, April 2022. Eurosurveillance, 27(19). 

Eurosurveillance | Severe acute hepatitis and 

acute liver failure of unknown origin in children: 

a questionnaire-based study within 34 pediatric 

liver centres in 22 European countries and Israel, 

April 2022 

European Center for Disease Prevention and Control 

(ECDC). (2022). Joint ECDC-WHO Regional 

Office for Europe Hepatitis of Unknown Origin in 

Children Surveillance Bulletin. Stockholm: ECDC; 

May 31, 2022. https://www.ecdc.europa.eu/en/ 

hepatitis/joint-weekly-hepatitis-unknown-originchildren-surveillance-bulletin 

World Health Organization (WHO). (2022). Acute 

hepatitis of unknown aetiology in children- Multicountry 

WHO; May 27, 2022. https://www.who. 

int/emergencies/disease-outbreak-news/item/ 

DON-389 

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 

For more information or an application, please contact 

Human Resources at 228-9314 or visit our website at 

www.smphealth.org/standrews 

Nevaeh Schmieg 

My name is Nevaeh 

Schmieg. I’m currently 

pursuing my BSN at the 

University of North Dakota. 

After graduation, I plan 

to stay in North Dakota 

and work as a registered 

nurse in family medicine 

or pediatrics. In the future, 

I hope to continue my 

education to become a 

nurse practitioner. 

Natalie Buck 

My name is Natalie Buck. 

I am from Grand Forks, ND 

and am currently a senior 

at the University of North 

Dakota majoring in nursing. 

Upon graduation I hope 

to work in a burn unit or 

the ICU as a bedside nurse 

and then continue my 

education to become a 

nurse practitioner. I have 

enjoyed getting involved at UND by also being 

a part of my sorority, Kappa Alpha Theta, and 

volunteering at UND’s Food for Thought Food 

Pantry. I enjoy spending my free time at the 

lake, playing golf, and reading. 

Greta Mclagan 

My name is Greta 

Mclagan and I’m from 

Fargo North Dakota. I am 

studying nursing, and I run 

track and cross country for 

UND. My interest in nursing 

started in high school when 

I took a health career class 

from my favorite teacher 

Mrs. Aho. After graduation, 

I plan on continuing to 

advance my nursing skills and become a 

pediatric or labor and delivery nurse. 

Ashley Davis 

My name is Ashley Davis, 

and I am from Belcourt, 

North Dakota. I currently 

am a nursing student at 

the University of North 

Dakota where I am a part 

of the RAIN Program, which 

focuses on the recruitment 

and retention of Native 

Americans into the nursing 

field. I am a board member 

of the UND Nursing Student 

Association. I also work as a 911 Dispatcher here 

in Grand Forks, ND and am a medication aide 

at Valley Senior Living as well. After graduation 

I would ideally like to work with, or alongside, 

the RAIN program. Native American students 

often face culture shock or other barriers when 

pursuing higher education and I would like to 

use my education and experience to assist 

them through this process in any way that I 

can. I would also like to work alongside Indian 

Health Services. I feel this will positively impact 

the Native American community greatly as I will 

be providing a familiar face and understanding 

when administering care. Providing better 

access to healthcare and education on the 

reservations has become a recent focus of mine 

and I want to do everything I can to help make 

that happen. 

NDNA member Susan Indvik and her 

husband are sponsoring these students for 

Student Subscriber memberships! Click here 

or go to the ANA website and hover over the 

Membership tab. Click on “Student Nurses” to 

read more! To sponsor a student, please email 

director@ndna.org. 

If you would If you are a nursing instructor 

and would like some of your students to be 

featured here or if you are a student, we would 

love to hear from you! Email director@ndna.org.


Psych Therapies Compared 

to Medication 

Appraised by: 

Taylor Painter & Mackenzie Duval 

Clinical question: How do psychological 

therapies, such as animal therapy or cognitive 

therapy, compare to medication therapies in 

calming dementia patients? 

Articles: 

Carrion, C., Folkyord, F., Anastasiaduo, D., & 

Aymerich, M. (2018). Cognitive therapy for 

dementia patients: A systematic review. 

Dementia and Geriatric Cognitive Disorder, 46(1- 

2), 1-26. https://doi.org/10.1159/000490851 

Madhusoodanan, S. & Ting, M.B. (2014). 

Pharmacological management of behavioral 

symptoms associated with dementia. World 

Journal of Psychiatry, 4(4), 72-79. https://doi. 

org/10.5498/wjp.v4.i4.72 

Muller-Spahn, F. (2003). Behavioral disturbances in 

dementia. Dialogues in Clinical Neuroscience, 

5(1), 49-59. https://doi.org/10.31887/ 

DCNS.2003.5.1/fmuellerspahn 

Sheikh, A.B., Javed, N., Leyba, K., Khair, A.H., Ijaz, 

Z., Dar, A.A., Hanif, H., Farooq, A., & Shekahr, 

R. (2021). Pet-assisted therapy for delirium 

and agitation in hospitalized patients with 

neurocognitive impairment: A review of 

literature. Geriatrics (Basel), 6(4). https://doi. 

org/10.3390/geriatrics6040096 

Synthesis of evidence: 

It is estimated that anywhere from 30 to 90 

percent of dementia patients experience some 

form of psychological or behavior symptoms 

(Muller-Spahn, 2022). It is important to treat 

these symptoms in order to maintain the safety 

and quality of life of the patient and those 

around them. This review focuses specifically on 

symptoms and behaviors that impact patient 

calmness, such as anxiety, agitation, and 

aggression. 

There are two forms of intervention that 

can be utilized: pharmaceutical and nonpharmaceutical. 

Pharmaceutical interventions 

use medications such as antidepressants, 

sedative hypnotics, cholinesterase inhibitors, 

mood stabilizers and antipsychotics. Because 

these medications can result in adverse 

effects, the possible risks and benefits must be 

weighed carefully. It is also recommended 

that pharmaceutical interventions are not 

used unless non-pharmaceutical therapies 

have failed or the patient’s symptoms require 

immediate treatment (Madhusoodanan & 

Ting, 2014). There is a wide variety of nonpharmaceutical 

treatment options, but this 

review focuses on cognitive therapy and 

animal-assisted therapy. Cognitive therapy 

utilizes a combination of reality orientation and 

skills training in an attempt to reverse or slow the 

development of cognitive impairment (Carrion 

et al., 2018). 

Bottom line: 

Many existing studies have found the use of 

cognitive therapy to be beneficial to patients 

while others have found it to have no effect. The 

same can be said for animal-assisted therapy, 

although some studies have found animal 

exposure can exacerbate symptoms in severe 

cases. Due to small sample sizes, inconsistent 

study designs, and lack of randomizedcontrolled 

trials, results are inconclusive at this 

time. It is currently unclear if psychological 

interventions are more effective at promoting 

patient calmness than pharmaceuticals, 

although they have proven to be less risky. 

Once the better intervention has been 

determined, more randomized-controlled 

trials are needed to determine the number 

of sessions, length of sessions, and duration of 

intervention that give the best results. 

Implication for nursing practice: 

Dementia can cause a wide variety of 

symptoms, some of which pose a threat 

to patients and those around them. It is 

important to try and combat these symptoms 

in a way that maintains quality of living for 

the patient, while also keeping everyone 

involved safe. Pharmaceutical intervention 

can be an effective treatment but can also 

cause other symptoms, decrease quality of 

life, and increase patient mortality. Cognitive 

and animal-assisted therapy have produced 

inconclusive results in terms of effectiveness but 

have not shown to have negative impacts on 

patients. When working with dementia patients, 

non-pharmaceutical interventions should be 

attempted first as they are less likely to cause 

harm to patients. 

NDNA’s Highlight a 

Nurse! 

Meet Megan Teske, BSN, RN 

Nursing Specialty: Family 

Practice Nursing 

By Joylyn Anderson, APRN, BSN 

What sparked your interest 

in nursing? 

As a freshman in high 

school, I had a family 

member suffer a medical 

illness that required 

hospitalization for several 

weeks. The nurses (in the 

same facility I now work 

in) showed so much love 

and compassion in the 

care they delivered that 

it created a drive in me to 

do the same for others. 

Although that experience 

wasn’t particularly a good 

one, I am so grateful for it for leading me into this 

profession of caring for others. 

What does a typical day look like for you? 

I work part-time in a rural health clinic 

specializing in allergy and family practice. It is a 

busy facility that provides care to people of all 

ages. Every day is different, which is one of the 

things I like most. 

What do you find challenging? 

Insurance companies. Seeing this side of 

nursing has shown me how difficult and frustrating 

it can be for patients to get the services they need 

in a timely manner. 

The past two years of the pandemic have been 

challenging for nurses. What self-care advice 

would you give to new graduate nurses? 

As a mom of three, self-care can be difficult 

to come by as is… but even more so as a nurse. 

Sleep is one of the most important things for my 

personal self-care at this stage of my life… it is 

hard to function and think critically without it. 

It is so important to make time for yourself & the 

activities you enjoy. It’s impossible to pour from an 

empty cup. 

The Quest for Excellence 

Karen L. Zimmerman, MSN, RN 

Have you ever found yourself in a position 

of asking if where you are is where you want 

to be? What are your aspirations and more 

importantly, how hard are you willing to work 

to get to where you want to be? As humans, 

we often unknowingly place a filtered lens 

(aka rose colored glasses) over our eyes that 

protects us in such a way, that we may be 

blinded by the reality of a situation. Humans 

were developed with that protection in part, 

to shield us from the impact of trauma. That 

becomes problematic when we are blinded to 

areas of opportunity. This filtered view may lead 

to complacency and/or blocking behaviors 

when changes are necessary. John Kotter 

(1996) author of Leading Change, states that 

“complacency, is supported by the very human 

tendency to deny that which we do not want to 

hear” (p. 43). This is especially problematic in a 

work environment when trying to drive change 

because “life is usually more pleasurable 

without problems” (Kotter, 1996, p. 43). 

If I were to ask you if you wanted to be known 

for excellence or mediocrity, you would likely 

look at me like I had two heads. Most of us do 

not desire to be average, yet there are times 

in our life, personally or professionally, that we 

find ourselves in that very place. Maybe fear is 

preventing us from challenging the status quo 

because we are afraid to confront someone or 

something that is blocking forward movement. 

Maybe we are too tired to expend the effort 

it will take to move from a place of comfort. 

Maybe we want to make changes or be part 

of the solution, but we do not know how and 

are afraid to show our vulnerability and ask for 

help due to fear of being judged or accused of 

being an imposter. Maybe we are afraid of our 

own judgment. Or just maybe doing the right 

thing is too difficult because of potential barriers 

or backlash. 

I issue the following challenge to each of us: 

1. Do not accept mediocrity. 

2. Strive for excellence wherever you are. 

3. Be part of the solution not the problem. 

4. Hold others accountable if you see 

deficiencies in their practice (i.e. seeing 

someone not performing hand hygiene). 

5. Join a committee or ask how you can 

contribute to an effort of change or 

improvement. 

6. Do not get defensive if someone coaches 

you. 

7. Do NOT be a blocker. 

Colin Powell once stated, “if you are going to 

achieve excellence in big things, you develop 

the habit in little matters. Excellence is not an 

exception; it is a prevailing attitude.” Rather 

than saying “no,” say “how” and make an effort 

to ensure your attitude is such that you support 

change and strive for excellence instead of 

accepting mediocrity. 

Kotter, J. (1996). Leading Change. Harvard Business 

Review Press. 

The North Dakota Department of Health has seen 

a decrease in the number of immunized children 

(regular immunization) as a result of not having 

access to care during the pandemic. Is this 

something that you are seeing in your rural area? 

We have definitely seen a decrease in our 

immunization rates due to the pandemic. Our 

rates are normally fairly high thanks to scheduled 

well child visits and our Public Health Nurse 

offering immunizations to children in our school 

systems. However, people were not scheduling 

routine exams for their children during the height 

of the pandemic, nor was there much time for 

our Public Health Nurse to offer routine screenings 

and visits to the schools. 

