Member Spotlight...enteral nutrition. While caring for these patients, nurses routinely use water to dilute the feeding solutions, flush the enteral tube, and administer medications

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Official publication of the Idaho Nurses AssociationQuarterly circulation approximately 21,000 to all RNs, LPNs, and Student Nurses in Idaho.

Volume 37, • No. 2 August, September, October 2014

Inside This Issue

Holly Carlson RN, MS, CCRNSt. Luke’s Regional Medical Center, Boise, Idaho

INA Member since 2012Email: [email protected]

BackgroundI started as a junior hospital

volunteer at the age of 14 and have been a registered nurse for over 15 years, employed in healthcare for over 20 years. I have a Master’s degree in Organizational Leadership and currently direct 32 critical care beds in Boise, Idaho. I have worked in essentially every bedside role that focuses on adult care. In the INA, I am currently the Secretary of the INA Board of Directors and love the involvement in conference planning. Healthcare’s variety and pace

invigorate me. I truly believe that the key to exceptional patient care is achieved through empowered happy nurses.

In what ways has membership in INA been valuable to you?My membership in INA has removed the misconception

that nurses are not respected or that nurses do not have a voice in healthcare. INA’s relationship with the ANA and the strategic planning that is conducted to advocate for nurses on a national level touches my heart deeply and I am hooked!

Why would you encourage other RNs to join INA?These are messages I would tell nurses:

• Empoweryourselftobecomeapartofthewhole!• Youarenotthevictim!Youhaveanopportunityto

advocate for yourself, your peers, and your patients. • Youcanhaveavoiceinhealthcarereformandbest

of all, the educational opportunities are bottomless. • BybeingapartofINAyouareapartof theANA

which is passionate about and advocating for our profession.

Member Spotlight

Holly Carlson

by Sandie Nadelson, R.N.,MSN, MSEd, CNE, PhD

Utah State UniversityEmail: [email protected]

The author reports no conflicts of interest.

In June, a group of nurses from education and industry gathered to discuss the progress made on the major INAC projects. These include the nurse residency program, the survey about advanced nurse practice in Idaho, and the meta-synthesis of research on nurses moving from practice positions to nurse educator roles. The work done in each of these areas is impressive and shows that the Idaho Nursing Action Coalition is very active and focused in its mission.

Idaho Nursing Action Coalition (INAC) 2014 Summit

There is a possibility that the INAC will apply for another grant for the coming year. Discussion about future funding needs focused on nursing education and advancing the number of nurses with degrees beyond the associate of nursing degree. Future meetings are being planned to help delineate how this work will be done and coordinated.

If you are interested in being a part of these new activities, please contact Margaret Henbest at 208-367-1171. I am moving to Utah and am leaving my role as the Co-Lead for the Idaho Action Coalition.

Editor’s Note: We thank Sandie for all of her contributions to the Idaho Nurses Association and to Idaho nurses. We wish her the very best.

www.IdahoNurses.org

Check out our website:

Enteral Nutrition, How Does Sterile Water Compare to Tap Water?

The 1918 Spanish Flu and Its Impact on Idaho

Importance of Tobacco Cessation

Do Anticonvulsant Medications Reduce Length of Psychiatric Hospital Stay?

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News Flash!

Page 2 • RN Idaho August, September, October 2014

RN Idaho is published by the Idaho Nurses Association

3525 Piedmont Road Building 5, Suite 300

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Toll-free Phone: 888-721-8904 Direct Dial:404-760-2803Extension:2803Email: [email protected]: 404-240-0998 Website: www.idahonurses.org

Editorial Board: BarbaraMcNeil,PhD,RN-BC,EditorTracyFlynn,PhD,RN,CNEAnna Hissong, MSN, RN-BCReginaRobuck,INAExecutiveDirectorKim Watt, BSN, RNC-NIC, CPNDorothyM.Witmer,EdD,RN

RN Idaho welcomes comments, suggestions and contributions. Articles, editorials and other submissions may be sent directly to the INA office via mail, faxore-mail.Pleasecall the INAoffice ifyouhave any questions.

Join INA TodayWe need you!

Membership applicationhttp://nursingworld.org/joinana.aspx

For advertising rates and information, please contact Arthur L. Davis Publishing Agency, Inc., 517 Washington Street, PO Box 216, Cedar Falls, Iowa50613, (800) 626-4081, [email protected]. INA 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 nextissueorrefundofpriceofadvertisement.

Acceptance of advertising does not imply endorsement or approval by the Idaho Nurses Association of products advertised, the advertisers, or the claims made. Rejection of an advertisement does not imply a product offered for advertising is without merit, or that the manufacturer lacks integrity, or that this association disapproves of the product or its use. INA and the Arthur L. Davis Publishing Agency, Inc. shall not be held liable for any consequences resulting from purchase or use of an advertiser’s product. Articles appearing in this publication express theopinions of the authors; they do not necessarily reflect views of the staff, board, or membership of INA or those of the national or local associations.

RN Idaho is published quarterly every February, May, August and November for the Idaho Nurses Association, a constituent member of the American Nurses Association.

Published by:Arthur L. Davis

Publishing Agency, Inc.www.idahonurses.org

RN Idaho (RNI), the official publication of the Idaho Nurses Association (INA), is a peer-reviewed journal that is published quarterly.Views expressed are solely those ofthe authors or persons quoted and do not necessarily reflect INA’s views or those of the publisher, Arthur L. Davis Publishing Agency, Inc. The RNIEditorialBoardoverseesthis publication and welcomes nursing and health-related news items, original articles, research abstracts and other pertinent contributions. Authors are not required to be INA members.

For information about manuscript format, submission of photographs, publication selection and rights, and advertising in RNI, please visit the INA website at http://www.idna.affiniscape.com/under“News/Links.”[email protected] or by phone 1-888-721-8904.

Guidelines for Submissions to RN Idaho

current resident or

Presort StandardUS PostagePAIDPermit #14Princeton, MN55371

Official publication of the Idaho Nurses Association

Quarterly circulation approximately 19,000 to all RNs, LPNs,

and Student Nurses in Idaho.

Volume 33, • No. 1

May, June, July 2010

Volume 33, • No. 1

May, June, July 2010Page 2

Page 3

Page 4

From the President

Charting Idaho Nursing History

Keeping It In the Family: Idaho Grandparents Raising Grandchildren.

Inside This IssueInside This IssueInside This IssueInside This IssueInside This IssueInside This Issue

Check OutOur Website:www.IdahoNurses.org

Mark your Calendar for the Big Event!Idaho Nurses Association 2010 Spring Conference

“Promoting a Healthy Idaho”April 29-30, 2010St. Luke’s Regional Medical Center–Boise, Idaho

Presented by:

Idaho Nurses Association • Idaho Public Health Association • Idaho Rural Health Association

With support from: Idaho Area Health Education CenterThursday, April 29thINA House of Delegates Meeting ReceptionFriday, April 30th

Spring ConferenceFeatured Speakers Include:

• Carol Moehrle, RN, Director, Idaho North Central District Health Department

• Carmen Nevarez, MD, MPH, President-elect, American Public Health Association and Public Health

Institute Medical Director and Vice-President of External RelationsVisit http://idahonurses.org for additional

information and to register.Also see article on page 5.

Contact hours for this continuing nursing education activity have been submitted to the Washington State

Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission

on accreditation. Please contact Marilyn Floyd at the Idaho Nurses Association for more information about

contact hours for this event.

Join INA TodayWe need you!Membership application

http://nursingworld.org/joinana.aspx

CHARTING IDAHO NURSING HISTORY

Verlene Kaiser Randall Hudspeth

In MemoriamINA is pleased to honor deceased registered nurses who

graduated from Idaho nursing programs and/or served in Idaho during their nursing careers. Included, when known or when space allows, will be the date when deceased and the Idaho nursing program. The names will be submitted to the American Nurses Association for inclusion in a memoriam held in conjunction with the ANA House of Delegates. Please enable the list’s inclusiveness by submitting information to [email protected].

