Constituent member of ANA

The mission of the Delaware Nurses Association is to improve healthcare in Delaware by the advancement of nursing.Quarterly publication direct mailed to approximately 12,000 RNs and LPNs in Delaware.

Volume 44 • Issue 3 August, September, October 2019

Reporter The Official Publication of the Delaware Nurses Association

Loneliness and Social Isolation: The Consequences

of Being Lonely

Page 4

Loneliness and Social Isolation Among College

Students with Type 1 Diabetes

Page 6Traci L. Williams,BSN, RN-BC

Jennifer Saylor, PhD, APRN, ACNS-BC

current resident or

Presort StandardUS Postage

PAIDPermit #14

Princeton, MN55371

InsideDNA

REPORTER

Executive Director’s ColumnGuest Editor

Sarah Carmody

Jennifer S. Graber, EdD, APRN, PMHCNS-BC

Jennifer Graber graduated from the University of Delaware with her BSN and minors in Biological Sciences and Psychology. She then went on to the University of Pennsylvania where she received her MSN in Psychiatric Mental Health Nursing. Jennifer is Board Certified by the ANCC as an Advanced Practice Clinical Nurse Specialist. She finished her doctorate in Educational Leadership at Delaware State University. Jennifer has worked for over twenty years as a psychiatric nurse in many roles and has taught psychiatric nursing for graduate and undergraduate students. She is the current President for the Beta Xi chapter of Sigma Theta Tau International Nursing Honor Society. Jennifer is a current member of the DNA Continuing Education Committee. She was the recipient of Delaware Today’s Top Nurse in Behavioral Health in 2016 and 2017 and was recently honorable mention as a Delaware Today’s Top Nurse for Service and Volunteerism. Jennifer can be reached at jgraber@udel.edu

Jennifer S. Graber

Loneliness – An Epidemic of the 21st Century

The advent of technology in the 21st century has led to a global epidemic of loneliness. Perlman and Peplau first defined loneliness in 1982 as “the unpleasant experience that occurs when a person’s network of social relations is deficient in some important way, either quantitatively or qualitatively” (p. 31). Since loneliness was first defined and recognized as a psychological phenomenon, there has been an approximately 30% increase in reported loneliness in adults over the last 40 years (Cacioppa, Grippo, London, Goosens, & Cacioppo, 2015).

Loneliness brings about a lack of social connections. Social connections are the relationships people have with others around them, the way in which people talk,

Guest Editor continued on page 2

Sarah J. Carmody, MBA

Health care delivery is dynamic and constantly changing in response to societal needs, new technology, and new scientific information. Nursing is equipped to meet the needs of Delawareans through nurse specialties that focus on a specific type of nursing or population. The ability of DNA to meet our mission of improving healthcare in Delaware is significantly strengthened by the knowledge and expertise of our specialty nursing organization affiliates. This June, the DNA Board of Directors approved the Delaware Organization of Nurse Leaders (DONL) as our newest organizational affiliate. Welcome!

Affiliation with DNA is much more than recognition on our website or in our publications. It is a way for nurses in Delaware to collaborate and find solutions to nursing issues and healthcare challenges in our state. It is a way to recognize nursing expertise and bring forward a stronger nursing voice to the Delaware General Assembly. If you are a leader of a specialty group, please consider affiliation with DNA. Together, we can make a difference in improving the lives of Delawareans while advancing the nursing profession.

This spring, DNA and the Delaware Today magazine celebrated nursing by acknowledging top nurses in our state. The Excellence in Nursing gala was a beautiful celebration of the nursing profession in Delaware. Congratulations to all! Thank you to Andrea Holecek EdD, MSN, MBA, RN, NE-BC, FACHE for delivering the keynote address.

President's Message . . . . . . . . . . . . . . . . . . . . . 2Loneliness and Social Isolation: The Consequences of Being Lonely . . . . . . . . 4Loneliness: The Effects on Mental Health and Wellness and the Nursing Role . . . . . . . . 5Loneliness and Social Isolation Among College Students with Type 1 Diabetes . . . . . 6Loneliness in the Elderly . . . . . . . . . . . . . . . . . 7

Nursing Excellence in 2019: Defining and Advancing . . . . . . . . . . . . . . .8-9LPN Membership Activation Form . . . . . . . . 10Delaware Today Magazine’s Excellence in Nursing Gala . . . . . . . . . . . . . 10DNA Membership Activation Form . . . . . . . 11

Welcome New and Returning Members . . . . 11

Page 2 • DNA Reporter August, September, October 2019

OFFICIAL PUBLICATIONof the

Delaware Nurses Association

4765 Ogletown-Stanton Road, Suite L10Newark, DE 19713

Phone: 302-733-5880Web: http://www.denurses.org

The DNA Reporter, (ISSN-0418-5412) is published quarterly every February, May, August and November by the Arthur L. Davis Publishing Agency, Inc., for the Delaware Nurses Association, a constituent member association of the American Nurses Association.

EXECUTIVE COMMITTEE

President Past PresidentGary W. Alderson, Leslie Verucci, RN, MSN, RN, Esq. CNS, CRNP-A, APRN-BC

Treasurer SecretaryJon M. Leeking, Christopher E. Otto, MSN, RN BSN, RN, CHFN, PCCN, CCRN

COMMITTEE CHAIRS

Continuing Education CommitteeKathleen Neal, PhD, RN on Nomination Felisha A. Alderson, Professional Development MSN, RN, CRRN

Sandra Nolan, PhD, RN Terry Towne, MSN, RN-BC, NE-BC

AdvocacyMembers of the Board of Directors

CommunicationsWilliam T. Campbell, Ed.D, RN

Karen Panunto, Ed.D, MSN, APRN

Executive DirectorSarah J. Carmody, MBA

ORGANIZATIONAL AFFILIATES

Oncology Nursing Society-Delaware Diamond Chaptercommunities.ons.org/delawarediamond/chapterleadership

Delaware Organization of Nurse Leaderswww.delawareone.org

Subscription to the DNA Reporter may be purchased for $20 per year, $30 per year for foreign addresses.

For advertising rates and information, please contact Arthur L. Davis Publishing Agency, Inc., 517 Washington Street, PO Box 216, Cedar Falls, Iowa 50613, (800) 626-4081, sales@aldpub.com. DNA and the Arthur L. Davis Publishing Agency, Inc. reserve the right to reject any advertisement. Responsibility for errors in advertising is limited to corrections in the next issue or refund of price of advertisement.