If so, is there anything that you recommend doing 

to help promote timely immunizations? 

We have a traveling Pediatrician that visits our 

facility once a month. She has been seeing a 

significant increase in the number of patients she 

sees when she visits our facility. We advertise on 

Facebook & our weekly newspaper to alert the 

community of her scheduled visits and for routine 

vaccination. 

Nursing Faculty position 

Beginning August 2022 

Teaching Mental Health and 

Medical Surgical Nursing 

For more details, 

visit www.uj.edu/employment.


NDNA Attends ANA Hill Day and 

Membership Assembly 2022 in Washington, DC 

Sherri Miller, BS, BSN, RN, 

NDNA Executive Director 

NDNA was back in DC! 

NDNA President Tessa Johnson, elected 

NDNA Membership Assembly Representative 

Susan Indvik, and I attended the 2022 ANA Hill 

Day and Membership Assembly in Washington, 

DC June 9-11. 

If you do not know, ANA Hill Day is a unique 

opportunity for nurses across the county to 

meet with their members of Congress and to 

share their perspectives on the most pressing 

issues facing nurses across the nation. 

At Membership Assembly, the representatives 

vote on everything, from bylaws to position 

statements, that affect legislation and nursing 

practice. Candidates for elected positions 

share their stance and discuss viewpoints. This 

particular event has been the first in-person 

event for ANA in three years! 

We were very excited as meetings began 

early Thursday morning with a breakfast briefing 

that provided a federal legislative overview 

and key talking points for nurse representatives 

to share with their members of Congress during 

the day’s scheduled meetings. 

Dr. Ernest Grant began this day with an 

inspiring speech and a fun, surprise impromptu 

rendition of “Sweet Caroline” when he filled 

time in the program (after a dare!). Brian Davis, 

Grassroots Advocacy Coordinator for ANA’s 

Department of Policy and Government Affairs, 

provided logistics for Hill Day, and Samuel 

Hewitt and Kristina Weger from ANA’s Federal 

Government Affairs reviewed the issue briefs 

which included Workplace Violence and the 

Value of Nursing. 

ANA-California’s President, Dr. Anita Girard 

DNP, RN, CNL, CPHQ, NEA-BC, introduced 

U.S. Representative Lucille Roybal-Allard. 

Representative Roybal-Allard reminds nurses to 

take steps to get their elected officials to get 

to know them and their staff. She encouraged 

us to offer to help and stated that “the more 

you get to know them, the more they’ll want to 

help.” This inspired us to start our meetings! 

We had a remote visit with Senator John 

Hoeven’s Legislative Assistant, Ty Kennedy, on 

June 23. 

We discussed: 

• “Valuing the Nursing Workforce” in which 

we provided findings from the American 

Nurses Foundation COVID-19 Two-Year 

Impact Assessment Survey. We noted that 

60% of acute care nurses report feeling 

burned out and 75% report feeling stressed, 

exhausted, and frustrated. Two out of three 

nurses under 35 reported feeling burned 

out. We asked them to cosponsor and 

pass the Workplace Violence Prevention 

for Health Care and Social Service Workers 

Act (S. 4182/H.R. 1195). 

• “Improving Seniors’ Timely Access to Care 

Act of 2021” with the goal of protecting 

patients from unnecessary delays in 

care by streamlining and standardizing 

prior authorization under the Medicare 

Advantage program. 

In discussing these bills and issues, we felt our 

meetings went very well and that we expressed 

our points clearly to the members of Congress 

who heard and received our message. We 

even felt that we had an emotional personal 

connection with them in telling our stories. 

We then went into ANA Membership 

Assembly on June 10th and 11th. Early morning 

on June 10th was an opportunity to meet the 

candidates and a Hearing on ANA Racial 

Reckoning Statement. President Ernest Grant 

gave a “Call to Order” and we began the 

order of business. His President’s Address 

was wonderful. He stated, “when nurses are 

protected, patients are as well.” He went on 

to say that we need to “push for changes to 

ensure that nurses have a professional home.” 

President Grant also shared a personal side as 

he gave an emotional thank you to the ANA 

Board of Directors, membership, and staff for his 

term in office which will be ending in December 

of 2022. We are so pleased that President Grant 

will be the keynote speaker at the NDNA Fall 

Conference, “Celebrating the Art of Nursing” 

September 20, 2022 in Bismarck. During 

President Grant’s address, NDNA was one of the 

C/SNAs (Constituent/State Nurses Associations) 

recognized for their years of existence – 110 

years for NDNA. (Watch for more upcoming 

celebration on that note!) 

In the afternoon on the first day, the Dialogue 

Forums were held on the below topics that had 

been submitted. 

• The Impact of Climate Change on Health 

• Advancing Solutions to Address Verbal 

Abuse and Workplace Violence Across 

the Continuum of Care where key points 

were brought out such as if someone on 

a flight assaulted a flight attendant, but 

not a nurse in a hospital! Verbal threats 

are violence as well and de-escalation 

techniques should be part of training/ 

orientation for staff 

• Nurse Staffing where discussion focused 

on patient outcomes, school nursing/ 

long term care (not just acute care) and 

referring to ratios as “standards.” 

Friday we also heard a very positive report 

from ANA’s Treasurer and some scheduling 

updates from the Vice President. 

On Saturday, the last day of Membership 

Assembly, we heard a moving Nightingale 

Tribute. We were then able to do some 

lunchtime networking and hear from the ANA 

Professional Policy Committee. 

For the elections, the Membership Assembly 

elected Jennifer Mensik Kennedy, PhD, MBA, 

RN, NEA-BC, FAAN, of the Oregon Nurses 

Association as the association’s next president 

to represent the interests of the nation’s more 

than 4.3 million registered nurses. Mensik has 

more than 25 years of nursing experience in a 

variety of settings ranging from rural critical 

access hospitals and home health to hospital 

administration, and academia. She has served 

as President of the Arizona Nurses Association 

and 2nd Vice President and Treasurer of ANA. 

The term of service for Dr. Mensik and all other 

newly elected leaders will begin January 1, 

2023. 

ANA’s Membership Assembly also elected 

four members to serve on the board of 

directors. The newly elected board members 

are: Secretary Amanda Oliver, BSN, RN, CCRN, 

of ANA–Illinois; Director-at-Large, Edward 

Briggs, DNP, MS, APRN, of the Florida Nurses 

Association; Director-at-Large, Jennifer Gil, MSN, 

RN, of the New Jersey State Nurses Association; 

and Director-at-Large, Staff Nurse, David 

Garcia, MSN, BSN, RN, PCCN, of the Washington 

State Nurses Association. 

The following ANA board members will 

continue their terms: Susan Swart, EdD, MS, 

RN, CAE, of ANA-Illinois as Vice President; 

Joan Widmer, MS, MSBA, RN, CEN, of the New 

Hampshire Nurses Association as Treasurer; 

Amy McCarthy, MSN, RNC-MNN, NE-BC, of 

the Texas Nurses Association as Director-at- 

Large; and Marcus Henderson, MSN, RN, of 

the Pennsylvania State Nurses Association as 

Director-at-Large, Recent Graduate. 

Elected to serve on the Nominations and 

Elections Committee are: MaryLee Pakieser, 

MSN, RN, FNP-BC, of ANA Michigan; Jennifer 

Tucker, MA, RN, of the Minnesota Organization 

of Registered Nurses; and Kimberly Velez, MSN, 

RN, of ANA - New York. 

This event is an excellent opportunity to 

express our nursing voices and represent our 

state. It was my second time to be “in person” 

for Hill Day and Membership Assembly, and 

again I felt it was an extreme honor and 

privilege! We were treated with respect by 

our legislators and their staff who were all 

hospitable and provided us the opportunity 

to engage in meaningful and collaborative 

discussions. It’s truly an experience that 

connects North Dakota nurses to ANA’s mission 

of “nurses advancing our profession to improve 

health for all.”


I would like to thank NDNA President Tessa 

Johnson and NDNA Membership Assembly 

Representative Susan Indvik for being excellent 

partners on this event. They deserve extra kudos 

for some travel woes they encountered on the 

way home – forcing each of them to stay in a 

few other cities and extra days before finally 

making it home. 

North Dakota nurses, if you are interested in 

being involved in Hill Day/Membership Assembly 

or any ANA/NDNA activities, you are welcome 

to attend our open Board Meetings to become 

engaged or talk to anyone at NDNA! 

Photo credit: Jerry Frishman Photo credit: Jerry Frishman Photo credit: Jerry Frishman


CAUTI’s and External Catheterization 

Appraised by: 

Brenna Hoger SN, Patricia Shepard SN, Kaylie 

Wilson SN, Ashley Wanner SN, Emily Russell SN, 

Morgane Inangorore SN 

Allison Sadowsky MSN RN Assistant Professor 

of Practice (Faculty) 

(NDSU School of Nursing at Sanford Bismarck) 


For women in need of urinary catheterization, 

does the use of external catheterization reduce 

the risk for urinary tract infections compared to 

indwelling foley catheters? 

List of Articles: 

Eckert, L., Mattia, L., Patel, S., Okumura, R., Reynolds, 

P., & Stuiver, I. (2020). Reducing the risk of 

indwelling catheter-associated urinary tract 

infection in female patients by implementing 

and alternative female external urinary 

collection device: A quality improvement 

project. Journal of wound, ostomy, and 

continence nursing: official publication of The 

Wound, Ostomy, and Continence Nurses Society, 

47(1), 50-53. 

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. 

Rearigh, L., Gillett, G., Sy, A., Micheels, T., Evans, L., 

Goetschkes, K., Van Schooneveld, T.C., Lyden, E., 

& Rupp, M.E. (2021). Effect of an external urinary 

collection device for women on institutional 

catheter utilization and catheter-associated 

urinary tract infections. Infection control and 

hospital epidemiology, 42(5), 619-621. https://doi. 

org/10.1017/ice.2020.1259 

Van Decker SG., Bosch N., Murphy J. (2021). Catheter 

associated urinary tract infection reduction 

in critical care units: a bundled care model. 

BMJ Open Quality, 10(e001534) Doi: 10.1136/ 

bmjoq-2021-001534 

Warren, C., Fosnacht, J. D., & Tremblay, E. E. (2021). 

Implementation of an external female urinary 

catheter as an alternative to an indwelling 

urinary catheter. American journal of infection 

control, 49(6), 764–768. https://doi.org/10.1016/j. 

ajic.2020.10.023 

Zavodnick, J., Harley, C., Zabriskie, K., & Brahmbhatt, 

Y. (2020). Effect of a female external urinary 

catheter on incidence of catheter-associated 

urinary tract infection. Cureus. https://doi. 

org/10.7759/cureus.11113 


Six articles were reviewed as evidence 

in this report, including three retrospective 

observational studies and three quasiexperimental 

quality improvement project 

studies. Rearigh et al (2021) stated “catheterassociated 

urinary tract infections (CAUTIs) are 

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a common hospital-acquired infection resulting 

in excess morbidity, mortality, and cost.” Urine 

management, for women in particular, has 

been challenging due to the limited options 

for control of urinary incontinence and the 

anatomy of the female body. The external 

catheter allows for urine management in a 

manner that is still easily measurable and 

accurate and avoids an indwelling catheter. 

Eckert et al (2020) conducted a quasiexperimental 

“quality improvement project.” 

This project entailed the use of a “test run” 

in one unit utilizing a female external urinary 

collection device in an effort to reduce the 

number of CAUTI rates in female patients 

needing urinary management. The trial run 

included a 60-bed telemetry unit for 30 female 

patients requiring urinary management. At 

the end of the trial period, each nurse on the 

unit who used the female external urinary 

collection device was given a survey, and the 

nursing usage reports were positive. After the 

trial run and survey analysis, the experiment 

was expanded to other units in the hospital. 

The amount of CAUTI rates with the use of a 

foley catheter were compared to CAUTI rates 

with the use of the female external urinary 

collection (FEUC) device. Before implementing 

the use of a FEUC device, the female CAUTI 

rate were eight cases per 7,181 indwelling 

catheter device days, so approximately 0.11%. 