Beisly-Mabry, Bobbi, 06/27/2014. Bobbi graduated with honors from the BSN Program at Idaho State University. She was a caring and compassionate nurse working at both St. Luke’s and Saint Alphonsus’ medical centers in Boise. She was most currently employed at Saint Alphonsus Medical Center in the cardiac care unit. Her nurse co-workers were at her side throughout her illness. Bobbi practiced holistic care of her patients and was named as “my earth bound angle” in a book authored by a patient. Bobbi was also known for “that beautiful smile.”

Faylor, Carole Ann, 06/23/2014. Carole graduated with her BSN and was a highly skilled and caring professional who worked at multiple world class medical centers in the Northwest. She is remembered for her zest for life and inner beauty.

Fergesen-Zimmer, Virginia Ruth, 06/2014. Virginia obtained her nursing education in Moline, Illinois, and worked in many places in the U.S. She specialized in intensive and coronary care and became one of Idaho’s first organ donation coordinators. Virginia worked as

office nurse, staff nurse, charge nurse educator, eye bank coordinator, and human resource nurse at Saint Alphonsus Medical Center in Boise. She loved nature, was passionate about helping others, was generous, and possessed an outgoing personality.

Hogg, Lola A., 05/07/2014. Lola graduated from the cadet nursing program at Mercy Hospital in Nampa, Idaho, and worked at Caldwell Memorial Hospital and Mercy Hospital. She was dedicated to school nursing, serving as the first school nurse at Vallivue High School and 13 other Caldwell elementary schools. She was president and secretary for her Idaho Nurses Association district and was the first president of the Canyon County School Nurses Association. Lola’s leadership and professional commitment to nursing are beacons to guide present and future nurses.

Illian, Dorothy Hild, 04/15/ 2014. Dorothy died at the age of 89 in Lewiston. She was a cherished nurse and friend across the country, and shared with her three daughters a lifelong love of reading, laughing, and celebration of family. Dorothy believed in the goodness of people.

Sproul, Pauline “Polly” M., 04/17/2014. After completing her nursing education in Astoria, Oregon, after WWII, Polly worked at the Veterans Administration Hospital in Boise, Idaho. While caring for her family, she worked part time at Saint Alphonsus Hospital in Boise. Later, she became a school nurse and sole supporter of her five children. Polly was a very hard working and compassionate individual.

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August, September, October 2014 RN Idaho • Page 3

by Sohayla M. Allen, R.N.FNP Student, Gonzaga University, Spokane, WA

Email: [email protected]

In the critical care setting, many patients are prescribed enteral nutrition. While caring for these patients, nurses routinely use water to dilute the feeding solutions, flush the enteral tube, and administer medications. Inevitably, the question that emerges is what type of water is the best agent. In 2006, the American Association of Critical Care Nurses (AACN) released a practice recommendation in response stating, “We aren’t sure.” The AACN (2006) stated that many factors must be considered in answering the question about choosing the flushing agent for enteral nutrition. The official AACN recommendation is to use, at a minimum, universal precautions and good handwashing. Filtered water should be used in enteral systems rather than using water directly from the hospital taps. According to the AACN (2006), sterile water should always be used when working with immunocompromised patients.

Although this best practice recommendation was made by the AACN in 2006, hospitals have yet to fully adopt this practice. Of further concern is the continued practice by critical care nurses of not using sterile water in enteral feeding tubes. This continued practice can result from the misconceptions about the use of sterile water: e.g., that it is not necessary to use sterile water because the stomach isn’t sterile and that patients routinely drink non-sterile water without a problem.

A systematic literature search with analysis was conducted by this author to review the scientific evidence regarding the clinical question of the use of sterile versus tapwater inenteral feeding tubes.Theexpectedoutcomeof this literature search was to determine the underlying rationale for using sterile water in enteral tube feeding systems.

Research StrategyA systematic inquiry of electronic databases was

conducted in order to address this research topic. Databases searched included CINAHL, The Cochrane Library, Medline, PubMed, and the National Guideline Clearinghouse. Initially, several research parameters and exclusion criteria were set (more information availableupon request from the author). However, the lack of studies pertaining specifically to intensive care patients receiving either temporary or long-term enteral nutrition was a significant obstacle. Thus, the study selection criteria were broadened to include all studies that compared

the relative risk of using sterile versus tap water in enteral feeding tubes. Interestingly, only one out of eight keeper studies focused exclusively on critically-ill orimmunocompromised populations, presumably because these patients are more susceptible to hospital-acquired infections.

Evidence CharacteristicsAt the time of writing, the bulk of available research

on this topic consists of case reports, expert opinion,and cohort studies. These types of research studies are historically not held as the gold standard of evidence- based practice. However, the findings in the research are consistent; there is an increased risk of nosocomial infection for critically ill patients when tap water is used in enteral feeding tubes (Bert, Maubec, Bruneau, Berry, & Lambert-Zechovsky, 1998; Hosein et al., 2005; Marrie et al., 1991; Rogues et al., 2007; Padula, Kenny, Planchon, & Lamoureux,2004;Venezia,Agresta,Hanley,Urguhart,&Schoonmaker, 1994).

The survey of literature suggests that bacteria, identified as causative organisms in nosocomial outbreaks, have been isolated from hospital sinks and taps (AACN, 2006; Bert et al., 1998; Hosein et al., 2005; Rogues et al., 2007; Venezia et al., 1994). There are several documented incidents of hospital-acquired infection within the ICU setting. These incidents can be attributed to outbreaks of Pseudomonas aeruginosa and Legionella sp. In most cases the causative organism was found to be colonized in the hospital sink faucets (Bert et al., 1998; Hosein et al., 2005; Rogues et al., 2007; Venezia et al., 1994). Bert et al. (1998) established that Pseudomonas aeruginosa was directly transmitted to patients via enteral feeds contaminated with tap water. Similarly, Hosein et al. (2005) and Venezia et al. (1994) found that cases of nosocomial Legionnaires’ disease could be attributed to the documented aspiration

of patients on enteral feeds, whose formula was likely contaminated with colonized tap water.

Critical care patients are at risk for bacterial translocation in the gastrointestinal system. The risk can be attributed to their critical disease processes, increased pH of the gastrointestinal track allowing for abnormal bacterial growth, and their decreased use of the intestinal tract (AACN, 2006; Padula et al., 2004). These risk factors can contribute to the patient’s critical state and lead to longer hospital stays, pneumonias associated with enteral feeds, and possibly death (Padula et al., 2004). A survey of literature has suggested that bacteria, identified as causative organisms in nosocomial outbreaks, have been isolated from hospital sinks and faucets (AACN, 2006; Bert et al., 1998; Hosein et al., 2005; Rogues et al., 2007; Venezia et al., 1994).

The relationship between contaminated tap water and nosocomial infection is particularly relevant in the ICU. A large percentage of critically ill patients are at risk for aspiration of contaminated enteral feeds secondary to mechanical ventilation, decreased level of consciousness, and significant maladies. However, evidence from the literature suggests that perhaps environmental infection control should be the first line of defense rather than a focus on aspiration prevention. For example, Rogues etal. (2007) found that once a particular ICU’s tap water was disinfected, the number of Pseudomonas aeruginosa carriers decreased by 65%. This finding was confirmed by replacing tap water with sterile water; the relative number of nosocomial infection cases decreased significantly (Hosein et al., 2005; Rogues et al., 2007; Venezia et al., 2004).

Most of the literature on this topic is dated and encompasses a noticeable lack of both randomized control trials and statistically significant data to support the clinical practice guideline conclusions. As such, the next step will be to initiate further research on thesubject. Specifically, more information is needed to compare findings among different patient populations as well as to compare the efficacy and cost-effectiveness of different interventions (e.g., using sterile water versus decontaminating the hospital water supply).