Acceptance of advertising does not imply endorsement or approval by the Delaware 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. DNA and the Arthur L. Davis Publishing Agency, Inc. shall not be held liable for any consequences resulting from purchase or use of an advertiser’s product. Articles appearing in this publication express the opinions of the authors; they do not necessarily reflect views of the staff, board, or membership of DNA or those of the national or local associations.

Managing EditorsWilliam T. Campbell, Ed.D, RN

Karen Panunto, Ed.D, MSN, APRN

The DNA Reporter welcomes unsolicited manuscripts by DNA members. Articles are submitted for the exclusive use of The DNA Reporter. All submitted articles must be original, not having been published before, and not under consideration for publication elsewhere. Submissions will be acknowledged by e-mail or a self-addressed stamped envelope provided by the author. All articles require a cover letter requesting consideration for publication. Articles can be submitted electronically by e-mail to Sarah J. Carmody, MBA @ sarah@denurses.org.

Each article should be prefaced with the title, author(s) names, educational degrees, certification or other licenses, current position, and how the position or personal experiences relate to the topic of the article. Include affiliations. Manuscripts should not exceed five (5) typewritten pages and include APA format. Also include the author’s mailing address, telephone number where messages may be left, and fax number. Authors are responsible for obtaining permission to use any copyrighted material; in the case of an institution, permission must be obtained from the administrator in writing before publication. All articles will be peer-reviewed and edited as necessary for content, style, clarity, grammar and spelling. While student submissions are greatly sought and appreciated, no articles will be accepted for the sole purpose of fulfilling any course requirements. It is the policy of DNA Reporter not to provide monetary compensation for articles.

Reporter

President’s Message

Gary W. Alderson

Gary W. Alderson, RN, Esq.

Author Maeve Maddox recently noted that nowadays “the word optics is being used as I would use the word perception … or appearance, ‘the way things look.’ (Maddox, n.d.). British author C.S. Lewis said that “what you see and hear depends a good deal on where you are standing; it also depends on what sort of person you are.” This is a story about the optics of healthcare from a peer.

My 91-year old father-in-law, Gene, recently fell and broke his hip. He had obvious deformity, could not stand or bear weight, and was in pain. I called 911, described the emergency and patient, in detail, then listened to the 911 operator tell me what to do and what not to do: don’t move him, don’t give him anything by mouth, stay with him, turn the porch light on (it was 5 pm, and 100% sunlight). I rolled my eyes – how silly; I’ve been a first responder for 45 years and an RN for 37. But I’ve also been an attorney for 20 years and therefore appreciate what has become of common sense. Rather than stopping her speech when I identified myself as a nurse, the 911 operator continued to the end and I listened. To her, going completely “by the book” was a shield. Good for her. So what are the optics when someone “goes by the book” as a sword not a shield?

Gene is a very proud, stoic man who happens to be blessed with a very high pain tolerance. But in the ED

with an obvious injury he was almost begging for pain medication. My wife, also an RN for over 30 years, and myself, both former ED nurses; asked his nurse to please get him medicated. Nurse Obvious then breezily told us that he could not have anything for pain until being seen by a physician and that it would be “hours and hours” before he could be seen “because they were very busy and had many people sicker than him.” A quick conversation with the charge nurse remedied that and he was quickly evaluated and medicated as he should have been. But that’s beside the point.

Not long before Nurse Obvious came in and denied him pain medicine, I walked through the ED to my father-in-law’s room and saw several staff members sitting at the nurse’s station laughing and talking amongst themselves or glued to their cell phones. I completely understand the flow of an ED and how things get backed up, so I will not assume they were goofing off or ignoring their patients. But consider the optics - which certainly were not good. I’ve usually been on the staff side of that scene and when I have been on the patient or family side I’ve been spoiled because I’ve almost always gone to a facility where we knew at least some of the staff and were treated as their own family. But should that matter?

I ask that as we all strive to improve our profession and increase our political clout, please always keep in mind the optics of what we do and how we do it. One bad apple does not spoil the whole bunch, and all of the other nurses we encountered were remarkable. But it may only take one of us to ruin the optics or perception of one’s entire healthcare – and nurse - experience.

ReferenceMaddox, M. (n.d.). Optics and perception. Retrieved from

http://maevemaddox.com/optics-and-perception.

behave toward, and deal with others. This lack of social connection has been linked to poor health outcomes and increased risk for mortality (Holt-Lunstad, Smith, Baker, Harris, & Stephenson, 2015). Having strong social connections can help reduce anxiety and depression and prevent declines in physical health while also help increase happiness and self-esteem (Seppala, 2014).

Healthcare providers must be able to assess for, identify, and offer resources for clients experiencing loneliness. Ideally, healthcare providers would bring about initiatives to prevent loneliness and lack of social connections to stop the possible negative consequences. Several countries have initiated several programs to reduce loneliness in an effort to improve quality of life (Cacioppo et al., 2015; de Jong Gierveld, van Tilburg, & Dykstra, 2016). Overall, there is an increased need for public awareness regarding loneliness as a health condition causing long lasting issues (Cacioppo et al., 2015).

In this DNA Reporter, we will address the silent epidemic of loneliness with several articles highlighting this important issue; Traci Williams, BSN, RN-BC will discuss Loneliness and Social Isolation, Andrea Jones, MSN, RN will explore the topic of Loneliness – The Effect on Mental Health and Wellness and the Nurse’s Role, Jennifer Saylor, PhD, APRN, ACNS-BC will describe Loneliness and Social Isolation Among College Students with Type 1 Diabetes, and Shari Tenner-Hooban, MSN, RN will share information related to Loneliness in the Elderly. Wrapping up Nurses’ Week, you will also find an article by Christopher Otto, MSN, RN, CHFN, PCCN, CCRN regarding Nursing Professional Excellence with a focus on governance, accountability, nursing organizations, certification, education, and meaningful recognition.

Several resources are listed below for healthcare providers to offer those feeling lonely and disconnected:

• The National Alliance on Mental Health (NAMI) works to improve the lives of Americans affected by mental illness.

• Halfofus.com addresses loneliness or any mental health issue.