After implementation of the FEUC device, 

CAUTI rates were approximately 0% in 2016, 

and 0.09% in 2017. It was found that the use 

of a female urinary collection device may 

reduce both indwelling catheter utilization and 

CAUTI rates if a consistent, comprehensive, and 

interdisciplinary approach is used to assess 

CAUTI bundle compliance that included a FEUC 

device. 

Leontie and Delawder (2021) conducted 

a quasi-experimental “quality improvement 

project” (QI). This QI was conducted to 

determine if implementing a ‘fight the Foley’ 

bundle would reduce the device utilization 

rates of indwelling catheters and reduce the 

rates of CAUTI. This study included anyone 

with an indwelling catheter on a critical care, 

intermediate care, or medical surgical unit in a 

238 bed Not-for-profit hospital. Pre-intervention 

data was collected from July 2017 to August 

2018 and post intervention data was collected 

from October 2018 to September 2019. The 

intervention developed an implementation 

of a daily ‘Fight the Foley’ line huddle for unit 

leaders, developed and implemented a Foley 

stop huddle prior to insertion and increased 

available alternative devices (Pure Wick). The 

major finding of this study found that there 

was a downward trend in CAUTIs, but no 

clinical significance was noted. There were 16 

CAUTIs captured pre-intervention and eight 

in the post-intervention timeframe. There was 

statistical significance in alternative device 

usage which increased with a 105% increase 

in condom catheter use, 16% with intermittent 

catheterization, and 409% increase in female 

urinary incontinence device usage such as Pure 

Wick. 

Rearigh et al (2021) conducted a 

retrospective quasi-experimental study to 

determine whether external urinary catheter 

devices, in comparison to indwelling catheters, 

decreased the amount of catheter usage days, 

catheter associated urinary tract infections in 

females, and adverse events associated with 

urinary catheterization. The study included 

2,347 adult inpatient women in need of urinary 

catheterization during the experimental period 

(14 months) and other female patients (number 

not stated) in the control comparison period 

(14 months). The intervention in this study was to 

initiate the external collection device, otherwise 

known as the “PureWick.” The study found that 

there was a significant decrease in catheter 

utilization (71.49 to 56.15), the rate of CAUTI 

decreased (0.15-0.09), and there were only five 

reported adverse events in the 14 months of the 

experimental period related to malposition of 

the “PureWick” and patient allergies. 

Van Decker SG., Bosch N., Murphy J. (2021) 

conducted a quasi-experimental quality 

improvement project utilizing the Plan/Do/ 

Study/Act (PDSA) Framework at a Boston 

Medical Center (BMC) hospital in Boston, 

Massachusetts starting in Spring 2013 and 

spanning five years. The CAUTI taskforce 

implemented the PDSA cycle and used CAUTI 

rates per 1000 patient days as measurement, 

which aimed at testing the effect of Purewick 

external catheter use among female ICU 

patients and resulted in a significant downward 

shift from 5.86 to 1.62 mean CAUTI rate post 

intervention. 

Warren et al (2021) conducted a quasiexperimental 

retrospective study. The purpose 

of this study was to analyze “the impact of a 

hospital-wide implementation of an external 

female urinary catheter at a large academic 

medical center.” This study compared predevice 

implementation and post-device 

implementation to see if there was a reduction 

of CAUTIs. This study took place in a large 

academic center in Madison, WI. Data was 

collected from March 1, 2016, until May 31, 

2018. This study compared CAUTI rates per unit 

month, indwelling urinary catheter utilization 

rate, and external urinary catheter utilization 

rate in a retrospective chart review from EPIC. 

The major findings of this study were that the 

overall female CAUTI rate went from 5.5 to 

1.7, indwelling urinary catheter utilization ratio 

decreased from 0.46 to 0.35, and external 

female urinary catheter device utilization 

increased from 0 to 0.17. 

Zavodnick, Zabriskie, and Brahmbhatt (2020) 

conducted a retrospective observational study. 

This study was conducted to investigate the 

effect of female external urinary catheters 

(FEUCs) on indwelling catheter use and female 

CAUTIs. The study focused on female ICU 

patients at Thomas Jefferson University Hospital. 

The study included ICU patients during the 

preintervention time period of Jan 1, 2017 to 

December 31, 2017 and then the intervention 

period of Jan 1, 2018 to December 31, 2019 

when the FEUC became available. The major 

findings were that female CAUTI rates were 

3.14 per 1000 catheter days and 1.42 after the 

FEUC was introduced. CAUTI rates decreased 

by over 50% after the FEUC was introduced. 

Device-associated pressure injury (DAPI) 

increased after the FEUC was introduced. The 

DAPI was 0.49% for preintervention and 0.61% 

during intervention. Overall, after the FEUC 

was introduced, CAUTI rates had a significant 

decrease. 

Conclusions: Brief Summary of the Evidence 

All six articles indicated a downward 

trend in catheter associated urinary tract 

infections after implementing an external 

catheter device in females in comparison to 

indwelling catheters. Also, all articles showed 

a decrease in overall catheter usage days 

after the implementation of the external 

female collection device. However, Zavodnick, 

Zabriskie, and Brahmbhatt (2020) found that 

there was an increase in adverse events after 

the implementation of the external device due 

to device associated pressure injuries. 


(Recommendations for Practice) 

According to this research, there is evidence 

to suggest that implementing an external 

urinary collection device will reduce catheter 

associated urinary infections and reduce the 

number of catheter usage days in female 

patients. Warren et al (2021) recommended 

that facilities first implement the device in 

the ICU as this level of care was where they 

observed the most significant impact, before 

facilities implement the device on every floor. 

This external female collection device provides 

a non-invasive method to manage female 

urinary incontinence, measure urinary output 

and reduce skin breakdown from urinary 

incontinence, which overall improves patient 

outcomes and associated costs.


Ozone Compared to 02 

Appraised By: 

Amanda Hanson, RN, Mayville State University 

RN-to-BSN Student; Ashley Locken, RN, Mayville 

State University RN-to-BSN Student; Brandon 

Ferguson, RN, Mayville State University RN-to- 

BSN Student. 


In patients hospitalized for COVID-19, how 

does integrating ozone treatment compared to 

O2 alone affect prognosis? 

Articles: 

Hernández, A., Viñals, M., Pablos, A., Vilás, F., 

Papadakos, P. J., Wijeysundera, D. N., Bergese, 

S. D., & Vives, M. (2020, December 5). Ozone 

therapy for patients with COVID-19 pneumonia: 

Preliminary report of a prospective case-control 

study. International immunopharmacology. 

Retrieved April 12, 2022, from https://www.ncbi. 

nlm.nih.gov/pmc/articles/PMC7833586/ 

Hernández, Viñals, M., Isidoro, T., & Vilás, F. (2020). 

Potential Role of Oxygen-Ozone Therapy 

in Treatment of COVID-19 Pneumonia. The 

American Journal of Case Reports, 21, e925849– 

e925849–6. https://doi.org/10.12659/AJCR.925849 

Orscelik, A., Karaaslan, B., Agiragac, B., Solmaz, 

I., & Parpucu, M. (2020). Could the minor 

autohemotherapy be a complementary therapy 

for healthcare professionals to prevent COVID-19 

infection? Annals of Medical Research, 

28(10), 1863–1869. https://doi.org/10.5455/ 

annalsmedres.2020.11.1133 


Ozone therapy is considered a nonpharmacologic 

method which can be used 

as a complementary therapy when paired 

with pharmacologic interventions in the 

treatment of COVID-19. The treatment method 

depends on the severity of the infection and 

what stage of the infection the patient is 

currently experiencing. Ozone therapy is used 

in conjunction with standard treatment for 

COVID-19 to improve patient outcomes and 

provide for a better prognosis than using O2 

therapy alone. “Ozone therapy acts as an 

auto-vaccine which can induce the oxidation 

of the viral components” and is administered 

as a minor hemotherapy (Orscelik, et al, 2020, 

g 1863). The treatment method depends on 

the severity of the infection and what stage 

of the infection the patient is currently in. It 

also depends on if the patient is receiving 

pharmacological treatment for the infection. 

The research for this study was a random 

sample study that was obtained from a group 

of people that had tested positive for COVID-19 

and were symptomatic. The research that 

was conduced was used to determine the 

benefits of the use of ozone therapy for patients 

that tested positive for COVID-19 and were 

experiencing symptoms. 

A randomized controlled group that 

consists of three covid positive individuals 

that acquired covid induced pneumonia, 

gave informed consent to receive ozone 

oxygenated treatment. These three individuals 

that presented with respiratory distress was 

a 49-year-old male, 61-year-old male, and 

64-year-old female. Each patient received four 

to six sessions of the ozone autohemotherapy. 

The outcomes were that each patient was 

able to discharge from the hospital on day two 

through four after ozone treatment. Laboratory 

tests and chest x-rays obtained before, during 

and after treatment and shown significant 

improvements throughout the study. None of 

these three patients needed invasive measures 

for breathing assistance, oxygenation, or 

mechanical ventilation. Each patient had an 

overall rapid clinical improvement after ozone 

therapy. 

Bottom Line: 

COVID-19 was a rapid outbreak that spread 

from person to person through airborne and 

droplets causing a global pandemic in March 

of 2020. This pandemic continued on through 

early 2022. Guidelines were put in place that 

instructed people to isolate in their homes and 

wear masks when they were out in public to 

hopefully stop the spread of this new infection. 

Treatment options were limited due to the 

unknowns of the infection transmission, cause, 

and barriers. When the infection first surfaced 

in the United States, standard treatment was 

supplemental oxygen therapy and occasional 

antibiotic treatment. Through research and trial 

and error, new standards for infection treatment 

have surfaced. 

One of the new treatments was ozone 

therapy. Ozone treatment is an alternative 

medical therapy that introduces ozone to the 

body. For the treatment of COVID-19, ozone is 

mixed with a patient’s blood and reinjected 

into the patient’s body. This process is known 

as autohemotherapy. “Ozone therapy can 

be giving in multiple treatments; it improves 

oxygenation through attaching to the blood 

cells and it consider to be ‘10 times more soluble 

than oxygen’” (Hernadez et. al. 2020). This 

therapy is shown to improve the overall immune 

system response. 

Studies have shown that ozone therapy 

combined with supplemental oxygen have 

significantly decreased COVID-19 symptoms 

and prevented the need for mechanical 

ventilation or intubation. Ozone therapy was 

trialed in some areas and was found to be 

successful in COVID treatment, however, there 

is not enough studied evidence to consider it a 

true treatment for COVID-19 symptoms. 

Ozone therapy can be used in the 

treatment of COVID-19 infection in addition 

to traditional treatment of the infection. There 

is not enough evidence to determine if using 

ozone therapy alone would provide better 

outcomes for the patient, so it is determined 

that using it in addition to oxygen therapy and 

pharmacologic treatment provides better 

outcomes for the patient. There is still more 

research available, and all studies are shortterm 

with moderate-small sample sizes. 


Ozone therapy cannot be said to provide 

sufficient protection alone but can be used 

with other treatments to provide better results in 

protection and therapy for COVID-19 infection. 

Using ozone as an adjuvant therapy in the 

treatment of COVID-19 associated pneumonia 

is shown to be beneficial to the patient. 

Determining what patients can receive ozone 

therapy and which patients are candidate for 

other forms of therapy is imperative to ensure 

the patient is getting the highest quality of 

care/treatment for the best results. Early results 

show that ozone therapy does benefit patients 

affected by the COVID-19 virus. 

Nurses should continue to educate 

themselves on potential treatment options for 

patients with COVID-19 infection. Many people 

are rather skeptical about the infection and 

the presented treatment options. Staying up to 

date by reading current studies can go a long 

way when talking to people about treatment 

options for COVID-19 infection, including Ozone 

therapy.


Progression of North Dakota POLST and Emergence of Honoring 

Choices® North Dakota 

Nancy E. Joyner, MS, CNS-BC, APRN, ACHPN® 

Karli Olson, DNP, APRN, FNP-C, CCRN 

Inception of POLST 

In 2003, Altru Health System staff from Grand 

Forks, Nancy Joyner, MS, CNS-BC, APRN, ACHPN® 

and Gayla Drengson, MS, LICSW, attended 

Physician Orders for Life Sustaining Treatment 

(POLST) session at a national conference and 

brought the information back to administration. 