Best PracticeBased on the available existing research, current

clinical practice guidelines suggest that for critically ill or immunocompromised patients, sterile water should

As a Flushing Agent for Enteral Nutrition, Does Sterile Water Compared to Tap Water Affect the Associated Risk of Infection

In Critically Ill Patients?

Sterile Water continued on page 4

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be used exclusively in enteral feeding systems includingmedication administration and flushes (National Guideline Clearinghouse, 2009). The level of evidence supporting this recommendation is rated as “fair,” (using the Agency for Healthcare Quality and Research categories) and is based on well-designed research studies withoutrandomization.Notonlyisexclusiveuseofsterilewater an effective way of decreasing nosocomial infection associated with contaminated tap water, but sterile water has also been shown to be safer for medication administration as the chemical contaminants in tap water can potentiate drug-drug interactions, thus decreasing the bioavailability of certain medications (Boullata, 2010; Bankhead et al., 2009; National Guideline Clearinghouse, 2009).

The AACN (2006) has suggested that hospitals collaborate with their epidemiology departments to test water supplies for infectious organisms. This suggestion may be problematic because of its feasibility in small, rural settings and costs to the practice settings. The costs of frequent water testing and the subsequent treatment of an entire water system may be far more than the cost of sterile water use in lieu of tap water. Therefore, unless there is contradictory evidence, if the quality of tap water cannot be established, the best practice is to err on the side ofcautionanduse sterilewaterexclusively in theenteralfeeding systems of critically ill patients.

ReferencesAmerican Association of Critical Care Nurses (AACN). (2006).

Practice resource network: Is sterile water preferred over tap water for irrigation of enteral feeding tubes and medication administration by nasogastric or feeding tubes in critically ill adult patients? AACN News, 23(7), 4-5. Retrieved from http://www.aacn.org/wd/aacnnews/content/2006/jul-practice.pcms?menu=practice

Bankhead, R., Boullata, J., Brantley, S., Corkins, M., Guenter, P., Krenitsky, J. & Weesel, J. (2009). ASPEN enteralnutrition practice recommendations. JPEN Journal of Parenteral & Enteral Nutrition, 33(2), 122-167. doi: 10.1177/0148607108330314.

Bert, F., Maubec, E., Bruneau, B., Berry, P., & Lambert-Zechovsky, N. (1998). Multi-resistant Pseudomonas aeruginosa outbreak associated with contaminated tap water in a neurosurgery intensive care unit. The Journal of Hospital Infection, 39(1), 53-62.

Boullata, J. (2010). Enteral nutrition practice: the water issue.Support Line, 32(3), 10.

Hosein,I.,Hill,D.,Tan,T.,Butchart,E.,Wilson,K.,Finlay,G.& Ribeiro, C. (2005). Point-of-care controls for nosocomial Legionellosis combinedwith chlorine dioxide potablewaterdecontamination: A two-year survey at a Welsh teaching hospital. The Journal of Hospital Infection, 61(2), 100-106.

Marrie, T.J., Haldane, D., MacDonald, S., Clarke, K., Fanning, C., Le Fort-Jost, S., ...Joly, J. (1991). Control of endemic nosocomial Legionnaires’ disease by using sterile potable water for high risk patients. Epidemiology & Infection, 107(3), 591 – 605. doi: 10.1017/S0950268800049293.

National Guideline Clearinghouse (NGC). Guideline summary: Enteral nutrition administration. In: National GuidelineClearinghouse (NGC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); [cited 2009 Jan]. Retrieved from http://www.guideline.gov.

Padula,C.,Kenny,A.,Planchon,C.andLamoureux,C.(2004).Enteral feedings: What the evidence says. The American Journal of Nursing, 104(7), 62-69. Retrieved from http://journals.lww.com/ajnonline/toc/2004/07000.

Rogues, A., Boulestreau, H., Lasheras, A., Boyer, A., Grunson, D., Merle, C. and Gachie, J. (2007). Contribution of tap water to patient colonization with Pseudomonas aeruginosa in a medical intensive care unit. Journal of Hospital Infection, 67(1), 72-78.

Venezia, R., Agresta, M., Hanley, E., Urguhart, K., &Schoonmaker, D. (1994). Nosocomial Legionellosis associated with aspiration of nasogastric feedings diluted in tap water. Infection Control and Hospital Epidemiology: The Official Journal of the Society of Hospital Epidemiologists of America, 15(8), 529-533.

Sterile Water continued from page 3

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by Rachel Lundquist, RN, BSNNurse Educator Track MSN Student,

Gonzaga University, Spokane, WAEmail: [email protected]

The author has disclosed she has no potential conflicts of interest, financial or otherwise.

Importance of Tobacco CessationIt is no surprise to nurses that tobacco use is the single

most preventable cause of death and disease in the United States (CDC, 2002). Tobacco use is linked to various cancers and is associated with pneumonia, lung disease, cardiovascular disease, and surgical complications which potentially lead to lengthy and costly hospital stays (HHS, 2004). Despite current public knowledge, tobacco-related deaths and disabilities continue to rise worldwide (Healthy People 2020, 2013).

Acute care bedside nurses have frequent contact with hospitalized patients and increasing numbers of hospitals have adopted tobacco-free policies. Also, the Joint Commission (2014) has dedicated a National Hospital Inpatient Quality Measure set for tobacco treatment (TOB) that addresses tobacco screening, treatment, and assessment of cessation post discharge. As a result, acute care nurses are invested in and well poised to support tobacco cessation when caring for their patients (Buckley & Matteucci, 2012; The Joint Commission, 2014; National Guideline Clearinghouse, 2014).

There are many questions that remain about tobacco cessation strategies:

• What is the most effective educational strategy fornurses to use when providing tobacco cessation education to hospitalized adults?

• In an effort to save time for nurses, should hospitalsconsider using video technology to provide tobacco cessation education to patients?

• Are nurse-to-patient counseling sessions the mosteffective tobacco cessation strategy as recommended by the National Guideline Clearinghouse (2014)?

In hospitalized adults who use tobacco (Population), how does viewing a video-based tobacco cessation decision aid (Intervention) compared to receiving brief cessation nurse counseling (Comparison) affect tobacco

abstinence (Outcome) within 3 months of discharge (Timeframe)?One critical step to improving the health and wellbeing

of individuals and our communities will be equipping acute nurses with the most effective tools for educating hospitalized patients about tobacco cessation. The purpose of this paper is to report findings from an evidence search investigating the impact of specific smoking cessation strategies on tobacco abstinence.

Search StrategyA systematic literature search of the following electronic

databases was conducted: the Cochrane Database of Systematic Reviews, the National Guideline Clearinghouse, Medline, and the Cumulative Index of Nursing and AlliedHealth Literature (CINAHL). The inclusion and exclusioncriteria for the search and an annotated bibliography are readily available upon request from the author. A total of nine studies met pre-determined selection criteria and were reviewed and then summarized for trends, patterns and recommendations for best practice.

Evidence FindingsFrom the body of evidence examined, several themes

emerged. First, three out of the nine studies reported that in hospitalized adults, the use of intensive face-to-face counseling for tobacco cessation with supportive follow-up after discharge improved tobacco abstinence outcomes more than low intensity interactions (Health Quality Ontario, 2010; NGC, 2014; Rigotti, Clair, Munafo, & Stead, 2012). Second, the results of four studies that included adults and college-age students from diverse backgrounds and socioeconomic status encouraged interactive and individually tailored tobacco cessation education (AHRQ, 2013; Civljak, Stead, Hartmann-Boyce, Sheikh, & Car, 2013; Escoffery, McCormick, &Bateman, 2004; NGC, 2014). These themes were prominent across the literature and were strengthened by the fact that they were findings from multiple systematic reviews.