• The Campaign to End Loneliness believes that people of all ages need connections that matter.

• 4Mind4Body is designed to help people develop social connections.

• The Center for Compassion and Altruism Research and Education has several articles and blogs for resources on combatting loneliness.

ReferencesCacioppo, S. Grippo, A.J., London, S., Goosens, L., & Cacioppo,

J.T. (2015). Loneliness: Clinical import and interventions. Perspectives on Psychological Science, 10(2), 238-249. DOI: 10.1177/1745691615570616.

de Jong Gierveld, J., van Tilburg, T.G., & Dykstra, P.A. (2016). New ways of theorizing and conducting research in the field of loneliness and social isolation. In A.L. Vangelisti & D. Perlman (Eds.), Cambridge Handbook of Personal Relationships (2nd Ed.) (pp. 391-404). Cambridge, New York: Cambridge University Press. DOI: 10.1017/9781316417867.031.

Holt-Lunstad, J., Smith, T.B., Baker, M., Harris, T., & Stephenson, D. (2015). Loneliness and social isolation as risk factors for mortality: A meta-analytic review. Perspectives on Psychological Science, 10(2), 227-237. DOI: 10.1177/1745691614568352

Peplau, L.A., & Perlman, D. (1982). Perspectives on loneliness. In L.A. Peplau & D. Perlman (Eds.), Loneliness: A source-book of current theory, research and therapy (pp. 1-8). New York, NY: Wiley.

Seppala, E.M. (2014). Connectedness & health: The science of social connection. The Center for Compassion and Altruism Research and Education. Retrieved from http://ccare.stanford.edu/uncategorized/connectedness-health-the-science-of-social-connection-infographic/

Guest Editor continued from page 1

Now Hiring “Difference Makers”RNs and LPNs who are ready and willing to make

a difference for those entrusted to our care!

Apply at:

https://exceptionallivingcenters.jobs.net/

Lewes Newark Wilmington

NEW CASTLE COUNTYVOCATIONAL TECHNICAL SCHOOL DISTRICT

Real Learning forReal Life

Teach the next generation of Medical Assistants and Nursing Techs!

An unencumbered and active RN license is required.

For career opportunities visit our website: www.nccvotech.comContact: Mr. Gerald Allen, 1417 Newport Rd.

Wilmington, DE 19804gerald.allen@nccvt.k12.de.us

EOE

http://healthydelaware.org/detect

Page 4 • DNA Reporter August, September, October 2019

Loneliness and Social Isolation: The Consequences of Being Lonely

Traci L. Williams BSN, RN-BC

Traci Williams graduated with her ADN from Delaware Technical Community College in 2009, and then earned her BSN from Wilmington University in 2013. She is a Board Certified Psychiatric–Mental Health Nurse. Traci has been with Christiana Care Health Systems for ten years. She served four years with Private Duty Nursing, and is currently a staff nurse in the Behavioral Health Department on the inpatient behavioral health unit. Traci currently serves as the Behavioral Health Department’s WISH (We Improve Senior Health) Champion. She works hand in hand with the psychiatry team to help patients with acute mental illnesses. Traci can be reached by email at TraWilliams@ChristianaCare.Org or at (302) 320-2352.

Traci L. Williams

Loneliness is different than social isolation. The best depiction of this is that a person can be alone, but not feel lonely. Also, a person can be surrounded by others and still feel lonely. Loneliness refers to a negative emotion related to a person’s perception of the quality of his or her relationships. Whereas social isolation refers to the number of people a person may have contact with. This would be a classic example of quantity versus quality. While the two concepts are very different, they are often significantly interconnected. A person who is isolated may grow to become lonely, and a person who feels lonely may isolate (“Care Connect & Age UK,” 2019). Loneliness is cited in many texts as being a risk factor for significant health consequences, poor recovery, and increased mortality. For this reason, it is important that health care providers assess at-risk individuals for loneliness, and help create interventions to promote healthy social environments.

For thousands of years, people seldom lived alone, but beginning in the mid-20th century a trend of individuals living alone began. As recently as 2013, it is estimated that more than a quarter of households in the United States (U.S.), Russia, Canada, Spain, and Japan are one-person households. Thirty percent of households in Germany, France, and England, and more than 40% of households in Scandinavian nations were estimated to be one-person (Klinenberg, 2016). That being said, not all of these individuals are lonely. A study in Denmark identified several risk factors for loneliness (Lasgaard, Friis, & Shevlin, 2016). Often aging is associated with loneliness due to conditions that naturally occur with aging (chronic disease, retirement, death of friends/family/spouse, disability, etc.) (Lasgaard et al., 2016). This is true, as a person grows older, there are a lot of changes that can lead to isolation and loneliness, but there are many more populations that also have high rates of loneliness. Many people experience loneliness across different periods of their lives. In the Danish study, 54,300 randomly selected individuals were invited to participate in a questionnaire, 33,285 people responded. The participants ranged from 16-102 years of age. The survey used a Danish version of the Three-Item Loneliness Scale, and compared data across socio-demographic and health-related factors. It was found that the highest rates of loneliness were among the adolescents, young adults, and older adults. Socio-economic status, health-related factors, minority status, living alone, and prolonged mental illness were also demonstrated to show increased incidence of loneliness (Lasgaard, et al., 2016). In 2011, the Centers for Disease Control and Prevention identified suicide as the third leading cause of death among adolescents. Social anxiety and loneliness play a large role in the development of suicidality in high-risk adolescents (Gallagher, Prinstein, Simon, & Spirito, 2014). There has also been evidence of loneliness in school aged children. A Finnish study showed that nearly 60% of children in grades five, seven, and nine experienced loneliness occasionally, and 10% expressed this was

common (Lyyra, Välimaa, & Tynjälä, 2018). A Greek study showed that 70% of the school aged children experienced loneliness sometimes, and 7% expressed feeling it often (Lyyra et al., 2018). In the U.S. a study showed that 14% of participants experienced high levels of loneliness over an extended time period (Lyyra et al., 2018). Essentially, loneliness is not exclusive to old age, but is something that is experienced across many demographics and ages.