At that time, Altru Health System was evaluating 

the change the code level status from numbers 

(e.g., 1,2,3) to nationally recognized wording 

(e.g., Full Code, Do Not Resuscitate (DNR), Do Not 

Intubate (DNI), and Allow Natural Death (AND) 

as well as promote engagement in serious illness 

conversations. 

By 2007, Altru Health System developed a 

workgroup of physicians, nurses, social workers, 

chaplains, and other disciplines to study and 

plan for the implementation of the POLST form. 

Both a POLST policy and form were developed 

and adapted through Altru Health System. Altru 

worked with first responders and paramedics in 

hopes of implementing POLST in the communities 

surrounding Grand Forks. The local long term care 

facilities also became involved. There was also 

interest, regarding the implementation of POLST, 

at the state level from the North Dakota Medical 

Association’s (NDMA) Ethics Committee at that 

time. 

In 2010, the North Dakota Medical Association’s 

House of Delegates adopted a resolution, urging 

North Dakota physicians and other healthcare 

professionals across all healthcare settings to 

consider POLST components in developing 

an initiative across the state. NDMA’s Ethics 

Committee reviewed the National Institutes of 

Health (NIH) support of POLST and analyzed 

studies published, regarding POLST, and 

concluded that engaging in POLST conversations 

have a significant advantage over traditional 

methods to communicate preferences about 

life-sustaining treatment. The Minnesota Medical 

Association Ethics Committee and Medical-Legal 

Affairs had also endorsed the POLST program in 

their state. 

In 2012, NDMA assigned the POLST project to 

the ND Healthcare Review in Minot (now formally 

known as Quality Health Associates of North 

Dakota). The project and workgroup were led by 

Quality Improvement Specialist, Sally May, BSN, 

RN. May invited interested parties throughout the 

state to explore a statewide POLST initiative as well 

as advance care planning. The ND advance care 

planning coalition grew from 10 to 40 members. 

By 2013, an initial POLST workgroup was formed. 

The original POLST form, created in 2007 at the 

Altru Health System, was updated to reflect 

the efforts and recommendations of the POLST 

workgroup. In 2017, the statewide ND POLST form 

and ND POLST program were established and 

went live on July 1, 2017. Lastly, in 2018, the ND 

POLST form was updated to meet the national 

standards. 

Commencement of Honoring Choices® North 

Dakota 

As the statewide POLST project was evolving, 

Sally May, BSN, RN presented a webinar in 

2013 titled, Advance Care Planning: Beyond 

an Advance Medical Directive. North Dakota 

Advance Care Planning Initiative face-to-face 

meeting. By December of 2013, members of the 

North Dakota Advance Care Planning Initiative 

had drafted a vision, goal, and objectives for a 

prospective organization with a focus to create 

a statewide initiative to improve advance care 

planning across the state. 

In 2014, several interested individuals 

participated in the Minnesota Network of Hospice 

and Palliative Care. At the conference, individuals 

learned about Respecting Choices®, an 

evidence-based practice program that focuses 

on person-centered decision-making to ensure 

individuals’ preferences and wishes, regarding 

their medical decisions, are known and respected 

as well as Honoring Choices® Minnesota (HCM), 

which was a public health initiative to help 

individuals make informed decisions about their 

future medical care. HCM recently dissolved in 

2021. At the time, HCM was creating a national 

network and with licensing through HCM/East 

Metro Medical Society Foundation, Honoring 

Choices® North Dakota (HCND) was formed. 

HCND created a steering committee and 

active workgroups, and by April of 2015, HCND 

was incorporated as a ND 501(c)3 nonprofit 

organization. 

The original vision of goal of HCND were as 

follows: 

Vision: To create a culture across ND where 

continuous (on-going) advance care planning 

is the standard of care, and every individual’s 

informed preferences for care are documented 

and upheld. 

Goal: To assist statewide community partners 

with the development and implementation of a 

comprehensive advance care planning program 

by December 2016 

In 2016, the efforts and aspirations of 

the North Dakota Advance Care Planning 

Initiative Committee and HCND came to 

light. In September of 2016, HCND held its first 

conference, Striving for Success: Challenges and 

Opportunities for Advance Care Planning. In 

November 2016, First Steps® ACP (Advance Care 

Planning) instructors were trained and prepared 

to educate ACP facilitators across the state. Lastly, 

in December of 2016, HCND was awarded a 

$10,000 grant from Consensus Council of Bismarck 

through its Community Innovation Grant Program, 

offered in partnership with the Bush Foundation, 

to assist with the statewide ACP facilitator 

training. The National Healthcare Decisions Day 

event on April 16th was recognized, and events 

were planned annually. ND POLST awareness, 

education, and implementation had gone 

statewide. 

In 2017, the HCND website was created and has 

been hosted by Quality Health Associates of ND. 

The HCND Board of Directors revised the previous 

vision and goals and composed the following: 

VISION: The health care choices a person 

makes become the health care the person 

receives. 

GOAL: To assist communities to develop a 

successful advance care planning process. 

OBJECTIVES: 

1: Promote advance care planning through 

community and professional outreach and 

education. 

2: Promote standardization of advance care 

planning. 

3: Establish base of financial support. 

In 2018, HCND held a second statewide 

presentation at a conference in Fargo titled, 

Improving Quality of Life—It Starts with 

Competent Caring Conversations. HCND 

continued offering the First Steps® ACP training 

opportunities. The HCND Board of Directors 

welcomed the first physician affiliate, Dr. 

Kristina Schlecht, MD, and Dr. Jonathon Berg, 

MD became the POLST medical director. 

Continuing medical education (CME) for POLST 

was endorsed nationally, and as previously 

mentioned, the statewide POLST policy went into 

effect. 

In 2019, HCND became affiliated with ND 

Palliative Care Taskforce and Center for Rural 

Health (CRH) with an emphasis on CRH’s Rural 

Community-Based Palliative Care program 

to promote all aspects of advance care 

planning (ACP) and POLST. With the support of 

CRH, HCND held educational POLST webinars 

throughout 2020 and 2021, which focus on 

increasing awareness and discuss key elements to 

implement the POLST process. The POLST webinars 

are available to multiple disciples, currently being 

offered, and are approved for 1.5 contact hours 

by the North Dakota Board of Nursing, North 

Dakota Board of Social Work Examiners, North 

Dakota Department of Health – EMS Division, and 

the Board of Chaplaincy Certification, Inc. 

In December 2021, HCND received a $10,000 

grant from the North Dakota Comprehensive 

Cancer Control Program to create, educate, 

and certify individuals who were interested in 

becoming ACP Facilitators. The ACP Facilitator 

training course utilized resources from The 

Conversation Project and the Serious Illness 

Conversation Guide. In total, there were twentyseven 

individuals who completed the training, are 

newly designated ACP facilitators, and received 

four continuing education (CEs) credits through 

the North Dakota Board of Nursing. 

To promote HCND as well as the process of 

ACP and POLST, HCND began sending bimonthly 

newsletters to update communities, local health 

care organizations, and interested individuals 

with recent activities, upcoming educational 

offerings, and progress within HCND. As of March 

2022, Honoring Choices® North Dakota became 

a 501(c)3 public charitable organization. To 

date, the organization is all volunteer, and HCND 

continues to pursue funding for hiring staff and 

program development. Currently, HCND’s Board 

of Directors is comprised of individuals across 

the state of North Dakota, who represent various 

organizations and professions, with a focus to 

promote advance care planning and POLST.


Throughout the next year, HCND has aspiring plans to promote ACP 

and POLST through community engagement (i.e., bimonthly newsletters, 

Facebook), professional education (i.e., POLST webinars), and expanding 

partnerships and affiliations. Advance care planning, or lack thereof, 

has recently been identified as a public health issue due to the aging 

population and the significant implications that ACP possesses, including 

enhanced, individualized care at the end-of-life, reduction in patient 

and family emotional stress as well as minimization of associated costs, 

which may be incurred by unwanted medical treatments. There are many 

components of ACP and POLST, but it all begins with a conversation. 

Call to Action: 

1. Please partner with us, join our email list, and stay abreast of upcoming 

activities, educational offerings, and opportunities to promote 

advance care planning and POLST within your local community and 

organization. 

2. Please do your part in promoting advance care planning and 

engaging in shared decision-making conversations, particularly with 

individuals who have a serious illness. 

3. Please reach out if you, your colleagues, or your local health care 

organization are interested in learning more about how ACP and 

POLST and how Honoring Choices® North Dakota can assist with 

individual and community outreach interventions. 

The name “Honoring Choices North Dakota” is used under license from East 

Metro Medical Society Foundation. 

https://www.honoringchoicesnd.org/ 

Nurse License Protection Case Study: 

Administering medication without an order 

Nurses and License Protection Case Study with 

Risk Management Strategies, Presented by NSO 

A State Board of Nursing (SBON) complaint 

may be filed against a nurse by a patient, 

colleague, employer, and/or other regulatory 

agency, such as the Department of Health. 

Complaints are subsequently investigated 

by the SBON in order to ensure that licensed 

nurses are practicing safely, professionally, 

and ethically. SBON investigations can lead to 

outcomes ranging from no action against the 

nurse to revocation of the nurse’s license to 

practice. This case study involves a registered 

nurse (RN) who was working as the clinical 

director of a small, rural emergency care 

center. 

Summary 

The insured RN was employed as the clinical 

director of a small, rural emergency care 

center when they responded to a Code Blue, 

arriving just as the patient was being intubated. 

The patient was fighting the intubation, so a 

physician gave a verbal order for propofol. 

The RN asked the pharmacy technician to 

withdraw a 100-cc bottle of propofol from the 

medication dispensing machine and asked 

another nurse to administer the medication to 

the patient. Shortly after the other nurse began 

administering the propofol, the patient’s blood 

pressure dropped, so the nurse was ordered to 

stop the propofol infusion. 

The patient continued to decompensate and 

suffered respiratory collapse/arrest. Following 

some delay, the patient was eventually 

intubated, then emergently transferred to a 

higher acuity hospital for further treatment. 

The patient ultimately suffered anoxic 

encephalopathy while he was in respiratory 

arrest. 

A recorder was present documenting 

the Code, and, afterwards, another nurse 

transcribed the recorder’s notes into the 

patient’s healthcare information record. The 

recorder noted that it was the insured RN who 

advised the pharmacy technician to remove 

propofol from the medication dispensing 

machine and instructed a nurse to administer 

the medication. However, the recorder failed to 

note that the physician gave a verbal order for 

the propofol. The insured RN failed to review the 

notes that the recorder and nurse entered into 

the patient’s healthcare information record and 

failed to note this error. The physician who was 

present during the Code also failed to catch this 

error in the record. 

Approximately six months later, the patient’s 

family filed a lawsuit against the emergency 

care center. During a review of the Code record 

in response to the lawsuit, it was noted that, 

during the Code, the RN instructed another 

nurse to administer propofol. However, there 

wasn’t any indication in the record that a 

physician had ordered the medication. The 

emergency care center dismissed the RN from 

employment and reported the incident to the 

SBON. The SBON opened its own investigation 

into the RN’s conduct. 

Resolution 

While the insured RN denied ordering another 

nurse to administer propofol without a verbal 

order from the physician, the RN could not deny 

failing to ensure that the propofol administration 

was documented in the patient's healthcare 

information record. 

The RN entered into a stipulation agreement 

with the SBON, under which: 

• the RN’s multi-state licensure privileges 

were revoked; 

• the RN was required to complete 

coursework on nursing jurisprudence 

and ethics, medication administration, 

documentation, and professional 

accountability; and 

• the RN was required to work under direct 

supervision for one year and submit 

quarterly nursing performance evaluations 

to the SBON. 

The total incurred expenses to defend the 

insured RN in this case exceeded $16,600. 