WhenexaminingtheeffectsofInternet-,video-,ormobilephone-based education, the evidence was weaker. A limited number of pilot studies and meta-analyses addressed the effectiveness of video-based tobacco cessation interventions for adults after three months. However, none of the evidence found addressed the use of these interventions in the specific population of interest, hospitalized patients.

There was also no head-to-head evidence comparing video-based interventions to brief counseling in adults. Internet- and mobile phone-based interventions may be effective strategies for providing tobacco cessation education to adolescents and young adults. However, in review of the evidence, the long-

term effects (greater than three months post-intervention) are unknown (Myung, McDonnell, Kazinets, Seg, & Moskowitz, 2009; Vick, Duffy, Ewing, Rugen, & Zak, 2013;Whittaker,McRobbie, Bullen, Borland, Rodgers, & Gu, 2012).

The National Guideline Clearinghouse’s (2014) “Guideline Synthesis: Treatment of Tobacco Dependence” reflects the findings of recent research. Recommendations include the use of person-to-person counseling as the primary form of tobacco cessation education. The guideline also advocates for some form of follow-up by recommending healthcare providers refer all tobacco users to a tobacco-cessation specialist. It also proposes that the counseling provided be tailored to each individual’s level of readiness and personal reasons for quitting (NGC, 2014). These three themes from the NGC are in agreement with the primary results found in other studies. The guideline does not address Internet-, computer-, or video-based education because the current research on these methods was compromised by weak methodological rigor or demonstrated that counseling was more effective.

Conclusions – Best PracticeBased on this search, there is strong evidence to support

interactive, individualized, intensive counseling with supportive follow-up as the most effective strategy for providing tobacco cessation education to hospitalized adults. Further research is needed to determine the effectiveness of intensive, interactive Internet-, video-, or mobile phone-based interventions on promoting tobacco abstinence in this population.

The evidence examined will guide nurses to provideface-to-face counseling on tobacco cessation to acute care patients. Best practice includes the nurse taking the initiative to discuss with patients their desire to quit, exploring whatmotivates them to quit, and encouraging them to make a detailed plan for tobacco cessation. As an acute care nurse, the author is also prompted to use this evidence to advocate for patient tobacco cessation follow-up after hospital discharge. This may take the form of a follow-up phone call or referral

Tobacco Cessation continued on page 10

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by Kathryn Devaney, RN, MSN, FNP-CGonzaga University, PMHNP Graduate Student

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The author has disclosed no potential conflicts of interest, financial or otherwise.

IntroductionBackground

Consumers and providers as well as health care organizations are in the process of navigating and implementing the changes mandated by the Patient Protection and Affordable Care Act (ACA) which was signed into law on March 23, 2010, and upheld by the Supreme Court on June 28, 2012. Evidenceof change is seen with the Centers for Medicare and Medicaid Services’ (CMS) implementation of a quality-reporting program that will apply to psychiatric hospitals paid under the Inpatient Psychiatric Facilities (IPF) Prospective Payment System (PPS) (Centers for Medicare & Medicaid Services, 2012). IPFs will be penalized two (2.0) percentage points of annual payment if they are non-compliant with the quality data submission requirements (Centers for Medicare & Medicaid Services, 2012). One of the measures of focus is multiple antipsychotic medication use (Centers for Medicare & Medicaid Services, 2012).

In 2005, the U.S. Food and Drug Administration (FDA) issued a public health advisory alerting all consumers and healthcare providers of increased mortality associated with the use of atypical antipsychotics for treating behavioral disorders in elderly patients with dementia (Centers for Medicare & Medicaid, 2012). Additionally, the CMS launched the National Partnership to Improve Dementia Care and Reduce Unnecessary Antipsychotic Drug Use in Nursing Homes (Centers for Medicare & Medicaid, 2013).

Given the scrutiny by the FDA and CMS in the use of antipsychotic medications, this clinical question is

designed to identify the role that the anticonvulsant mood stabilizer medications have in managing aggressive behavior in the elderly patient population with Alzheimer’s Dementia (AD).

Evidence FindingsKeeper Study Findings

The analysis of 17 “keeper studies” for this evidence summary were identified through a systematic literature search(inclusionandexclusioncriteriaavailablefromtheauthor) of electronic databases (ALOIS, The Cochrane Database of Systematic Reviews, PubMed/Medline, CMS, the Agency for Healthcare Research and Quality (AHRQ), the National Guideline Clearinghouse (NGC), PsychINFO, and CINAHL). The studies were selected to provide a comprehensive overview of the best available information on the subject of the use of neuroleptic/antipsychotic medications and anticonvulsant mood stabilizer medications in the management of agitation/aggression in the AD patient population.

Unfortunately, the studies found provided limited evidence regarding the comparative use of anticonvulsant/mood stabilizer medications. Only five randomized controlled trials (RCTs) examining the effectiveness ofvalproate were reported through a systematic review (SR) by Konovalov, Muralee and Rampi (2008). Poor study design, the use of multiple instruments to assess aggression/agitation, limited patient sample size, the use of a variety of concomitant psychotropic medications, and the high drop-out rates limited the statistical power of many of thestudiesexaminedintheSR.Thisreviewalsoidentifiedtwo RCTs of carbamazepine compared to placebo and equivocal efficacy was reported.

One RCT by Sommer, Aga, Cvancarova, Olsen, Selbaek, and Engedal (2009) investigated the effect ofoxcarbazepine compared to placebo and the data failedto show a statistically significant effect over placebo in treating agitation and aggression. Poor statistical power limited study results.

Four RCTs (Ballard, Lana, Theodoulou, Douglas, McShand, Jacoby, & Juszczak, 2008; Deberdt, Dysken, Rappaport, Feldman, Young, Hay, & Breier ,2005;DeDeyn, Carrasco, Deberdt, Jeandel, Hay, Feldman, & Breier, 2004; and Devanand, Pelton, Cunqueiro, Sackeim, & Marder, 2011), and three meta-analyses or

systematic reviews (Ballard, Waite, & Birks, 2006; Breder, Swanink, Marcus, Kostic, Iwamoto, Carson, McQuade, & Bristol-Myers Squibb Company, 2004; Lonergan, Luxenberg,Colford,&Birks, 2002) evaluated the use ofthe neuroleptic/antipsychotic category of medications. Findings were slightly more encouraging for the benefits of this category of medication in the management of aggression/agitation in the AD patient population. The meta-analysis by Lonergan et al. (2002) revealed decreased aggression/agitation with haloperidol compared to placebo, but at the cost of increased adverse events including stroke.

In the RCT of 109 patients with a possible or probable diagnosis of AD who were taking neuroleptics, Ballard, et al. (2008) reported a non-significant difference in Neuropsychiatric Inventory (NPI) scores from baseline to sixmonthswhen the continuation of neurolepticswascompared to discontinuation of neuroleptics. For patients with high baseline NPI scores (>14) which reflect more severe aggression/agitation, an improvement in aggressive/agitated behaviors was found for patients continuing neuroleptics. This patient group demonstrated an almost five point advantage with the use of either thioridazine, chlorpromazine, haloperidol, trifluoperazine, or risperidone for the treatment of aggression and agitation; results were statistically nonsignificant due to limited statistical power.

Overall, the keeper studies emphasized the complexnature of the patient population and the difficulty in collecting meaningful data based on very subjective instruments to rate the degree of aggression/agitation and response to medication intervention. The very nature of the progressive disease process in dementia makes it very difficult to objectively assess the impact of drug therapy versus disease progression. Several studies suggested that the improvement in behavior in both intervention and placebo groups maybe secondary to the additional attention from staff rather than the drug therapy (DeDeyn, et al., 2004; Ballard, et al., 2006). Importantly, the studies conducted on the use of the neuroleptic/antipsychotic medications consistently identified the increased risk of adverse side effects, many of which are life threatening (Ballard, et al., 2008) and cautioned that the risks and benefits must be weighed carefully. The clinical practice guidelines (AHRQ, 2012; NGC, 2009) supported the findings of the other keeper studies in regard to the increased risk of adverse events with the use of the neuroleptic/antipsychotic drugs. The guidelines do not recommend the use of neuroleptic/antipsychotic drugs in the treatment of aggression and agitation in the AD patient population.