There are many risks and consequences associated with loneliness. The literature reviewed was able to find a correlation between negative health (mental and physical), and loneliness. Loneliness experienced over a long period is associated with anxiety, depression, negative academic performance, poorer (self-reported) health, and substance abuse. In children there is a correlation between increased subjective health complaints (headaches, shoulder and back pain) and increased reports of loneliness (Lyyra et al., 2018). There is also evidence to support that loneliness contributes to higher health care utilization and negative outcomes such as high blood pressure, cardiovascular disease, increased incidence of disability, cognitive decline, and increased incidence of mental illness. It is also suggested that individuals that are chronically lonely may utilize their healthcare team for social contact (Gerst-Emerson, & Jayawardhana, 2015). Similar to medical outcomes, individuals with loneliness have worse outcomes in their mental health. A systematic review evaluated literature and research about outcomes of mental health problems and their correlation with loneliness. In depression the research supported that an individual that perceives they have poor social support or greater loneliness would be more likely to have higher depressive symptoms, and they would have poorer outcomes at follow-up appointments (Wang, Mann, Lloyd-Evans, Ma, & Johnson, 2018). Similar results were found in bipolar disorder, as well as a greater impairment in the individuals functioning, and prolonged recovery time. In schizophrenia or schizoaffective disorders individuals with greater social support would predict better satisfaction with quality of life. In individuals with anxiety disorders greater feelings of loneliness or poor social support was consistent with more severe anxiety, and those that perceived greater support reported a better quality of life over time (Wang et al., 2018).

Through the research reviewed, there were several suggestions consistently made for solutions. It is identified that loneliness can occur throughout the lifetime and can affect anyone. It is even considered by some as a new health epidemic that greatly affects the quality of life and the health outcomes of individuals. Assessing a person’s perception of their support network and identifying individuals experiencing loneliness, or that have a lack of social support, allows a provider to better plan interventions that work for the clients’ needs, but also allows the provider to recognize gaps in care. If a person is identified to be lonely, a provider can make referrals to programs or an appropriate intervention that may benefit the individual (Wang et al., 2018). There are also some protective factors identified for isolated individuals such as wisdom, emotional regulation, and pro-social behaviors (Lee et al., 2018).

Overall there is a large body of evidence that supports a correlation of poor outcomes with individuals who perceive they have poor social supports or loneliness. It is something that affects people across different ages, socio-economic statuses, and demographics. It is important to identify individuals with limited social support to improve health outcomes, and improve quality of life overall. Community programs, volunteering, recreational programs, and church involvement are great low-cost solutions for lonely older adults. For adolescence, after school programs, enrichment programs, reducing screen time, and athletic activities are great options for encouraging social interactions. Each person is different, an isolated person is not necessarily lonely, but a lonely person is at risk for increased physical, social, emotional, financial, and health consequences.

ReferencesCare Connect, & Age UK Group. (2019, March 5). Loneliness

and isolation – understanding the difference and why it matters. Retrieved March 15, 2019, from https://w w w.ageuk.org.uk/our-impact/pol icy-research/loneliness-research-and-resources/loneliness-isolation-understanding-the-difference-why-it-matters/

Gallagher, M., Prinstein, M., Simon, V., & Spirito, A. (2014, August). Social anxiety symptoms and suicidal ideation in a clinical sample of early adolescents: Examining loneliness and social support as longitudinal mediators. Journal of Abnormal Child Psychology, 42(6), 2014, pp. 871–883., doi:10.1007/s10802-013-9844-7.

Gerst-Emerson, K., & Jayawardhana, J. (2015). Loneliness as a public health issue: The impact of loneliness on health care utilization among older adults. American Journal of Public Health, 105(5), 1013-9. doi:10.2105/AJPH.2014.302427

Klinenberg, E. (2016). Social isolation, loneliness, and living alone: Identifying the risks for public health. American Journal of Public Health, 106(5), 786–787. https://doi-org.mylibrary.wilmu.edu/10.2105/AJPH.2016.303166

Lasgaard, M., Friis, K., & Shevlin, M. (2016). “Where are all the lonely people?” A population-based study of high-risk groups across the life span. Social Psychiatry and Psychiatric Epidemiology, 51(10), 1373-1384. doi:10.1007/s00127-016-1279-3

Lee, E., Depp, C. Palmer, B. Glorioso, D., Daly, R., Liu, J., … Jeste, D. (2018, December 18). High prevalence and adverse health effects of loneliness in community-dwelling adults across the lifespan: Role of wisdom as a protective factor. International Psychogeriatrics, U.S. National Library of Medicine, www.ncbi.nlm.nih.gov/pubmed/30560747.

Lyyra, N., Välimaa, R., & Tynjälä, J. (2018). Loneliness and subjective health complaints among school-aged children. Scandinavian Journal of Public Health, 46(20_suppl), 87-93. doi:10.1177/1403494817743901

Wang, J., Mann, F., Lloyd-Evans, B., Ma, R., Johnson, S. (2018, May 29). Associations between loneliness and perceived social support and outcomes of mental health problems: A systematic review. BMC Psychiatry, 18(1), 2018, doi:10.1186/s12888-018-1736-5.

Did you know the DNA Reporter goes to all registered nurses in

Delaware for free?

Arthur L. Davis Publishing does a great job of contacting advertisers, who support the publication of our newsletter. Without Arthur L. Davis Publishing and advertising support, DNA would not be able to provide the newsletter to all the nurses in Delaware.

Now that you know that, did you know receiving the DNA Reporter does not automatically provide membership to

the Delaware Nurses Association?

DNA needs you! The Delaware Nurses Association works for the nursing profession as a whole in Delaware. Without the financial and volunteer support of our members, our work would not be possible. Even if you cannot give your time, your membership dollars work for you and your profession both at the state and national levels. The DNA works hard to bring the voice of nursing to Legislative Hall, advocate for the profession on regulatory committees, protect the nurse practice act, and provide educational programs that support your required continuing nursing education.

At the national level, the American Nurses Association lobbies, advocates and educates about the nursing profession to national legislators/regulators, supports continuing education and provides a unified nationwide network for the voice of nurses.

Now is the time! Now is the time to join your state nurses

association! Visit www.denurses.org to join or

call (302) 733-5880.