Risk Control Recommendations 

• Know the parameters of your state’s 

nursing scope of practice act, and your 

facility’s policies and procedures, related 

to medication administration. 

• Only accept verbal drug orders from 

practitioners during emergencies or 

sterile procedures. Before carrying out 

a verbal order, repeat it back to the 

prescriber. During a Code Blue, be sure to 

communicate all procedures, medications, 

treatments to the recorder. 

• Review Code Blue records for 

completeness and process of care 

after each Code. Report any concerns 

and provide feedback through proper 

channels to ensure that any errors in 

the record or areas of improvement are 

identified and addressed. 

• Document simultaneously with medication 

administration, whenever possible, in order 

to prevent critical gaps or oversights. 

Disclaimers 

These are illustrations of actual claims that were 

managed by the CNA insurance companies. 

However, every claim arises out of its own unique 

set of facts which must be considered within the 

context of applicable state and federal laws and 

regulations, as well as the specific terms, conditions 

and exclusions of each insurance policy, their forms, 

and optional coverages. The information contained 

herein is not intended to establish any standard 

of care, serve as professional advice or address 

the circumstances of any specific entity. These 

statements do not constitute a risk management 

directive from CNA. No organization or individual 

should act upon this information without appropriate 

professional advice, including advice of legal 

counsel, given after a thorough examination of 

the individual situation, encompassing a review of 

relevant facts, laws and regulations. CNA assumes 

no responsibility for the consequences of the use or 

nonuse of this information. 

This publication is intended to inform Affinity 

Insurance Services, Inc., customers of potential 

liability in their practice. This information is provided 

for general informational purposes only and is not 

intended to provide individualized guidance. All 

descriptions, summaries or highlights of coverage 

are for general informational purposes only and 

do not amend, alter or modify the actual terms 

or conditions of any insurance policy. Coverage 

is governed only by the terms and conditions of 

the relevant policy. Any references to non-Aon, 

AIS, NSO, NSO websites are provided solely for 

convenience, and Aon, AIS, NSO and NSO disclaims 

any responsibility with respect to such websites. This 

information is not intended to offer legal advice or 

to establish appropriate or acceptable standards of 

professional conduct. Readers should consult with a 

lawyer if they have specific concerns. Neither Affinity 

Insurance Services, Inc., NSO, nor CNA assumes any 

liability for how this information is applied in practice 

or for the accuracy of this information. 

Nurses Service Organization is a registered trade 

name of Affinity Insurance Services, Inc., a licensed 

producer in all states (TX 13695); (AR 100106022); 

in CA, MN, AIS Affinity Insurance Agency, Inc. (CA 

0795465); in OK, AIS Affinity Insurance Services, Inc.; 

in CA, Aon Affinity Insurance Services, Inc., (CA 

0G94493), Aon Direct Insurance Administrators and 

Berkely Insurance Agency and in NY, AIS Affinity 

Insurance Agency.


Timed Repositioning Effect on Pressure Injury Incidence 

Appraised By: 

Kailey Fiske SN, Kylee Grabow SN, Courtney 

Hawkinson SN, Alexis Helm SN, Hailey Fried SN, 

Sarah Selle SN 

Allison Sadowsky MSN RN Assistant Professor of 

Practice (Faculty) 

(NDSU School of Nursing at Sanford Health) 


For adult patients with decreased mobility, 

does the use of timed repositioning reduce the risk 

for pressure injuries? 


Chew, H.S., Thiara, E., Lopez, V., & Shorey, S. (2018). 

Turning frequency in adult bedridden patients 

to prevent hospital-acquired pressure ulcer: A 

scoping review. International Wound Journal, 15(2), 

225–236. https://doi.org/10.1111/iwj.12855 

Cyriacks, B. (2019). Reducing HAPI by Cultivating Team 

Ownership of Prevention with Budget-Neutral Turn 

Teams. MEDSURG Nursing, 28(1), 48–52. 

Darvall, J. N., Mesfin, L., & Gorelik, A. (2018). Increasing 

frequency of critically ill patient turns is associated 

with a reduction in pressure injuries. Critical Care 

and Resuscitation, 20(3), 217-222. 

De Meyer, D., Van Hecke, A., Verhaeghe, S., & 

Beeckman, D. (2019). PROTECT – Trial: A cluster RCT 

to study the effectiveness of a repositioning aid 

and tailored repositioning to increase repositioning 

compliance. Journal Of Advanced Nursing, 75(5), 

1085-1098. doi: 10.1111/jan.13932 

Harmon, L. C., Grobbel, C., & Palleschi, M. (2016). 

Reducing Pressure Injury Incidence Using a 

Turn Team Assignment: Analysis of a Quality 

Improvement Project. Journal of wound, ostomy, 

and continence nursing : official publication 

of The Wound, Ostomy and Continence Nurses 

Society, 43(5), 477–482. https://doi-org.ezproxy.lib. 

ndsu.nodak.edu/10.1097/WON.0000000000000258 

Kahn, M., & Jonusas, E. (2019). Turn Teams: How Do You 

Prevent Pressure Injuries? MedSurg Nursing, 257– 

261. 


Six articles were reviewed as evidenced in 

this report. A systematic review, three quasiexperimental, 

a descriptive correlational study, 

and a randomized control trial. Pressure ulcers are 

a result of decreased mobility due to increased 

pressure on body prominences and decreased 

blood flow to the tissue. This is important because 

pressure injuries are associated with increased 

mortality rate and cost of treatment (Kahn & 

Jonusas, 2019). This report will assess the effect of 

timed repositioning on the incidence of pressure 

injuries. 

Chew, Thiara, Lopez and Shorey (2018) 

conducted a systematic review which included 

five randomized control studies, one prospective 

cohort study and one literature review. These 

studies took place in various hospital and longterm 

care facilities and included immobile, 

elderly, hospitalized or nursing home residents 

with a focus on pressure ulcer prevention 

interventions. In total, the sample size ranged 

from 63-335 patients. The interventions included: 

pressure ulcer incidences with foam mattresses, 

incidence of pressure ulcer development using 

various repositioning schedules, stages of pressure 

ulcers related to differing turning schedules 

and lastly degree of blanchable erythema. 

The findings did not statistically differ from one 

intervention to another. The evidence was not 

statistically significant, however, repositioning 

every two hours had a pressure ulcer rate of 

10.3% while repositioning every four hours had a 

13.4%. This systematic review brings forward the 

idea of implementing facility-wide pressure redistributing 

air-mattresses in hospitals and nursing 

homes to prevent pressure ulcer development 

while reducing manpower needed to reposition 

patients. 

Cyriacks (2019) conducted an evidencebased 

quality improvement project with a 

quasi-experimental design. The purpose of 

this study was to empower nurses with direct 

responsibility for HAPI prevention, ensure patients 

were repositioned every two hours, and remove 

barriers to allow staff to reach this expectation. 

The study took place in a 36-bed medical 

surgical pulmonary unit in an academic medical 

center. The population included 36 adults that 

were at higher acuity with multiple risk factors 

for occurrence of pressure injury. The study 

implemented turn teams who turned the patients 

every two hours and found that the reduction of 

hospital acquired pressure injury decreased by 

75%, no new pressure injuries occurred on the 

coccyx, sacrum, heel, or ischium for any patients, 

and staff benefitted in that they were engaged, 

teamwork was enhanced, and time saving was 

notable. 

Daravall, Mesfin, and Gorelik (2018) conducted 

a quasi-experimental prospective intervention 

evaluation study. The study was conducted at 

Royal Melbourne Hospital ICU and included 

adult critically ill patients that were admitted to 

the ICU; the sample included a pre-intervention 

group, with 1094 patients, and a post-intervention 

group, with 1165 patients. The total sample size 

was 2259 patients. The studied interventions were 

a five-hourly turn schedule, the pre-intervention 

group, and a three-hourly turn schedule, the 

post-intervention group, and the interventions 

effect on pressure injury and decubitus injury 

incidence. The results concluded that there was 

a 49% reduction in the risk of pressure injuries and 

the rate of decubitus pressure injury fell from 62.5% 

to 25.0% when the turning schedule was changed 

from five-hourly to three-hourly. 

De Meyer, Van Hecke, Verhaeghe, & 

Beeckman (2019) conducted a three-arm, 

randomized, controlled pragmatic trial. This 

study was conducted to see the outcomes of 

repositioning with the Turn and Position System 

on patients and what that does for nurse 

compliance, the incidence of pressure ulcers, 

patient comfort, and budget. This study included 

226 patients, all patients who are 18 years and 

older that are at risk for pressure ulcers. The 

intervention included repositioning that varied 

every one to four hours using devices such as 

the Prevalon Turn and Position System. The results 

concluded that the nurses’ compliance to 

repositioning was increased significantly. Few 

pressure ulcers and incontinence-associated 

dermatitis incidents occurred, 2.22% of patients 

compared to the mean prevalence of 20.9% 

before the trial. Patients reported their comfort as 

a 6.1/10. The cost of materials to prevent pressure 

ulcers increased to $15.40 per day, but the cost 

of treating pressure ulcers ($2.52-$83.43 per day) 

went down through prevention. 

Harmon, Grobbel, and Palleschi (2016) 

conducted a descriptive correlational study. The 

purpose of this study was to analyze outcomes 

of a quality improvement project that evaluated 

a Turn Team intervention for prevention of facilityacquired 

pressure injuries. The study took place in 

a Midwest teaching hospital with twelve surgical 

intensive care units. The findings were that unit 

acquired pressure injury occurrence declined 

from 24.9% to 16.8% following implementation 

of the intervention; evaluation of verbal cueing 

intervention to increase compliance with regular 

patient repositioning and achieved a 77.8% 

compliance rate; and half the participants 

indicated that the turn team provided adequate 

two-hour reminders needed for turning. 

Kahn & Jonusas (2019) conducted a quasiexperimental 

quality improvement project that 

looked at the effectiveness of "turn teams" in a 

51-bed medical-surgical unit in the southeastern 

United States. The population consisted of all 

adult patients at risk for developing pressure 

injuries which was evidenced by a Braden Scale 

score of 18 or below and the inability to turn 

independently in bed. Turn Teams were used to 

turn these at-risk patients every two hours. Unitacquired 

pressure injury data was assessed 12 

months before implementation of Turn Teams 

and 12 months after implementation. Weekly 

skin assessment audits were also performed for 

a 12-month period after implementation. The 

results included that the number of unit-acquired 

pressure injuries over a 12-month period was 

reduced by 54 percent. 

Conclusion: 

Five out of the six studies found a statistically 

significant decrease in the incidence of pressure 

injuries with the implementation of regular 

repositioning schedule. However, the study by 

Chew, Thiara, Lopez, and Shorey showed that 

having widespread pressure redistributing airmattresses 

in hospitals and nursing homes can 

be used to prevent pressure ulcer development, 

while reducing the need to reposition patients. 

Implications of Nursing Practice: 

Preventing pressure injuries is important 

because they are associated with increased 

mortality and cost of care. The evidence showed 

that the implementation of turn teams utilizing a 

regular timed repositioning schedule is beneficial 

to reduce the incidence of pressure injuries 

in patients with decreased mobility. Pressure 

relieving hospital beds can also be implemented 

to reduce the incidence of pressure injuries. 

Healthcare facilities need to implement a variety 

of pressure prevention interventions to prevent 

healthcare related pressure injuries. 

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Play Therapy in Autistic Children 

Appraised By: 

McKenna Johnson SN,Jessica Hansen SN, Ryley Gunderson SN, Kimberly 

San Juan SN, Rachel Leblanc SN 


(NDSU School of Nursing at Sanford) 


In autistic children, what is the effect of play therapy on behavior? 

List of Articles: 

Baranek, G.T., Boyd, B.A., Crais, E.R., Dykstra, J.R., Watson, L.R. (2012). The impact 

of the Advancing Social-communication And Play (ASAP) intervention on 

preschoolers with autism spectrum disorder. Sage Pub, 16 (1), 27-44. 