EffectonLengthofPsychiatricHospitalStayThere are limited answers to the question of how

the use of the anticonvulsant mood stabilizers versus neuroleptic/antipsychotics reduces the number of hospital days in the AD patient who is exhibiting aggression/agitation. Every aspect of the PICOT question was leftunanswered; no head-to-head studies were found that compared the two categories of medication. Very few of the studies were conducted in hospitalized patients, most were outpatient, and some were in homes or care facilities. This finding is important because the degree of aggression/agitation is most severe in the hospitalized patient while the majority of studies were conducted with patients demonstrating less severe aggression/agitation.

Limitations of this Body of EvidenceThe remaining studies found through this systematic

search were too complex in their design and statisticalanalysis (DeDeyn, et al., 2004) to be conclusive. Gentile (2010) reported that so many of the RCTs reviewed in his systematic review had flaws that it made it difficult to evaluate the significance of the data. However, the strength of this body of evidence was found in reporting of study limitations and implications for future research.

In the meta-analysis of valproate preparations for agitation in dementia by Lonergan et al. (2009), one

CLINICAL QUESTION: Does the use of anticonvulsant/mood stabilizer medication (Intervention) compared to antipsychotic medication (Comparison) reduce the length of psychiatric hospital stay (Outcome) for age 65 years or older Alzheimer Dementia

(AD) patients with aggressive behavior (Population)?

Clinical Question continued on page 7

“ALDID”


individual study reported high dropout rates secondary to adverse side effects among patientstreatedwithdivalproexsodium.Asecondstudycontainedflawsinmethodologyand lack of standardization in the ways of treating and assessing patients. A third study in the meta-analysis utilized a statistical analysis which drew into question the validity of the statistical results. Overall, the limitations of the studies reviewed in this meta-analysis point to the need for well-designed studies to evaluate the usefulness of the anticonvulsant mood stabilizer category of medication in the AD patient population.

Conclusions and Recommendations for Best PracticeBased on this systematic search and summary of research studies, the AD patient with

aggression/agitation may benefit from the use of the neuroleptic/antipsychotic drugs, particularly haloperidol, risperidol, and olanzapine. However, this benefit is outweighed by adverse side-effects. In certain situations where aggressive/agitated behavior prevents the AD patient from being cared for by family or a care facility, the use of these medications could be beneficial. The evidence is less supportive of the benefit derived with the anticonvulsant mood stabilizer category of medication in managing aggressive/agitated behavior.

From a clinical perspective, the insight from this evidence summary is somewhat frustrating. Clinical and federal regulatory guidelines appear to be based on studies of limited sample size and devoid of a standardized instrument to assess behavioral responses to a medication intervention in a patient population whose quality of life is severely impacted by aggressive/agitated behavior. In this author’s view, the regulatory agenciesmaybe imposingexpectationsonprovidersandfacilities toavoidneuroleptic/antipsychotic drugs for treating behavioral problems in AD patients based upon findings from RCTs which have many methodological limitations.

The urgent need for further research focused on treatment of aggression and agitation in the Alzheimer’s dementia patient population is paramount as the United States continues to see increasing numbers of aging “baby boomers” accessing the health care system, not only for medical problems but for mental health needs as well.

ReferencesAgency for Healthcare Research and Quality (AHRQ). Guideline summary: EFNS-ENS

guidelines on the diagnosis and management of disorders associated with dementia. I n : Agency for Healthcare Research and Quality (AHRQ) [www.ahrq.gov]. Rockville, MD: Agency for Healthcare Research and Quality; [cited 2012 November 20]. Retrieved from http://www.guideline.gov/content.aspx?id=38470&search=hospital+and+aggression.

Ballard, C., Corbett, A., Chitramohan, R., & Aarsland, D., (2009). Management of agitation and aggression associated with Alzeimer’s disease: Controversies and possible solutions. Current Opinion in Psychiatry, 22,532-540.doi:10.1097/YCO.obo13e32833111f9.

Ballard,C.,Lana,M.M.,Theodoulou,M.,Douglas,S.,McShand,R.,Jacoby,R.,&Juszczak,E.(2008). A randomized, blinded, placebo-controlled trial in dementia patients continuing or stopping neuroleptics (the DART-AD trial). Public Library of Science, 5, 0587-0599 Retrieved from www.plosmedicine.org.

Ballard, C.G., Waite, J., & Birks, J. (2006). Atypical antipsychotics for aggression and psychosis in Alzheimer’s disease. Cochrane Database of Systematic Reviews, 2006(1), 1-135. doi:10.1002/14651858.CD003476.pub2.

Breder, C., Swanink, R., Marcus, R., Kostic, D., Iwamoto, T., Carson, W., McQuade, R., & Bristol-Myers Squibb Company, Wallingford, CT, USA. (2004) Dose-ranging study of Apripiprazole in patients with dementia of Alzheimer’s disease. Neurobiology of Aging, 25(S2). Retrieved fromhttp://www.medicine.ox.ac.uk/alois/content/breder-2004-nct00036114.

Centers for Medicare & Medicaid Services (CMS). (2012) Fact sheets: CMS makes changes to improve quality of care during hospital inpatient stay. Retrieved from http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2012-Fact-Sheets-Items/2012-08-012.html

Centers for Medicare & Medicaid Services (CMS) (2013) Center for clinical standards and quality/survey & certification group (www.cms.gov). Baltimore, Md: Retrieved from http://www.cms.gov/medicare/provider-enrollment-and-certification/surveycertificationgeninfo/downloads/survey-and-cert-letter-13-35.pdf

Deberdt, W. G., Dysken, M. W., Rappaport, S. A., Feldman, P.D., Young, C.A., Hay, P.D., &Breier, A. (2005). Comparison of olanzapine and risperidone in the treatment of psychosis and associated behavioral disturbances in patients With Dementia. American Journal of Geriatric Psychiatry, 13, 722-720. Retrieved from http://www.medicine.ox.ac.uk/alois/content/deberdt-2005-fld-mc-hggu-1701.

DeDeyn, P.P., Carrasco, M.M., Deberdt, W., Jeandel, C., Hay, D.P., Feldman, P.D. & Breier, A. (2004). Olanzapine versus placebo in the treatment of psychosis with or without associated behavioral disturbances in patients with Alzheimer’s disease. International Journal of Geriatric Psychiatry 19(2),115-26.Retrievedfromhttp://www.medicine.ox.ac.uk/alois/content/dedeyn-2004-f1d-mc-hgiv-4414.

Devanand,D.P.,Pelton,G.H.,Cunqueiro,K.,Sackeim,H.A.,&Marder,K.A.,(2011)Six-month,randomized, double-blind, placebo-controlled pilot discontinuation trial following response to haloperidol treatment of psychosis and agitation in Alzheimer’s disease. International Journal

of Geriatric Psychiatry, 25(9), 937-943. Retrieved from http://www.medicine.ox.ac.uk/alois/content/devanand-2011-nct00009217

Gentile, S. (2010). Second-generation antipsychotics in dementia: beyond safety concerns. A clinical, systematic review of efficacy data from randomized controlled trials. Psychopharmacology, 212, 119-129. doi:10.1007/s00213-010-1939-z.

Guay, D.R., (2007). Newer antiepileptic drugs in the management of agitation/aggression in patients with dementia or developmental disability (Abstract). The Consultant Pharmacist: The Journal of the American Society of Consultant Pharmacists, 22(12), 1004-34. Abstract retrievedfromhttp://www.mdconsult.com.proxy.foley.gonzaga.edu.