Did ?YouKnow

August, September, October 2019 DNA Reporter • Page 5

Loneliness: The Effects on Mental Health and Wellness and the Nursing Role

Andrea B. Jones, MSN, RN

Andrea B. Jones earned her LPN and ADN from Salem Community College, and her BSN and MSN from Wilmington University. She aspires to become a distance learning educator while continuing to serve as a staff nurse. Andrea began her nursing career with Drenk Behavioral Health, a resident treatment facility for adolescents. She currently works as a behavioral health staff nurse within Christiana Care Health System. Andrea serves on several councils and committees, professionally and personally. She is passionate about serving as a missionary nurse and has served locally, nationally, and globally. Most recently, Andrea received a Jefferson Award for her dedication to serving others. Andrea can be reached by email: mrsandreabjones@yahoo.com or by phone: (856) 364-3817.

Andrea B. Jones

Before one can appreciate the effects loneliness has on mental health and wellness, it is imperative to understand their correlation. Abraham Maslow, a prominent psychologist, established that human motivation is based on achieving fulfillment through personal growth. Maslow developed a pyramid known as Maslow's Hierarchy of Needs: beginning at its base with physiological needs, then continuing upward with safety needs, love and belonging needs, esteem needs, and finally self-actualization needs. In other words, humans must have basic needs met before progressing to the next level. Self-actualization cannot be attained without having love and belonging needs met, which includes loneliness.

Maslow is not the only expert to identify the interconnectedness between the lack of social well-being (loneliness) and mental illness. Edward Deci and Richard Ryan, psychologists, developed the self-determination theory. Deci and Ryan concluded humans have three basic needs for "sustained, volitional motivation: (a) autonomy, (b) competence, and (c) relatedness" (Martino, Pegg, & Frates, 2017, p. 466-467). As a basic human need, humans desire connectedness. When connectedness is diminished, or absent, this contributes to feelings of loneliness.

Next, is the concept of loneliness. Loneliness is universal and may seem straightforward. However, loneliness is a very complex human emotion and is especially subjective. In spite of its subjectivity, loneliness is a measurable concept, most commonly measured using the UCLA Loneliness Scale (Russell, Peplau, & Ferguson, 1996). Originally developed in 1978, this tool has been revised and Version 3 is the latest adaptation. "..., scores on the UCLA Loneliness Scale supports theoretical views linking loneliness to emotional states such as depression, anxiety, ... loneliness is a serious mental health problem" (Russell et al., 1996, p. 293). "Loneliness is one of the main indicators of social well-being" (R. Mushtaq, Shoib, Shah, & S. Mushtaq, 2014, p. 1). Mushtaq et al. (2014) stated that > 80% of adolescents and > 40% of elderly reported loneliness. Social well-being is one of Maslow's needs and the lack of social well-being may lead to mental illness. Therefore, loneliness assessment is paramount.

Providers diagnose mental illness using criterion established in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). While loneliness is not listed in the DSM-5, it must be strongly considered and evaluated when patients report symptoms of mental illness, especially those related to depression. It is also important to know that depression is a leading cause for patients seeking mental health treatment. No one is immune to depression, regardless of age, socioeconomics, and global locale. According to the World Health Organization (2018), "Depression is a common worldwide illness, with more than 300 million people affected." Depression is precipitated by a multitude of factors, more specifically, loneliness. Additionally, validated research indicates a direct correlation between loneliness and depression.

Two types of evidenced-based healthcare specifically identify the need to assess for feelings of loneliness. They are lifestyle medicine and positive psychiatry. Lifestyle medicine uses an evidence-based lifestyle therapeutic approach that includes having a strong support system (American College of Lifestyle Medicine, n.d.). According to Jeste, Palmer, Retter, and Boardman (2015), positive psychiatry is "the science and practice of promoting well-being, through the utilization of assessment and interventions that employ positive psychosocial characteristics (PPCs) ..." (p. 676) including social support. Lifestyle medicine and positive psychiatry further demonstrate the importance of social being and its interconnectedness to mental wellness.

Therefore, if loneliness is a primary indicator of social well-being and the lack of social well-being can lead to mental illness, most commonly manifesting as depression, loneliness directly correlates to depression. For this reason, it is essential that clinicians can skillfully assess loneliness. When appropriate, nurses must assess patient loneliness and can accurately do so by incorporating the 20 question UCLA Loneliness Scale during the initial assessment phase. Objective listening may indicate signs of potential loneliness. Furthermore, nurses can evaluate if a patient is meeting treatment goals by reassessing loneliness throughout treatment.

Nursing care is a finely balanced combination of applying evidenced based practices (EBP) and the art of nursing. Finding this balance is especially important when caring for a patient with mental illness. To be successful in doing so, nurses need to be well versed in the etiology and epidemiology of loneliness, its impacts on mental health and wellness, developing care plans to decrease loneliness, and assisting a patient to return to wellness.

A non-judgmental, empathetic approach should be employed. Establishing a therapeutic relationship, coupled with effective communication skills and the utilization of therapeutic techniques proves most beneficial for patient success. Self-awareness of verbal and non-verbal communication, as well as attention to the same in the patient, greatly impacts the successful development of a great nurse-patient

relationship. When appropriate, cultural sensitivity should be considered, as cultural views on mental illness vary.

The following are some nursing intervention strategies to consider when developing care plans. The nurse should pay particular attention to the reported happiness with their social support rather than the quantity of social support during assessments, as this may have the greatest impact on loneliness. Nurses can teach patients' skills for communicating with providers or family members and make referrals to support services. Since lonely patients often feel misunderstood, the nurse should work toward reducing loneliness by normalizing the experience. Nurses may help patients develop different patterns of thinking to considering another explanation for the perceived behavior of others. For example, a patient says someone rarely calls and perceives this behavior to be a lack of caring. An alternate thought might be the friend is worried about disturbing the patient’s sleep. Consequently, through assessment, intervention, and referral, the nurse plays a vital role in decreasing patient loneliness while assisting in their return to an optimum level of health and wellness.

Since loneliness can affect anyone, nursing awareness and education should not be limited to psychiatric and behavioral health nursing. Nurses will care for patients experiencing loneliness in all patient care settings, including inpatient, outpatient, and specialty treatment facilities. Due to the brevity of this article, it is impossible to fully address loneliness, the effects on mental health and wellness, as well as the nursing role. It is the hope that this article will motivate nurses to increase awareness and augment current practices.