Hillman, H. (2018). Child-centered play therapy as an intervention for children with 

autism: A literature review. International Journal of Play Therapy, 27(4), 198-204. 

https://doi.org/10.1037/pla0000083 

Schottelkorb, A. A., Swan, K. L., & Ogawa, Y. (2020). Intensive Child-Centered 

Play Therapy for Children on the Autism Spectrum: A Pilot Study. Journal of 

Counseling & Development, 98(1), 63–73. https://doi-org.ezproxy.lib.ndsu.nodak. 

edu/10.1002/jcad.12300 

Tilmont Pittala, E., Saint-Georges-Chaumet, Y., Favrot, C., Tanet, A., Cohen, D., 

& Saint-Georges, C. (2018). Clinical outcomes of interactive, intensive and 

individual (3i) play therapy for children with ASD: a two-year follow-up study. 

BMC pediatrics, 18(1), 165. https://doi-org 

Tseng, K. C., Tseng, S. H., & Cheng, H. Y. (2016). Design, development, and clinical 

validation of therapeutic toys for autistic children. Journal of physical therapy 

science, 28(7), 1972–1980. https://doi.org/10.1589/jpts.28.1972 


Autism spectrum disorder (ASD) is the fastest growing 

neurodevelopmental disorder in the U.S. The prevalence of ASD calls for 

study on symptoms of autism, etiology, and treatments. Symptoms of ASD 

include communication and language deficits, social impairment, and 

restricted and repetitive behaviors. ADHS, oppositional defiant disorder 

(ODD), obsessive-compulsive disorder (OCD), and generalized anxiety 

disorder (GAD) are common in children on the autism spectrum. These 

children are at risk for emotional and behavioral problems. Children 

diagnosed with ASD may have decreased quality of life, adaptive 

functioning, and educational achievement. As stated above, further study 

is needed on treatments/management for autism (Schottelkorb, 2020). Five 

articles including a single case study, a systemic review of four case studies, 

a randomized control trial, quasi-experimental and quantitative exploratory 

studies were reviewed as evidence in this report. 

Baranek (2012) conducted a single case study to examine the effect of 

the Advancing Social-communication And Play (ASAP) intervention on 

preschoolers with autism in public school classrooms. The study addressed 

if the implementation improved social-communication and play skills in 

these children and if the implementation of ASAP in both a group setting 

and one-to-one setting resulted in further improvements. The design utilized 

three phases for each participant. In Phase A, pre-data was collected as 

children received their typical instruction in the classroom. In Phase B, 

teachers and/or teaching assistants were trained and began implementing 

the ASAP interventions during already occurring group activities in the 

classroom. In Phase C, the speech-language pathologist was trained 

and began to implement ASAP, making social-communication and play 

intervention a part of both one-to-one and group settings. The study results 

showed at least some improvement in social communication and play skills. 

All participants showed either increases in frequency or more stability in 

targeted behaviors such as initiating social interactions. 

Hillman (2018) conducted a systematic review of four studies. The 

systematic review had two case studies and two single case designs. They 

threw out one of the studies so I will only talk about three of them. The 

studies included nine children ages 4-11 that had autism and were receiving 

play therapy, seven boys and two girls in all the studies. The intervention they 

used was child centered play therapy, which is when the children, instead 

of the therapist, control the pace, direction, and content of the therapeutic 

journey. The findings overall showed an increase in social and emotional 

behaviors, and a reduction in ritualistic behaviors from the use of playtherapy. 

Schottelkorb, A. A., Swan, K. L., & Ogawa, Y. (2020) conducted a 

randomized control trial that aimed to test the efficacy of Child-Centered 

Play Therapy (CCPT) using validated rating scales to measure core autism 

symptoms, attention problems, aggression problems, and externalizing 

problems. Participants were recruited from five elementary schools in the 

Northwestern United States. Play therapy rooms were established at each 

participant’s school. The participants consisted of 23 children aged 4-10 (19 

male, four female) who displayed moderate to severe symptoms on the SRS- 

2 scale. The items of the SRS-2 were used on a likert scale to measure the 

symptoms of social impairment. Additionally, the items of the Child Behavior 

Checklist were used on a likert scale to examine emotional and behavioral 

problems as well as adaptive functioning. The children in the CCPT group 

showed a decrease of eight points on the SRS-2, while the control group’s 

score increased by four. In addition, the children in the CCPT group showed 

an eight-point decrease in attention problems, a six-point decrease in 

aggressive problems, and a five-point decrease in externalizing problems, 

while the children in the control group showed a two-point increase in 

attention and externalizing problems (aggressive behavior remained the 

same). 

Tilmont Pittala, Saint-Georges-Chaumet, Favrot, Tanet, Cohen, and 

Saint-Georges (2018) conducted a quantitative prospective exploratory 

study. The study aimed to “assess the outcome of 20 Autism spectrum 

disorder (ASD) subjects who followed the 3i method for 24 months.” 

Using appropriate scales, they estimated the course of developmental 

and behavioral skills and autism severity. The 3i method was used as the 

intervention in this study which included the study occurring in a specific 

room for one on one interaction and designed to reduce unwanted 

sensorial stimuli, focuses on sensory specificities of the child, provides 

participants with developmental roadmap that improves understanding 

of the present abilities and difficulties on their developmental path and 

it distinguished three developmental age stages in their corresponding 

agenda (0-18 months, 18-36 months, and older than 36 months). The study 

found an increase by 83% in the socialization and an increase by 34% in 

communication. There was an increase in imitation scores by 53%. CARS 

(Chilhood Autism Rating Score) scores dropped significantly since the 

beginning of the study where 94% of the patients were considered severely 

autistic and 6% were moderately autistic and at the end only 21% remained 

severely autistic and 53% progressed to moderate autistic and 26% could be 

considered to no longer have autism. 

Tseng (2016) conducted a quasi-experimental study aimed at helping 

autistic children to “experience healthy growth and development and 

improve their language ability, behavior, and social interaction.” The 

study had four stages, all except one took place in a playroom at Taiwan 

university hospital. This playroom used direct observation with hidden 

cameras and microphones and measured the interaction using the Penn 

Interactive Peer Play Scale (PIPPS). The first stage included two autistic boys 

and results showed mainly passive behavior; the second stage included 

13 boys and showed the interaction increased significantly between 

neurotypical child; the 3rd stage included just the psychiatrists and 

they discussed the effectiveness of the toys from their point of view and 

concluded that the play needed fixed rules and progressive variations; 

the last stage only discussed types of toys and beneficial features. Overall 

test results showed after the introduction of the cooperative play toy into 

the autism play therapy, the interaction between the children increased 

significantly; 2.1419 whereas it was 2.8571. 

Conclusions: 

The studies conducted in the articles included: a systematic review, a 

single case study, a randomized control trial, a quasi-experimental study 

and a quantitative prospective exploratory study with 3-23 participants 

in each study. Each study implemented some sort of play therapy such as 

the use of blocks, sensory play or pretend play. The results of all five articles 

indicated an improvement in social interaction with the implementation 

of play therapy in children with ASD. Implementing play therapy improves 

social and emotional behaviors and reduces negative behaviors. 


There is evidence to suggest implementing play therapy into interactions 

with children who have ASD improves social interaction and decreases 

negative behavior (ex. aggression). The evidence supports improvement 

in both group settings and one-on-one settings. The effects of this 

implementation will be beneficial to children with ASD and to healthcare 

team members when working with this specific pediatric population in all 

healthcare settings. Collaborating with Child Life Specialists to implement 

the delivery of developmentally appropriate play activities within the 

healthcare settings, whether it be in the patient’s room or in the play room, 

will promote positive behavior and social communication. The goal of 

implementing play therapy is to promote healthy growth, development, 

and improve their language ability, behavior, and social interaction. Using 

cooperative play to create a bridge between staff and the child with 

autism to overall improve the delivery of care.


Answering Your Questions on Vaccines 

MMR Vaccination: Protecting the Public 

and Nurses Against Measles 

Jessica Allen, Immunization Health Educator, 

North Dakota Department of Health 

Did you know, two doses of the MMR 

(measles, mumps, and rubella) vaccine is 

97% effective at preventing measles? MMR 

vaccination plays an important part in keeping 

you and your community safe from measles. 

Here’s what you need to know about measles 

and the MMR vaccine! 

In April of 2022, the World Health 

Organization (WHO) and the United Nations 

International Children’s Emergency Fund 

(UNICEF) announced that in the first two months 

of 2022, global cases of measles had increased 

by 79% when compared to that same time 

period last year. These agencies and public 

health officials across the planet are concerned 

that this could trigger larger measles outbreaks 

that may impact millions of children in 2022. 

Fortunately, measles is a vaccine-preventable 

illness, with two doses of the MMR (measles, 

mumps, and rubella) vaccine being 97% 

effective at preventing measles. However, 

vaccination rates around the world have 

substantially decreased during the COVID-19 

pandemic. In fact, it is estimated that 23 million 

children missed out on routine immunizations 

through routine wellness visits during 2020, 

the highest number since 2009. Disruptions in 

routine wellness visits and vaccinations among 

pediatric populations has ultimately left us all 

increasingly vulnerable to a measles outbreak. 

What are North Dakota’s current MMR 

vaccination coverage rates? 

In North Dakota, MMR vaccination rates 

amongst North Dakota infants aged 19-35 

months decreased more than 6%, from 84.7% 

in December 2019 to 78.3% in December 

2021. Additionally, kindergarten-entry MMR 

vaccination rates decreased from 94.75% 

during the 2019-2020 school year to 92.36% 

during the 2021-2022 school year. A reduction 

in vaccination coverage can lead to pockets 

of un- or under-immunized children across 

the state, which lowers our state and local 

community’s herd immunity against the 

measles virus. Herd immunity, also known as 

community immunity, refers to the term in 

which a certain threshold of the population 

is immune to an infectious disease. As a result, 

the infectious disease is no longer able to easily 

spread and infect those who are not immune. 

Herd immunity against measles is crucial for 

keeping all of us, especially those who are 

immunocompromised and infants too young 

to be vaccinated, safe from inadvertently 

contracting measles from the unvaccinated. 

Nationally for the 2020-2021 school year, 

vaccination coverage rates for all required 

vaccines was approximately 1% lower than 

that of the previous year. Only 93.9% of children 

entering kindergarten in the United States 

were vaccinated with two doses of the MMR 

vaccine. While a 93% vaccination coverage 

rate for measles may not sound concerning to 

most people, it is quite concerning to public 

health officials. According to Yale Medicine, 

“the percentage of the population that needs 

to be immune to attain herd immunity varies 

by disease and how contagious that disease 

is. Measles, for example, spreads so easily that 

an estimated 95% of a population needs to be 

vaccinated to achieve herd immunity. In turn, 

the remaining 5% have protection because, at 

95% coverage, measles will no longer spread.” 

Once an individual is vaccinated against 

measles, they are considered immune for life. 

Kindergarteners are our next generation of 

North Dakotans, which is why it is important 

that all those who are eligible be vaccinated 

against measles in order to continue to keep 

our communities safe into the future. 

What is measles, who is at risk, and what are the 

side effects? 

Measles is caused by a single stranded RNA 

virus with only 1 serotype (for reference there 

are over 90 serotypes of the pneumococcal 

bacteria). This virus falls under the family of 

other Paramyxoviridae viruses and the only 

known host of this virus is humans. Measles is 

transmitted from person to person through 

direct contact of infected droplets or through 

airborne transmission when an infected person 

sneezes, coughs, or breathes. Measles is a highly 

contagious virus. In fact, 90% of unprotected 

(un- or under vaccinated) people who come 

into contact with an infected person will 

consequently become infected with measles as 

well. 

Measles is typically characterized by 

a maculopapular rash (a type of rash 

characterized by a flat, red area on the skin 

that is covered with small confluent bumps), 

usually developing within 14 days following 

exposure and spreading from the patient’s 

head down through their trunk and lower 

extremities. Please note that sometimes 

immunocompromised patients will not develop 

a rash. Other commonly reported side effects 

include ear infections and diarrhea. 

Even children who were previously healthy 

can become severely ill from an infection due 

to measles and may require hospitalization. 