Howland, R.H., (2008). Risks and benefits of antipsychotic drugs in elderly patients with dementia (Abstract). Journal of Psychosocial Nursing and Mental Health Services, 46(11), 19-23. Abstractretrievedfromhttp://www.mdconsult.com.proxy.foley.gonzaga.edu.

Konovalov, S., Muralee, S., & Tampi, S.S. (2008). Anticonvulsants for the treatment of behavioral and psychological symptoms of dementia: A literature review (Abstract). International Psychogeriatrics, 20(2), 293-308. Abstract retrieved from http://www.mdconsult.com.roxy.foley.gonzaga.edu.

Lonergan,E.,Luxenberg,J.,Colford,J.,&Birks,J.(2002).Haloperidolforagitationindementia.Cochrane Database of Systematic Reviews, 2002(2), 1-47. doi:10.1002/14651858.CD002852.

Mowla, A., & Pani, A., (2010). Comparison of topiramate and risperidone for the treatment of behavioral disturbances of patients with Alzheimer disease: A double-blind, randomized clinical trial. Journal of Clinical Psychopharmacology, 30(1), 40-43. Retrieved from http://www.medicine.ox.ac.uk/alois/content/mowla-2010.

National Guideline Clearinghouse (NGC) (Reaffirmed for currency in 2009). Guideline summary: Management of patients with dementia. A national clinical guideline. In: National Guideline Clearinghouse (NGC) [www.guideline.gov]. Rockville, MD. Retrieved from http://www.guideline.gov/popups/printView.aspx?id=8809.

Porsteinsson, A.P., Tariot, P.N., Jakimovich, L.J., Kowalski, N., Holt, C., Erb, R., & Cox, C.(2003).Valproatetherapyforagitationindementia:open-labelextensionofadouble-blindtrial.American Journal of Geriatric Psychiatry, 11(4), 434-40. Retrieved from http://www.medicine.ox.ac.uk/alois/content/porsteinsson-2001

Sival, R.C., Duivenvoorden, H.J., Haffman, P.M.J., Jansen, P.A.F., Duursma, S.A., & Eikelenboom, P. (2004). Sodium valproate in aggressive behaviour in dementia: A twelve-week open label follow-up study. International Journal of Geriatric Psychiatry, 19, 305-312. Retrievedfromhttp://www.medicine.ox.ac.uk/alois/content/sival-2002.

Sommer,O.H.Aga,O.,Cvancarova,M.,Olsen,I.C.,Selbaek,G.,&Engedal,K.(2009).Effectofoxcarbazepine in the treatment of agitation and aggression in severe dementia.Dementia & Geriatric Cognitive Disorders, 2,155-163.Retrievedfromhttp://www.medicine.ox.ac.uk/alois/content/sommer-2009.

U.S. Department of Health and Human Services (USDHHS). Executive summary (2011). Off-Label Use of Atypical Antipsychotics: An Update. Comparative Effectiveness Review No. 43 (Southern California/RAND Evidence-based Practice Center under Contract No.HSA290-2007-10062-1)(AHRQPublicationNo. 11-EHC087-EF).Retrieved from http://www.effectivehealthcare.ahrq.gov/reports/final.cfm

Vickland, V., Chilko, N., Draper, B., Low, L.F., O’Connor, D., & Brodaty, H. (2012) Individualized guideline for the management of aggression in dementia. Part 2: Appraisal of current guidelines. International Psychogeriatrics, 24(7), 1125-32. Retrieved from http://www.mdconsult.com/proxy.foley.gonzaga.edu

Clinical Question continued from page 6

After receiving treatment in an emergency department (ED), a 36-year-old woman died of undiagnosed sepsis. The physician and nurse who treated her were sued by the family.

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by Randall Hudspeth, PhD, MSN, APRN-CNP/CNS, FRE, FAANP


Each fall we begin to think about the upcomingflu season, where to get our annual flu shots and also about the necessary immunizations for children that are needed when school begins. Today, the flu has become a manageable nuisance to most of us and our fear is getting it and missing work or school in addition to just feeling miserable for a few days. In the past, the flu was not always considered so lightly or so commonplace. In the days before vaccines, contracting the flu could be devastating to individuals and to entire communities.

The First Outbreak of Flu and Its PathAlmost 100 years ago, in 1918 during World War I,

the world experienced its first major flu pandemic inmodern times. This flu was so globally devastating that the duration of the pandemic was extended to include

the time that was also impacted by its residual, January, 1918, through December, 1920. During that time period, the virus infected 500 million people worldwide and nearly 100 million died. However, unlike flu viruses that commonly have a negative impact on the very young, the frail elderly and those who are otherwise compromised, the 1918 pandemic killed young, healthy adults.

World War I military censors, in an attempt to maintain higher morale amongst the troops, minimized reports of the flu’s devastation in the war zones of Germany, France and Great Britain. Reports from neutral countries like Spain, whose king was very ill from the flu, were not censored and a false impression emerged that Spain was more severely devastated than other countries. Thus the flu was nicknamed the Spanish Flu or Spanish Influenza.

How this flu was globally transmitted remains a mystery. Theories have linked it to the 100,000 Chinese workers who were brought to support troops at the front in France and have attributed it to transmission by contact with birds and animals. Certainly close quarters and the massive movement of the troops contributed to its spread. In November 1918, when the war ended, the pandemic was at its height and returning soldiers brought it to many American communities, although the first documented American case was in Kansas in January 1918.

Devastation from the Flu Affects Idaho Communities and Nurses

An Idaho nurse, Miss Geneva Castevens, who was a 1913 graduate of the St. Luke’s Hospital School of Nursing, became the first American nurse to die in Europe.Shewasnotkilledwhiletendingtosoldiersonthebattlefield, but from the flu in a London hospital.

Idaho residents did not go without being impacted. Communities were concerned and the Idaho Daily Statesman newspaper in Boise reported on “The Idaho Quarantine War.” Residents of Challis took up arms to prevent hunters from entering the town. In Boise, Mrs. Lucy Emery, R.N., Superintendent at St. Luke’sHospitaldied, one of the 238 reported deaths from the flu. Lewiston was especially hard hit and at St. Joseph’s Hospital all beds were filled with flu victims. Seven of the Catholic sisters who were nurses at the hospital caught the flu and died. This major depletion of the nursing staff forced the sister superior to make plans to open a school of nursing at St. Joseph’s Hospital to replenish the nursing staff numbers. The first class graduated in 1922 consisting of four Catholic sisters and three lay young ladies.

The number of patients who remained in hospitals for weeks placed a heavy work burden on the nurses, who were already in short supply because of the number

of nurses who were in the military and the number who chose not to work for fear of bringing the flu home to their families. Nurses worked around the clock for months without days off. Sadly, many of the nurses who did work became ill themselves and died. The resulting nurse shortage prompted the creation of the Boise Visiting Nurses Association, who would send a nurse to care for homebound patients for $1.00 daily. The Idaho Daily Statesman, which was distributed statewide, printed an article calling for any women who had nursing education to contact the Ada County Council of Defense or the Idaho State Graduate Nurse’s Association to notify these agencies of their interest and availability to work.

During this time, many women who took nursing jobs did not possess a nursing diploma or had dropped out of a nurse training program before completion. Between 1911 and 1921, a nursing license was voluntary. An outcome of this nurse shortage was the identification that this “voluntary nursing license” was ineffective in identifying nurses and where they lived and worked. Having a “state license” as a nurse was one way to maintain an accurate inventory of who was and who was not a trained nurse. After 1921, legislation passed that required all nursing graduates to present their diploma to the nursing association office, pay the minimal license fee, and have their name entered onto a register of licensed graduate nurses. Thus the term Registered Nurse was born.