ReferencesAmerican College of Lifestyle Medicine. (n.d.). Lifestyle medicine. Retrieved from https://life

stylemedicine.org/What-is-Lifestyle-MedicineJeste, D. V., Palmer, B. W., Retter, D. C. and Boardman, S. (2015). Positive psychiatry: Its time

has come. Journal of Clinical Psychiatry, 76(6), p. 675-683. DOI: 10.4088/jcp.14nr 09599Martino, J., Pegg, J. and Frates, E. P. (2017). The connection prescription: Using the power of

social interactions and the deep desire for connectedness to empower health and wellness. American Journal of Lifestyle Medicine, 11(6), 466-475. DOI:10.1177/155982761508788

Mushtaq, R., Shoib, S., Shah, T. and Mushtaq, S. (2014). Relationship between loneliness, psychiatric disorders and physical health? A review on the psychological aspects of loneliness. Journal of Clinical and Diagnostic Research, 8(9). DOI: 10.7860/JCDR/2014/10077.4828

Russell, D. W., Peplau, L. A. and Ferguson, M. L. (1996). UCLA loneliness scale (Version 3): Reliability, validity, and factor structure. Journal of Personality Assessment, 42(3), 290-294. DOI: 10.1207/s15 327752jpa6601_2

World Health Organization. (2018). Depression. Retrieved from https://www.who.int/news-room/fact-sheets/detail/depression

Page 6 • DNA Reporter August, September, October 2019

Loneliness and Social Isolation Among College Students with Type 1 Diabetes

Jennifer Saylor, PhD, APRN, ACNS-BC

Jennifer Saylor is an Assistant Professor in the School of Nursing at the University of Delaware. Jennifer also holds a joint position with the Department of Health and Nutrition and is the Director of Diabetes and You: Kamp for Kids, which is a week-long diabetes day camp for children and their siblings/friends. Jennifer’s expertise is in transition to college of emerging young adults with type 1 diabetes and psychosocial needs. She works collaboratively with the College Diabetes Network as the Research Liaison and as a member of their Campus Advisory Council Committee and Clinical Scientific Committee. Jennifer has presented to numerous audiences locally, nationally, and internationally on topics related to college students with type 1 diabetes, leadership, mentoring, global health, simulation, and transitioning. She has published in a variety of journals and completed funded research focusing on type 1 diabetes among college students. The combination of Jennifer’s clinical practice, scholarship, diabetes camp directorship, and involvement in the College Diabetes Network illustrates a strong commitment to diabetes research, policy, and campus life for college students with diabetes. Jennifer can be reached at jsaylor@udel.edu or 302-831-8196.

Jennifer Saylor

In the United States, there are approximately 20.4 million college students and many of them have a chronic condition (Integrated Postsecondary Education Data System, 2016). Among these chronic conditions, there are an estimated 53,000 students with Type 1 Diabetes (T1D) attending colleges/universities (Roth, 2014), yet only 1.3% of undergraduate college students reported their diabetes diagnosis (combined type 1 and type 2 in survey) (ACHA, 2018).

The transition to college is a milestone for emerging young adults (18-25 years old), filled with excitement and new found freedoms. However, the college campus culture is complex with erratic academic schedules, unlimited food choices,

independent studying schedules, new social environments, potential risky behavior, sports, and little to no parental oversight. For many students all these changes are overwhelming and they feel pressure to succeed in all areas. It is not surprising that one in four students are diagnosed with a mental health condition due to the pressure of academia (Liu, Stevens, Won, Yasu & Chen, 2018).

The American College Health Association (ACHA) conducted a national survey examining student habits, behaviors, and perceptions on prevalent health topics. In spring 2018, 62.8% of college students who completed the survey reported feeling lonely in the past 12 months (ACHA, 2018). This survey did not delineate between those with and without a chronic condition, even though those with a chronic condition are at a greater risk for social isolation and loneliness, especially during transition periods. When compared to healthy first-year college students, students with a chronic medical condition have impaired health-related quality of life and report higher levels of loneliness and isolation (Herts, Wallis & Maslow, 2014).

Students with T1D experience more stress, loneliness, and social isolation as they feel like they are the only person with T1D. In addition, they must incorporate their diabetes management and develop a self-care routine while living with college campus conditions (Saylor & Calamaro, 2016). This is essential as emerging young adults with T1D are at increased risk for diabetes related complications since they have higher hemoglobin A1C levels than other age groups (Monaghan, King, Alvarez, Cogen, & Wang, 2016). Glycemic levels can increase due to stress and lack of sleep, which are both shown to occur with feelings of loneliness and social isolation.

Peer support may decrease the feelings of loneliness and social isolation while also helping with chronic condition management. Colleges and universities have student organizations for students to join and support one another such as Chronic Illness Advocates, Active Minds, and College Diabetes Network (CDN). CDN is a non-profit organization that was founded by Christina Roth in 2009. As a college student with T1D, she felt isolated, misunderstood by her peers without T1D, and faced difficulties incorporating daily T1D management into her college life (CDN, 2019). CDN’s “mission is singularly focused on providing young adults with T1D the peer connections they value, and expert resources they need, to successfully manage the challenging transition to independence at college and beyond” (CDN, 2019).

In a national survey of CDN members in college with T1D, researchers found a statistically significant difference between those with peer

support from a university-based CDN chapter and those without a university-based CDN chapter. Students with T1D involved with a university-based CDN chapter were significantly less likely to report increased levels of isolation (P < .0001), anxiety (P < .0001), and depressive symptoms (P < .0001). In addition, students with a CDN chapter also reported decreased A1C levels (P < .0001) since joining their university-based CDN chapter. Peer support for college students is essential to promote academic success, especially for those with a chronic condition such as T1D (Lombardi, Gerdes, Murray, 2011). Overall, peer networks increase sense of belonging, provide social support, and strengthen development academically and socially.

Healthcare professionals, campus faculty, and campus administrators must be aware of the physical and psychological impact of loneliness, especially for those with chronic conditions such as T1D. The advance practice nurse (APRN) is critical in a successful and safe transition to college for emerging young adults with T1D. APRN’s must be aware that T1D requires a great deal of teaching and support for incorporating diabetes management into the unpredictability of college campus life (Saylor & Calamaro, 2016).