Here are some quick facts on the seriousness 

of this disease and the complications you and 

your patients could expect if they were to 

become ill: 

• One out of five unvaccinated people in the 

United States who get measles will require 

hospitalization. 

• An estimated one out of every 20 children 

infected with measles will develop 

pneumonia, the most common cause of 

death for children with measles. 

• Approximately one out of every 1,000 

children infected with measles will 

develop encephalitis, that could lead to 

convulsions and leave a child permanently 

disabled or deaf. 

• Nearly one to three out of every 1,000 

children who are infected with measles will 

die. 

Measles can be a serious illness among 

any age group. However, there are several 

populations that are at a particularly higher 

risk for severe complications. Those populations 

include children younger than the age of 

five years, adults over the age of 20 years, 

individuals who are pregnant, and those who 

are immunocompromised. 

Are there any long-term complications 

associated with measles? 

Yes, there are potential long-term 

complications that can follow a prior infection 

with the measles virus. Subacute sclerosing 

panencephalitis (SSPE) is a very rare, but fatal 

disease of the central nervous system that 

results from a measles viral infection acquired 

earlier in life. While SSPE is rarely reported in the 

United States, patients who survived measles 

during early childhood, specifically before 

the age of two years old, are at an increased 

risk of developing this condition generally 

seven to ten years later. Patients who develop 

SSPE may experience a slow progression of 

symptoms including mild mental deterioration, 

memory loss, changes in behavior and mobility 

impairment. Over a period of months to 

potentially years, many patients proceed to 

generalized convulsions, dementia, coma, and 

death. 

Vaccine hesitant parents of your pediatric 

patients who are due for their MMR vaccination 

may not know about SSPE. They also may not 

know about SSPE’s potentially life-threatening 

complications later in life if their unvaccinated 

child does end up contracting measles. You 

can help your community maintain high 

levels of herd immunity by encouraging and 

educating your patients and their parents on 

the benefits of MMR vaccination as well as the 

risks associated with measles infection. Because 

preventing measles also means protecting 

against measles induced SSPE later in life. For 

more information on SSPE, check out this video 

or visit the NIH’s website. 

If measles is an eliminated disease in the United 

States, how come we continue to see cases? 

In 2000 the United States declared measles 

an eliminated disease. Meaning the country 

had become free of infections. However, there 

were nearly 1,300 cases of measles reported 

in the year 2019. The measles outbreaks that 

occurred during 2019 in the U.S. were all 

linked to infected travelers that had entered 

communities with high-risk populations of un- or 

under vaccinated people. These communities 

did not mount the herd immunity needed to 

prevent an outbreak of measles. So, while 

measles is an eliminated disease, ultimately the 

next measles outbreak may only be just one 

plane ride away. 

With many North Dakotans considering 

returning back to their pre-pandemic 

international travel plans, we can expect 

that some individuals may begin traveling 

to areas of the world, including African and 

Eastern Mediterranean regions, where measles 

outbreaks continue to persist. The risk of 

bringing measles back into the state of North 

Dakota through international travel puts several 

of our communities who have higher levels of 

un- or under vaccinated residents at greater risk 

of potential measles outbreaks. 

What is the recommended vaccination 

schedule for the MMR vaccine? 

The CDC’s Advisory Committee on 

Immunization Practices (ACIP) recommends 

that those without presumptive evidence of 

immunity against measles be vaccinated with 

either the MMR or the MMRV (measles, mumps, 

rubella, and varicella) vaccine. 

CDC recommends two doses of a measlescontaining 

vaccine routinely for children, 

starting with the first dose at age 12 through 

15 months and the second dose at age four 

through six years. Adults should also be up to 

date on MMR vaccinations with either one or 

two doses (depending on risk factors) unless 

they have other presumptive evidence of 

immunity to measles. Providers generally do 

not need to actively screen adult patients for 

measles immunity in non-outbreak areas of the 

United States. 

There are situations in which special 

populations may be recommended to be 

vaccinated against measles. Additionally, 

individuals who may have missed their routine 

immunizations are encouraged to catch up 

on their vaccines. For more information on 

vaccinating these populations, please visit the 

CDC’s immunization schedules. 

Do nurses need to be revaccinated against 

measles? 

Once an individual is vaccinated against 

measles or has recovered from a prior 

infection of measles, they are considered to 

be immune for life. Oftentimes, health care 

workers including nurses are at an increased 

risk for exposure to serious, and sometimes 

deadly, diseases. If you work directly with 

patients or handle material that could spread 

measles infection, you should get appropriate 

vaccinations to reduce the chance that you will 

get or spread this vaccine-preventable disease.


If you have not yet received your MMR vaccines yet, now is a great 

time to do so! If you fall into one of the following populations you may 

want to consider MMR or MMRV vaccination: 

• If you were born in 1957 or later and have not had the MMR vaccine, 

or if you don’t have a blood test that shows you are immune to 

measles or mumps (i.e., no serologic evidence of immunity or prior 

vaccination) 

• Health care workers born before 1957 who lack laboratory evidence 

of immunity or laboratory confirmation of disease. 

Nurses without presumptive evidence of immunity should get two 

doses of MMR vaccine, separated by at least 28 days. The MMR vaccine 

is very effective at protecting people against measles, mumps, and 

rubella, and preventing the complications caused by these diseases. 

• MMR Vaccine (Measles, Mumps, and Rubella Vaccine) | Oxford 

Vaccine Group 

North Dakota Data 

• Coverage Rates | Department of Health (nd.gov) 

Related Articles 

• UNICEF and WHO warn of perfect storm of conditions for measles 

outbreaks, affecting children 

• Herd Immunity: Will We Ever Get There? Yale Medicine 

• Vaccination Coverage with Selected Vaccines and Exemption 

Rates Among Children in Kindergarten — United States, 2020–21 

School Year | CDC MMWR 

• Subacute Sclerosing Panencephalitis | NIH 

How can I address vaccine hesitancy among my patients? 

We can all agree that it is important for health care providers, 

including nurses, to have conversations about the benefits of 

immunizations with their patients. Today however, having those 

conversations regarding the importance of routine immunizations can 

be uncomfortable at times. Especially if you do not feel equipped with 

the communication skills needed to diffuse vaccine misinformation your 

patients may have found online. Below are strategies you can use to 

help you feel more confident recommending vaccines to your vaccine 

hesitant patients. 

• Know your patient’s vaccination status before their appointment. 

• Respectfully address your patient’s vaccine concerns by practicing 

empathy and active listening without being judgmental. 

• Use presumptive language with your patients. 

- Example: “Your child needs their MMR, varicella, and 

pneumococcal vaccines today.” versus “What do you want to do 

about your child’s shots that they are due for today?” 

• Do your part in building patient-provider trust at all medical 

encounters, including non-vaccine related appointments. 

Your recommendation matters. YOU play an essential role in 

promoting and building trust in vaccinations. Nurses are consistently 

found to be one of the most trusted professions in our country. It is 

important to provide patients with high quality, evidence-based 

information regarding their vaccine-related questions. Before 

considering vaccine information on the internet, check that the 

information comes from a credible source and is updated on a regular 

basis. While the internet is a useful tool for researching health-related 

issues, it should not replace a discussion with a health care professional. 

Clear and consistent messaging across all levels of health care needs 

to be followed in order for patients to feel safe and prepared to 

get themselves and their families immunized. Research has shown 

that vaccine-hesitant individuals became less hesitant after a brief 

recommendation from a health care professional. It is important that 

all nurses in North Dakota offer a strong recommendation to vaccinate 

against measles to all vaccine eligible patients ages 12 months and 

older. 

For more information, please consider checking out the following 

resources: 

General Information 

• Measles, Mumps, and Rubella (MMR) Vaccination | CDC 

• Vaccination Is the Best Protection Against Measles | FDA 

• Measles (Rubeola) For Healthcare Providers | CDC 

• Global Measles Outbreaks (cdc.gov) 

Addressing Vaccine Hesitancy 

• How to Have Productive Vaccine Conversations: Moving the Needle 

Toward Vaccine Acceptance - NDSU CIRE YouTube 

Measles Complications 

NDC3 is improving health 

and wellness in communities 

across North Dakota 

Through a network of local leaders, community organizations and health systems, NDC3 

delivers programs to help individuals manage chronic health conditions, prevent falls, 

and foster well-being. If you are coping with high blood pressure, heart disease, COPD, 

arthritis, diabetes or other chronic conditions, NDC3 can support your efforts to live life 

as fully and independently as possible. 

Better Choices, Better Health: Diabetes 

(online) 

Aug. 16, 2022 - Sept. 20, 2022 

3:00 PM - 5:30 PM 

See All Dates 

Cost: $0 

Contact Name: Amanda H 

Contact Email: bcbh@sanfordhealth.org 

Contact Phone: 701-417-4905 

People with type 2 diabetes attend the class in 

groups of 12-16. Participants will make weekly action 

plans, share experiences, and help each other solve 

problems they encounter in creating and carrying out 

their self-management program. Physicians, diabetes 

educators, dietitians, and other health professionals 

both at Stanford and in the community, have 

reviewed all materials in the class. 

This "virtual" class will be held via Zoom. Don't know 

how to use Zoom? Don't worry we will help you! All 

participants must have audio and visual technology 

to participate. 

Diabetes Prevention Program 

Aug. 23, 2022 - Aug. 15, 2023 

5:15 PM - 6:15 PM 

See All Dates 

Cass County Annex Building 

1010 2nd Ave. S 

Fargo, ND 58103 

Cost: $0 

Contact Name: Rita Ussatis 

Contact Email: Rita.Ussatis@ndsu.edu 

Contact Phone: 701-241-5700 

National Diabetes Prevention Program (NDPP) is a 

collaborative, community-based, lifestyle change 

program designed for people with pre-diabetes. 

It is based on the Centers for Disease Control and 

Prevention’s curriculum and National Diabetes 

Prevention Recognition standards. 

This class is 24 sessions, The first 12 classes will 

be weekly, followed by 4 biweekly class and then 

monthly for the 1 year duration. 

Melissa Kainz, DNP, MSN, RN, Community Clinical Coordinator, 

Division of Health Promotion 701-328-4568 | mkainz@nd.gov 

NDC3.org


How Nurses Can Counter Health Misinformation 

Georgia Reiner, MS, CPHRM, Risk Analyst, 

Nurses Service Organization (NSO) 

The wealth of health information available online can be beneficial 

for patients, but only if that information is accurate. Although recent 

issues on misinformation have centered on the COVID-19 pandemic, 

misinformation has been a problem in many other areas related to 

wellness and healthcare, such as dieting, exercise, and vitamins and 

supplements. Although misinformation isn’t new, the internet and social 

media have supercharged the ability for it to spread. 

Nurses and nurse practitioners have the power to counteract 

misinformation, but first, they need to understand why people may be 

inclined to believe information that is not grounded in science. 

Why do people believe misinformation? 

Several factors can lead to people accepting misinformation: 

Health literacy. Health literacy refers not only to the ability to read and 

understand health information, but the appraisal and application of 

knowledge. People with lower levels of health literacy may be less able 

to critically assess the quality of online information, leading to flawed 

decision-making. One particular problem is that content is frequently 

written at a level that is too high for most consumers. 

Distrust in institutions. Past experiences with the healthcare system 

can influence a person’s willingness to trust the information provided. 

This includes not only experiences as an individual but also experiences 

of those in groups people affiliate with. Many people of color and those 

with disabilities, for example, have had experiences with healthcare 

providers where they did not feel heard or received substandard care, 

eroding trust. In addition, some people have an inherent distrust of 

government, leading them to turn to alternative sources of information 

that state government provided facts are not correct. 

Emotions. Emotions can play a role in both the spread and 

acceptance of misinformation. For example, false information tends to 

spread faster than true information, possibly because of the emotions it 

elicits. And Chou and colleagues note that during a crisis when emotions 

are high, people feel more secure and in control when they have 

information—even when that information is incorrect. 

Cognitive bias. This refers to the tendency to seek out evidence that 

supports a person’s own point of view while ignoring evidence that does 

not. If the misinformation supports their view, they might accept it even 

when it’s incorrect. 