ConclusionBoth adversity and unintended consequences are the

results of disasters and major disease outbreaks. Over the past century, these circumstances have prompted the nursing profession to respond and forced it to grow. We can learn much from our history and the impact of the 1918 Spanish Flu in Idaho.

Hudspeth, R., & Kaiser, V. (2009). Charting Idaho nursing history.Caldwell,ID:CaxtonPrinters.

The 1918 Spanish Flu and Its Impact on Idaho

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by Sandra Evans, Executive DirectorEmail: [email protected]

The nine governor-appointed members of the Idaho Board of Nursing (IBON) met April 10-11, 2014, for the conduct of routine business consistent with their strategic goals related to licensure, practice, discipline and alternatives to discipline, education, governance, communication and organization.

At this April meeting, the Board reviewed routine reports and updates, including a summary of legislation and administrative rules adopted by the 2014 Idaho Legislature prior to their adjournment on March 20th. The Senate bills 1261 and 1288a successfully amended the Idaho Nursing Practice Act by:

• Correcting deficiencies in the Board’s processes for conducting fingerprint-basedcriminal background checks of applicants for initial and reinstatement licensure;

• Broadening the statute to authorize theBoard to imposedisciplinewhen any typeofformal disciplinary sanction has been imposed on a license applicant or licensee in any jurisdiction; and

• Expressly adding sexual misconduct or sexual exploitation by a licensee as specificgrounds for discipline.

The Administrative Rules of the Board were amended to:• Add to functions that may be performed by RNs and LPNs to specifically include

engaging in appropriate interfaces with healthcare providers and other workers in settings where there is not a structured nursing organization and in settings where health care plays a secondary role; and

• Delete a list of specific procedures that should not be delegated by a licensed nurseto unlicensed persons, thereby allowing nurses to appropriately delegate functions without limiting their authority to determine which tasks can be safely delegated in any individual circumstance and setting.

As they do every spring, in April, the Board conducted their annual Self-Assessment and assessmentofexecutiveperformanceconsistentwiththeirphilosophicalbeliefthat“continuousmeasurement of performance fosters public accountability and achievement of desired outcomes.” In addition, the Board adopted updates to their Strategic Plan for implementation on July 1, 2014, to reflect priorities and direction for the coming four-year period.

Formal Complaints ReviewedBoard members considered formal complaints alleging violations of the Idaho Nursing

Practice Act and took action to adopt factual findings of violations of the Idaho Nursing Practice Act and revoked four LPN and five RN licenses. The Board placed one RN license on probation with terms and conditions, denied one application for reinstatement of a previously revoked RN license, and granted reinstatement with conditions of one previously disciplined LPN license.

Proposed Administrative RulesFollowing considerable dialog and extensive study, the Board directed staff and

attorneys to draft separate dockets of proposed administrative rules to 1) implement provisions of Senate Bill 1288a, passed by the 2014 Idaho Legislature; and 2) to require demonstrated continuous professional development for licensure renewal in the near future. The draft language, to be considered by the Board at a meeting in July, will likely proceed to the rule-making process early in the fall for consideration by the 2015 Idaho Legislature. For copies of proposed rules, contact Lyn Moore at 208-577-2500 or [email protected].

New Board Staff MembersThe Board of Nursing is pleased to welcome the following new staff members:

Report From the April, 2014, Meeting of the Idaho Board of Nursing

Kathleen Pollard, RN, BSN, Associate Director for Alternative Programs, joined the Board in May of 2013. Kathleen oversees the Board’s Program for Recovering Nurses (PRN), an alternative to discipline for nurses whose practice is or may be impaired as a result of substance use and/or mental health disorders. She is also developing and will oversee the Practice Remediation Program (PRP), an alternative to discipline for nurses whose minor substandard practice does not rise to a level that warrants formal discipline.

Judy Taylor, RN, MSN, Associate Director for Practice and Education, assumed her position in May, 2014, having most recently served as Interim Director of Nursing at St. Luke’s McCall. Judy administers activities related to the regulation of nursing practice:

•Activitiesandservicesrelated to regulation of the practice of LPNs, RNs, APRNs and MA-Cs (certified medication assistants)

•Communicatingandenforcing standards for nursing education programs approved by the Board; and

•Monitoringandanalyzing regulatory trends in nursing practice and education

Andrea Anzalone, RN, BSPH, MSN-Ed, assumed the position of Associate Director for Investigation and Discipline on June 23, 2014. Andrea, who is new to Idaho, receives and investigates the full-range of complaints of violations of the Nursing Practice Act and Administrative Rules of the Board. Working closely with the Board’s prosecutor, she prepares cases for presentation to the members of the Board and provides testimony in case hearings. In addition, she reports significant investigative information to other regulatory boards and law enforcement.

Board Input is Welcome/Next Meeting Scheduled As always, the Board welcomes your input and invites the public to attend scheduled

Board meetings and participate in the Open Forum held on the second day of each

meeting.ThenextmeetingoftheBoardistentativelyscheduledforOctober9-10,2014ata location to be determined.

Current Board Members

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Susan Odom, RN, Moscow, Chair; Vicki Allen, RN, Pocatello, Vice Chair; Jill Howell, RN, Jerome; Whitney Hunter, consumer member, Boise; Christopher Jenkins, RN, Homedale;

Jan Moseley, RN, Coeur d’Alene; Carrie Nutsch, LPN, Jerome; Rebecca Reese, LPN, Post Falls; and Clay Sanders, APRN, CRNA, Boise,


News

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[email protected]

Call for papers for RN Idaho for the November Quarterly issue: deadline is September 25th, 2014

Idaho Nurses Association Fall Conference is

November 14, 2014: Early bird registration is now until

October 20th. More information is available at

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Tobacco Cessation continued from page 5

to an outside service, although patient confidentiality must be considered.

The literature reviewed does indicate that hospitals may benefitfromexploringtheadjunctuseoftechnology,includingInternet- or mobile phone-based education for tobacco cessation. Further evidence is needed to determine if these technological interventions could be as effective as intensive counseling. The cost-effectiveness of such interventions also deserves attention as the available evidence indicates they may not be effective for all populations and that “interactive” and “tailored” must be key features of these technologies.

References Cited and Studies AnalyzedAgency for Healthcare Research and Quality (AHRQ). (2013).

Culturally appropriate, interactive decision aid yields high quit rates among underserved, low literacy Hispanic smokers. Retrievedfromhttp://innovations.ahrq.gov/content.aspx?id=3254

Buckley, L. L., & Matteucci, R. (2012). Smoking cessation: Nursing interventions in hospitalized patients. CINAHL Plus with Full Text – Evidence-Based Care Sheets. Glendale, CA: CINAHL Information Systems.

Centers for Disease Control and Prevention (CDC). (2002). Annual smoking-attributable mortality, years of potential life lost, and economic costs – United States 1995-1999. MMWR, 51 (14), 300-303. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5114a2.htm

Civljak, M., Stead, L. F., Hartmann-Boyce, J., Sheikh, A., & Car, J. (2013). Internet-based interventions for smoking cessation. The Cochrane Database of Systematic Reviews, 2013(7), 1-75. doi: 10.1002/14651858.CD007078.pub4.

Escoffery,C.,McCormick,L.,&Bateman,K.(2004).Developmentand process evaluation of a web-based smoking cessation program for college smokers: Innovative tool for education. Patient Education and Counseling, 2004 (53), 217 225.

Health Quality Ontario. (2010). Population-based smoking cessation strategies: A summary of a select group of evidence-based reviews. Ontario Health Technology Assessment Series, 10 (1), 1-44.

Healthy People 2020. (2013). Tobacco use. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=41

Myung, S. K., McDonnell, D. D., Kazinets, G., Seg, H. G., & Moskowitz, J. M. (2009). Effects of web- and computer-basedsmoking cessation programs: Meta-analysis of randomized controlled trials. Archives of Internal Medicine, 169 (10), 929-937.