Beyond basic T1D education, this unique age group in college requires education in mental well-being, alcohol use, sexual activity, and maintaining healthy relationships with a desirable A1C level (Saylor, et al., 2017). Most importantly, the APRN has a great opportunity to foster healthcare professional relationships with the college student by providing individualized, nonjudgmental care, updates on the latest diabetes technology, and ways to avoid hypoglycemia/hyperglycemia (Saylor & Calamaro, 2016). This approach must be holistic and include not only the physical medical management, but also mental well-being that will last through the transition to adult care.

References American College Health Association. American College

Health Association-National College Health Assessment II: Reference Group Executive Summary Spring 2018. Silver Spring, MD: American College Health Association; 2018.

College Diabetes Network. (2019). About Us. Retrieved from https://collegediabetesnetwork.org/

Herts, K., L,, Wallis, E., & Maslow, G. (2014). College freshmen with chronic illness: A comparison with healthy first-year students. Journal of College Student Development, 55(5), 475-480.

Integrated Postsecondary Education Data System. Fall Enrollment Survey (IPEDS-EF:90-99); IPEDS Spring 2001 Through Spring 2016, Fall Enrollment Component; and Enrollment in Degree Granting Institutions Projection Model, 2000 Through 2026. Washington, DC: US Department of Education, National Center for Education Statistics: Common Core of Data (CCD); 2016.

Liu, C.H., Stevens, C., Won, S.H.M., Yasu, M., & Chen, J.A. (2018). The prevalence and predictors of mental health diagnoses and suicide among U.S. college students: Implications for addressing disparities in service use. Depression and Anxiety, 36(1), 8-17. https://doi.org/10.1002/da.22830

Monaghan, M., King, M., M., Alvarez, V., Cogen, F., R., & Wang, J. (2016). Changes in type 1 diabetes health indicators from high school to college. Journal of American College Health, 64(2), 157-161.

Roth C. (2014, August 6-9). Supporting young adults with diabetes: Changing systems to address the issues. Presented at the American Association for Diabetes Educators 2014 Annual Meeting & Exhibition, Orlando, FL.

Saylor, J., & Calamaro, C., J. (2016). Transitioning young adults with type 1 diabetes to campus life. Journal of Nursing Practice, 12(1), 41-46.

Saylor, J., West, S., Roth, C., Ike, E., Hanna, K., & Calamaro, C., J. (2017). Psychosocial educational needs of college students who are newly diagnosed with type 1 diabetes. AADE in Practice, 5(6), 40-45.

Elzufon Austin & MondEll, P.A.

GAry W. AldErsonAttornEy At lAW, rEGistErEd nursE

Visit nursingALD.com today!

Search job listingsin all 50 states, and filter by location and credentials.

Browse our online databaseof articles and content.

Find eventsfor nursing professionals in your area.

Your always-on resource for nursing jobs, research, and events.

August, September, October 2019 DNA Reporter • Page 7

Loneliness in the Elderly Shari Tenner-Hooban, MSN. RN

Shari Tenner-Hooban is the Director of Learning Resources in the Nursing Department of Wesley College in Dover, Delaware. Shari studied nursing at Ann May School of Nursing receiving a diploma in 1979. She went on to receive a BSN and MSN from Drexel University. Currently Shari is pursuing an Ed.D at Drexel University with the focus on student engagement, innovation and creativity in the learning environment, with a graduation date of 2023. Her career began in the intensive care unit and moved to the operating room with the majority of her career in the practice area of perioperative nursing; successfully receiving certification as a CNOR from the AORN. Shari resides in Lewes, Delaware with her husband Jim. She is the mother of two grown children Benjamin and Allyson and the grandmother to Jameson. Ms. Tenner-Hooban can be reached at Shari.Tenner@Wesley.edu

Shari Tenner-Hooban

How does one describe the elderly? Is it a number or a state of mind? For this writer, it is undoubtedly a state of mind. As the term elderly describes those of my generation who are 65 or older, and the word geriatric begins to get bantered about, a shiver runs down my spine. The truth is the 2018 census found the demographics of the United States (U.S.) have changed. By the year 2035, the US will have “78 million people over the age of 65” and “the elderly population will outnumber the children for the first time in the country’s history” (Meinert, 2018, p. 1). The US is a diverse population. A lifetime of advanced medical treatments find today’s senior citizens in better physical health than generations before, yet mental health and socialization needs remain complicated for this maturing population (Gilford, 1988). While the need for mental health care in the United States has increased, the funding is not necessarily available making the problem more complex (Meinert, 2018).

Successful aging is a quest and a phenomenon linked to a perceived quality of life. Despite those who persevere the dynamic of aging, change is inevitable. The golden years find changes in physical and mental health, finances, and actual quality of life (Gilford, 1988). Deviation of the nuclear family structure finds many senior citizens living alone far from family or in acute care, long-term care, or extended care facilities with limited family or peer social interaction. These changes result in a “disintegrating identity in society” (Wong, Chau, Fang and Woo, 2017, p. 9). Suddenly the perception arises that the elderly are less valuable, less involved, and less relevant. Wong et al. (2017) discussed social alienation that occurs, describing it as a threefold concern:

1. Negative personal perception by the elderly concerning their healthcare, family interaction, and change in identity within their social circle

2. Adverse behavioral manifestation in response to a new lifestyle and or location

3. Bad feelings perceived toward aging including anger, vulnerability, and helplessness. (p.6).

Thus it becomes imperative to enhance the quality of life to reduce the risk of social alienation and inadequate response to the aging process to reduce other adverse sequlae.

Social isolation, as reported by Owen (2007), results in loneliness, fear, and anxiety. Often used interchangeably, social isolation and loneliness are not the same. Social isolation is defined “as a lack of structural and functional social support, while loneliness is a ‘perceptual’ concept” (Zamir, Hennessy, Taylor, and Jones, 2018, p. 2). This negative concept is unhealthy. Wong et al. (2017) referred to loneliness as a “geriatric giant” contributing to a myriad of physical and mental health dysfunction, associated with high morbidity and mortality (p. 1). To maintain physical and psychological well-being the social environment must be rich with interaction keeping loneliness at bay.

Fifty percent of the elderly surveyed by Owen (2007) cited “television as their main companion,” rarely leaving their homes to visit peers or local businesses (p. 115). While loneliness is subjective; retirement, loss of a spouse, and change in environment due to relocation leads to feelings of alienation and social-connection disruption. Without intervention, social exclusion leads to depression and a subsequent decline in self-esteem and self-confidence.