How to combat misinformation 

Recommending resources, teaching consumers how to evaluate 

resources, and communicating effectively can help reduce the negative 

effects of misinformation. 

Recommendations. In many cases, patients and families feel they 

have a trusting relationship with their healthcare providers. Nurses 

can leverage that trust by recommending credible sources of health 

information. Villarruel and James (https://www.myamericannurse.com/ 

preventing-the-spread-of-misinformation/) note that before making a 

recommendation, nurses should consider the appropriateness of the 

source. For example, a source may be credible, but the vocabulary used 

may be at too high a level for the patient to understand. Before making 

a recommendation, nurses should consider the appropriateness of the 

source for the patient’s health literacy level. Kington and colleagues 

(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8486420/) explain the 

importance of evaluating sources to ensure the information provided is 

science-based, objective, transparent, and accountable. 

Although the tendency is to recommend government sources such as 

the Centers for Disease Control and Prevention and National Institutes 

of Health, as noted earlier, some people do not trust the government. In 

this case, sources such as MedlinePlus, World Health Organization, and 

condition-specific nonprofit organizations (e.g., the American Heart 

Association, American Cancer Society, Alzheimer’s Association) might be 

preferred. 

Education. The sheer scope of the information found online can 

make it difficult for even the most astute consumer to determine what 

is accurate. Nurses can help patients by providing tools they can use 

to evaluate what they read. The website Stronger suggests a fourstep 

process for checking for misinformation (https://stronger.org/ 

resources/how-tospot-misinformation), and MedlinePlus offers additional 

resources for evaluating health information (https://medlineplus.gov/ 

evaluatinghealthinformation.html). UCSF Health (https://www.ucsfhealth. 

org/education/evaluating-health-information) provides a useful short 

overview for patients on how to evaluate the credibility and accuracy of 

health information and red flags to watch for. 

Communication. From the start, the nurse should establish the 

principle of shared decision-making, which encourages open discussion. 

A toolkit from the U.S. Surgeon General on misinformation (https:// 

www.hhs.gov/sites/default/files/health-misinformation-toolkit-english. 

pdf) recommends that nurses take time to understand each person’s 

knowledge, beliefs, and values and to listen with empathy. It’s best to 

take a proactive approach and create an environment that encourages 

patients and families to share their thoughts and concerns (see “A 

proactive approach”). Nurses should remain calm, unemotional, and 

nonjudgmental. 

misinformation instead of the recommended treatment plan, this 

documentation would demonstrate the nurse’s efforts and could help 

avoid legal action. 

A positive connection 

Nurses can serve as a counterbalance to the misinformation that 

is widely available online. Providing useful resources, educating 

consumers, and engaging in open dialogue will promote the ability of 

patients to receive accurate information so they can make informed 

decisions about their care. 

References 

CDC. How to address COVID-19 vaccine misinformation. 2021. https:// 

www.cdc.gov/vaccines/covid-19/health-departments/addressingvaccinemisinformation.html 

Chou W-YS, Gaysynsky A, Vanderpool RC The COVID-19 misinfodemic: Moving 

beyond fact-checking. Health Educ Behav. 2020;1090198120980675:1-5. 

Kington RS, Arnesen S, Chou W-YS, Curry SJ, Lazer D, and Villarruel AM. 

Identifying credible sources of health information in social media: Principles 

and attributes. NAM Perspect. 2021:10.31478/202107a. https://www.ncbi.nlm. 

nih.gov/pmc/articles/PMC8486420/ 

MedlinePlus. Evaluating Health Information. National Library of Medicine. 2022. 

https://medlineplus.gov/evaluatinghealthinformation.html 

Office of the Surgeon General. A Community Toolkit for Addressing Health 

Misinformation. US Department of Health and Human Services. 2021. https:// 

www.hhs.gov/sites/default/files/health-misinformation-toolkit-english.pdf 

Stronger. How to spot misinformation. n.d. https://stronger.org/resources/how-tospot-misinformation 

Schulz PJ, Nakamoto K. The perils of misinformation: When health literacy goes 

awry. Nat Rev Nephrol. 2022. https://www.nature.com/articles/s41581-021- 

00534-z 

Swire-Thompson B, Lazer D. Public health and online misinformation: Challenges 

and recommendations. Annu Rev Public Health. 2020;41:433-451. 

UCSF Health. Evaluating health information. n.d. https://www.ucsfhealth.org/ 

education/evaluating-health-information 

Villarruel AM, James R. Preventing the spread of misinformation. Am Nurs J. 

2022;17(2):22-26. https://www.myamericannurse.com/preventing-thespreadof-misinformation/ 

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. Please note that Internet hyperlinks cited herein are active as of the 

date of publication but may be subject to change or discontinuation. 

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. 

Documentation 

As with any patient education, it’s important to document discussions 

related to misinformation in the patient’s health record. Nurses should 

objectively record what occurred and include any education material 

they provided. Should the patient experience harm because of following


Using an Independent Double Check 

When Administering High Risk Medications 

Appraised by: 

Maddie Guthmiller SN, Kendra Essert SN, Megan Dean SN, Morgan 

Paul SN, Caroline Senn SN 


(NDSU School of Nursing at Sanford Bismarck) 


For patients in acute care settings does the use of double-checking 

medications with a second nurse reduce the risk for inadequate patient 

safety? 

Sources Of Evidence: 

Cochran, G. L., Barrett, R. S., & Horn, S. D. (2016). Comparison of medication 

safety systems in critical access hospitals: Combined analysis of two studies. 

American Journal of Health-System Pharmacy, 73(15), 1167–1173. https://doi. 

org/10.2146/ajhp150760 

Douglass, A. M., Elder, J., Watson, R., Kallay, T., Kirsh, D., Robb, W. G., Kaji, 

A. H., & Coil, C. J. (2018). A randomized controlled trial on the effect of a 

double check on the detection of medication errors. Annals of Emergency 

Medicine, 71(1), 74–82. https://doi.org/10.1016/j.annemergmed.2017.03.022 

Koyama, A. K., Sheridan Maddox, C.-S., Ling Li, Bucknall, T., & Westbrook, 

J. I. (2020). Effectiveness of double checking to reduce medication 

administration errors: a systematic review. BMJ Quality & Safety, 29(7), 595– 

603. https://doi-org.ezproxy.lib.ndsu.nodak.edu/10.1136/bmjqs-2019-009552 

Manias, E., Street, M., Lowe, G., Low, J.K., Gray, K., & Botti, M. (2021). Associations 

of person-related, environment-related, and communication-related factors 

on medication errors in public and private hospitals: a retrospective clinical 

audit. BMC Health Services Research, 21(1025). Retrieved from: https://doi. 

org/10.1186/s12913-021-07033-8 

Westbrook, J. I., Ling Li, Raban, M. Z., Woods, A., Koyama, A. K., Baysari, M. T., 

Day, R. O., McCullagh, C., Prgomet, M., Mumford, V., Dalla-Pozza, L., 

Gazarian, M., Gates, P. J., Lichtner, V., Barclay, P., Gardo, A., Wiggins, M., & 

White, L. (2021). Associations between double-checking and medication 

administration errors: a direct observational study of paediatric inpatients. 

BMJ Quality & Safety, 30(4), 320–330. https://doi-org.ezproxy.lib.ndsu.nodak. 

edu/10.1136/bmjqs-2020-011473 


Five articles were reviewed in relation to this issue of medication errors 

related to the double checking of high-risk medications. In nursing 

practice, nurses administer drugs that can have a debilitating or deadly 

impact to the patient if they are given incorrectly. The nurse’s license is 

at risk everyday if he or she does not follow the five rights of medication 

administration. 

The first study conducted by Douglass et al. (2018) was a prospective, 

randomized, blinded, controlled trail. The study conducted a simulation 

that included 43 pairs of emergency room and intensive care nurses. The 

study looked at how often the double check was utilized by the nurses, 

the effect of the double check, and qualitative factors that affected 

the double check. The trained evaluator watched the simulations and 

found that all nurses in the double check group used a double check, 

in the wrong vial scenario, all double-checking groups found the error 

versus only 54% of the single check group found that error. In the weightbased 

group, 33% of double-checking groups versus 9% in the single 

check group found the error. Total, out of the 13 simulations, 54% were 

caught by the first nurse independently, 15% were identified by two 

nurses working together, and 31% were identified by the second nurse 

independently. Factors that effect a double check are the other nurse 

not catching the error, or the second nurse rushing the first nurse, and 

nurse confusion. The use of an independent double check was found 

to be superior to that of a single check in medication administration, so 

nurses should utilize the double check appropriately. 

The second study conducted by Westbrook, Li, & Raban (2020) was 

a quantitative study. This study was conducted to examine the effects 

of double-checking medications to reduce medication errors with 

pediatric patients. The study included 1523 children within a 340-bed 

tertiary pediatric hospital and 298 nurses. The interventions included: 

observing the nurses and using a time stamping system and average 

hourly rates with oncosts. The results concluded that there was no 

statistical difference found for double-checking administrations. Among 

the medication administrations where double checking was mandated, 

36 were independently double-checked, 3296 were primed double 

checking and 231 received an incomplete or no double-check. Double 

checking was optional for 1577 administrations but applied in 416 of 

these. In only seven administrations was an independent double check 

performed. Lastly, among all 5240 medications administrations observed, 

3563 required double checking according to hospital policy. 

The third study conducted by Koyama, Sheridan, Maddox, Ling, 

Bucknall, and Westbrook (2020), was a systematic review that analyzes 

thirteen studies, including ten observative study designs, and three 

randomized control trails sampling around 47-1,374 patients. The systemic 

review examined contemporary evidence of the effectiveness of double 

checking to reduce medication administration errors and associated 

harm to identify both the strength of that evidence and where future 

research needs to focus. The study also highlighted compliance with 

double checking practices. Double checking adherence rates ranged 

from 52% to 97%. Overall, there was insufficient evidence that double 

checking versus single checking medications were associated with lower 

MAE, however one of the higher quality studies did show a significant 

association between double checking and reduction in MAE. 

The fourth study conducted by Manias, Street, Lowe, Low, Gray, & Botti 

(2021), was a retrospective descriptive clinical audit that used 16 hospitals 

in Australia from October 1st, 2015, to March 31st, 2017, that found a total 

of 11,540 medication errors. Out of 11,540 only 3,260 medication errors 

were documented to be in relation to double checking medication. 

The purpose of this study was to determine the associations of personrelated, 

environmental-related, and communication-related factors 

on the severity of medication errors occurring in two health services. 

Health professionals submitted medication errors to an on-line voluntary 

incident reporting system with all medication errors reported during the 

18-month period. Single checking of medications was documented in 

8271 of medication errors while double checking was documented in 

3269 medication errors. 

The fifth study conducted by Cochran, Barrett, & Horn (2016) was 

a direct observational prospective two-phase quantitative analysis 

of 12 Nebraska critical assess hospitals observing 6,497 medications 

being administrated to 1,374 patients. This study has several different 

medication administration safety interventions put in place to 

compare medication error rates amongst one another. The different 

interventions include barcode-assisted medication administration, 

automated dispensing cabinets, nurse-nurse double checks, pharmacist 

transcription, and onsite pharmacist dispensing. During the dispensing 

phase of medication administration, the use of manual double-checking 

medications prevented 10% of errors from reaching the patient. Manual 

double-checking of medications was proven aside from the other 

administration interventions to be the most cost-effective strategy. 

Conclusions: 

The four out of the five articles found that a double check with a 

second nurse was effective in reducing medication errors. However, 

the study by Westbrook, Li, & Raban (2020) found that there was no 

statistically significant safety benefit when using nurse to nurse double 

checking. However, the study utilized primed double checking of 

medications more often, rather than independent double checking, 

which may have skewed the results. 


The research studies overall found that a second nurse double check, 

specifically an independent second nurse double check was indeed 

effective in reducing medication errors in weight-based and high-risk 

medications. These reductions in medication errors can improve overall 

patient safety. Therefore, the independent second nurse double check 

should be utilized in nursing practice.

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.

The North Dakota Nurse - July 2022

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