National Guideline Clearinghouse (NGC). Guideline synthesis: Treatment of tobacco dependence. In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); [2014 April 03]. Retrieved from http://www.guideline.gov/syntheses/synthesis.aspx?id=47753

Rigotti, N. A., Clair, C., Munafo, M. R., & Stead, L. F. (2012). Interventions for smoking cessation in hospitalized patients. The Cochrane Database of Systematic Reviews, 2012 (5), 1-86. doi: 10.1002/14651858.CD001837.pub3.

The Joint Commission. (2014). Core measure sets: Tobacco treatment. Retrieved from http://www.jointcommission.org/core_measure_sets.aspx.

U.S. Department of Health and Human Services (HHS), Public Health Service, Office of the Surgeon General. (2004). The health consequences of smoking: A report of the Surgeon General. Rockville, MD: HHS. Retrieved from http://www.cdc.gov/tobacco/data_statistics/sgr/2004/index.htm

Vick,L.,Duffy,S.A.,Ewing,L.A.,Rugen,K.,&Zak,C. (2013).Implementation of an inpatient smoking cessation program in a Veterans Affairs facility. Journal of Clinical Nursing, 22 (5/6), 866-880.

Whittaker, R., McRobbie, H., Bullen, C., Borland, R., Rodgers, A., &Gu,Y. (2012).Mobilephone-based interventions forsmokingcessation. Cochrane Database of Systematic Reviews, 2012 (11), 1-24. doi: 10.1002/14651858.CD006611.pub3.

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by Alice Kane, Idaho State University,Pocatello, Idaho


Idaho State University’s (ISU) School of Nursing has successfully implemented its Northwest Rural Nursing Residency (NWRNR) grant-funded program. The 6-year, $1.3 grant was funded by the Health Resources and Services Administration and ended June 30, 2014. Over the grant period, the project enrolled 323 graduate nurses from 23 states who were employed by the 106 rural hospital facilities. The NWRNR focused on closing the gap between education and practice. In Idaho, it was a collaborative project between ISU and rural hospital facilities intended to improve nursing practice in small, rural, underserved facilities and thereby increasing patient care quality. Overall, facilities developed better prepared nurses and preceptors while nurses gained skills, confidence and continuing education certification credits. Moreover, retention rates at participating facilities increased. The facilities could tailor each residency to meet the rural generalist’s needs. Preceptors and residents experienced flexiblecurriculum, clinical simulations, and mentoring.

CurriculumNWRNR classes were based on the Institute of

Medicine’s areas of needs; some of which were classes for resident nurses including an overview of legal issues, an anaphylaxis simulation, a simulation for gunshotwounds, a pertussis simulation, and a class entitled, Pharmaceutical Crisis Assessment Management. For nurse preceptors the leadership courses included Interprofessional Collaboration, Adaptive Leadership, Risk Management, Transforming Care, and Coaches (training coaches to teach R.N. leaders). Respected and internationally-known rural nurse specialist Angie Bush PhD, RN, FAAN, PHCNS-BC led the class on Rural Nursing, the central topic for the NWRNR program. Kathleen Olsen PhD, RN was the primary facilitator for the live simulations while Dr. Beverly Hewett from ISU’s School of Nursing was the Project Director.

Each year-long rotating syllabus delivered over 30classes of continuing nurse education coursework via synchronous video technology, for both live simulation and live lectures. Enrollees, no matter where therural facility in which they worked, from Alaska to Louisiana, could go online at pre-scheduled class times and go live into their virtual classrooms. Recordings were always available for later viewing. But it was the live, real-time classroom that provided participants

the opportunity to collaborate with other participants, to share experiences and ideas, and to learn fromeach other. Rural hospital facility administrators who signed up for NWRNR recognized the value of the training offered which included a continuing education curriculum for newly graduated nurse residents transitioning into the hospital workplace environment and the development of leadership and coaching skills for nurse preceptors. This training was at no cost to the facility or nurse.

Program OutcomesA variety of surveys and evaluations were used to

gauge competency in delivering a quality residency program. Data collected showed that participants very much appreciated the coursework, instructors, live-simulation classes, and confidence building. Facilities profited from reduced travel expenses (online classesduring normal business hours delivered to workplace), increased nurse confidence, reduced turnover, and fostering of best practices.

In addition to the collaborative efforts between NWRNR and rural facility administrators, the program could not have succeeded without the collaboration between ISU’s School of Nursing, and other University departments, including Pharmacy, the Institute of Rural Health, Contracts & Grants, the Office of the Vice-President for Research & Economic Development,and ISU’s Instructional Technology Resource Center (ITRC). ITRC was instrumental in facilitating participants’ online learning via the University’s learning management system, Moodle.

The professional structure and selection of these classes and the advanced delivery methods greatly enhanced the quality of the education and the students’ success in completion of the required coursework to earn their certification. In fact, an increasing number of nurse residents over the course of the grant period were using their Continuing Education (CE) creditsfor their licensing requirements which more states are beginning to demand. It was this modeling of educational professionalism that earned NWRNR accreditation from the American Nurses Credentialing Center (ANCC) through2016.Adherence toexcellenceto ensure the NWRNR program remains ANCC accredited has been carefully maintained.

Report from the Idaho State University Rural Nurse Residency Program

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Cardinal Health’s ‘RNspire’ Program Aims to Recognize, Honor and

Inspire NursesIn honor of the inspiring work nurses do, Cardinal

Health, headquartered in Dublin, Ohio, has launched RNspire, a new program dedicated to informing, inspiring, honoring, and recognizing the nursing community. The program launched during National Nurses Week (May 6 – 12) with a Facebook competition to solicit stories of nursing inspiration.

Cardinal Health is a healthcare services company that provides pharmaceuticals, medical products, and services to more than 100,000 locations each day (see Cardinal Health’s Website). According to Don Casey, CEOoftheMedicalsegmentofCardinalHealth:

“We know that nurses touch the lives of those witnessing their care – be they patients or colleagues or family – and we appreciate how they inspire and lead those around them. Our hope in initiating a grassroots campaign like the RNspire program is that all those affected by nurses will seize the opportunity to recognize them. We know they deserve it.”

On Facebook, nurses shared personal stories about what inspires them as a nurse and voted for their favorite one. Nearly three-thousand votes later, Cardinal Health named Marvin Delfin of Trinity Mother Frances Hospital in Tyler, Texas, the winner onMay 27, 2014,and donated $5,000 to the Wounded Warrior Project® in his honor.

Marvin wrote in his submission: “With my scrubs as my superhero costume, with compassionate care as my weapon, I believe I can make a difference in someone else’s life.” No one said it was easy, but the work of Marvin and all nurses inspire thousands of people every day. See the RNspire Website at http://www.RNspire.com for further information and to watch a video that honors the contributions nurses make every day.

For this and other ‘RNspire’ updates, join the community on Facebook at http://facebook.com/RNspire.

Cardinal Health (2014). Cardinal Health launches RNspire nurse appreciation program to recognize and inspire nurses. Retrieved from http://cardinalhealth.mediaroom.com/2014-05-05-Cardina l-Health-Launches-RNspi re-Nurse-Appreciation-Program-To-Recognize-And-Inspire-Nurses


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Spread the word

Please tell your patients: Medicare covers screening for prediabetes and diabetes for seniors at risk.

In America, approximately half of seniors 65 years or older have undiagnosed prediabetes or diabetes. But millions of seniors aren’t aware that Medicare covers the cost of diabetes screening if they’re at risk, so they might not be getting the treatment they need to prevent heart disease, stroke, blindness, kidney disease and amputations.

Help get the message out about the need for diabetes screening and the coverage that Medicare provides. Spread the word.

Documents

Member Spotlight...enteral nutrition. While caring for these patients, nurses routinely use water to dilute the feeding solutions, flush the enteral tube, and administer medications