Loneliness in the elderly is a downward spiral necessitating assessment and early intervention. Vlaming et al. (2014) utilized the Loneliness Literacy Scale as a needs assessment tool for those at risk for loneliness; finding low income, physical restrictions, mild psychological symptomatology, and the widowed as those at higher risk. Identifying those in greater need of intervention provides a mechanism to assist the most vulnerable in achieving socialization resulting in reduced loneliness and isolation.

Daycare programs and senior centers cannot always meet the needs of the population due to contractual agreements, lack of transportation, health care aids and providers, and prohibitive costs. For many, the stigma of senior day camp keeps the elderly at home. The arduous travail of red tape finds many without intervention or entry into a system of help and care (Owen, 2007).

Social engagement and interaction are vital. Wong et al. (2017) proposed sociality, including an active social life and family interaction. Face-to-face communications add a dimension of presence, finding ‘video call’ preferable to email or telephone communication (Zamir, Hennessy, Taylor, & Jones, 2018). Technology, when available to the elderly, offers an easy solution to connect to family and peers. Simplicity and cost effectiveness leads to the cause.

Severo (1983) introduced the “Volunteer Services Group” to the reader. One of the original agencies, this program works as a Telefriend to the elderly (p. 57). The agency receives referrals from local health care providers, hospitals, and community members. This simple mechanism of communication provides a connection for this vulnerable population by a daily phone call. Volunteer workers connect to their clients via telephone in a brief call at the same time each day, seven days a week. Those receiving the service find the connection a relief to the loneliness and fear of dying alone and without discovery. Other services include escorts; library services-but the leading service is daily social interaction.

In conclusion, loneliness is a factor leading to increased morbidity and mortality in the elderly. Review of the literature finds communication as a critical component to keeping senior citizens active, vital, and engaged. A single point of entry for assessment from healthcare providers is a proactive mechanism to identify vulnerable senior citizens. Additional research is needed to find tools to reach seniors especially those who are alone and homebound. Eliminating social isolation and loneliness through socialization programs and interventions mitigating the risk of psychological and physical exacerbations aids healthy aging.

ReferencesGilford, D. M. (Ed.). (1988). The aging population in the twenty-first century: Statistics

for health policy. Washington, DC: The National Press. doi: 10.17226/737Meinert, M. (2018, June 21). Seniors will soon outnumber children, but the U.S. isn’t

ready. USC News: University of Southern California. Retrieved from https://news.usc.edu/143675/aging-u-s-population-unique-health-challenges/

Owen, T. (2007). Working with socially isolated older people. British Journal of Community Nursing, 12(3), 115-116.

Severo, R. (1983, November 6). Volunteers’ calls ease lonliness of elderly. New York Times. p. A 57.

Vlaming, R. H-d, Haveman-Nies, A., Groeniger, I. B-o, Van Duysduynen, E. J., De Groot, L. C., & Van’T Veer, P. (2014). Loneliness literacy scale: Development and evaluation of an early indicator for loneliness prevention. Social Indicators Research, 116,(989-1001). doi: 10.1007/s11205-013-0322-y

Wong, A., Chau, A. K., Fang, Y., & Woo, J. (2017). Illuminating the psychological experience of elderly loneliness from a societal perspective: A qualitative study of alienation between older people and society. International Journal of Environmental Research and Public Health, 14(824). doi: 10.3390/ijerph14070824

Zamir, S., Hennessy, C. H., Taylor, A. H., & Jones, R. B. (2018). Video calls to reduce loneliness and social isolation within care environments for older people: an implementation study using collaborative action research. BioMed Central Geriatrics, 18(62). doi: 10.1186. /s12877-018-0746-

Make sure you have the right professional liability insurance coverage with you along the way. Apply for an affordable professional liability insurance policy that gets you covered. Coverage Includes*:

• Limits of liability of $1 million per incident/$6 million annual aggregate

• Coverage for licensing board hearings and depositions• Coverage for HIPAA fines, penalties and notification costs,

where permissible by law• And much more!

DNA members can save 10%! See if you qualify for one of four ways to save.

Call 1-800-375-2764 or visit www.proliability.com/88566

Your career will take you places!

Program Administered by Mercer Health & Benefits Administration LLCIn CA d/b/a Mercer Health & Benefits Insurance Services LLC AR Insurance License #100102691 CA Insurance License #0G39709Underwritten by Liberty Insurance Underwriters Inc.*This literature is a summary only and does not include all terms, conditions, or exclusions of the coverage described. Please refer to the actual policy issued for complete details of coverages and exclusions.

88566 (6/19) Copyright 2019 Mercer LLC. All rights reserved.

DNA’s authorized provider of Professional

Liability Insurance

Page 8 • DNA Reporter August, September, October 2019

Nursing Excellence in 2019: Defining and Advancing

Nursing practice is an art and science built upon decades of caring, advocacy, education, research, collaboration, and advancement. For 17 consecutive years the public has rated nurses highest for honesty and ethics among 20 major professions (Brenan, 2018). This has been achieved while nursing remains the largest sector of the healthcare workforce (Institute of Medicine [IOM], 2010). The American Nurses Association (ANA) proclaimed the 2019 National Nurses Week theme as “4 Million Reasons to Celebrate,” confirming the expansiveness of the nursing workforce. Being rated the most honest

and ethical profession is an exceptional recognition and attestation of the mission of nursing, built upon a solid and long standing code of ethics. This recognition also provides the profession a responsibility to sustain and advance the professional image and work of nursing. The vision for advancing nursing can be built upon our roots and synthesized with an unwavering aim for continued excellence. In this article we will examine how nursing excellence came to be, what it is today, and key strategies for advancing.

Defining Nursing ExcellenceThe ANA Code of Ethics for Nurses with Interpretive

Statements defines nursing as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations” (ANA, 2015a, p44). The English Oxford Living Dictionaries defines excellence as “the quality of being outstanding or extremely good” (Excellence, n.d.). Combined, nursing excellence can be defined as the outstanding performance of nursing practice focused on human health and abilities, prevention of illness and injury, alleviation of suffering, and advocacy for care of individuals, families, communities, and populations. This definition of nursing has evolved over the last 150+ years, just as our profession has evolved. The catalyst for the definition of nursing excellence can be traced back to 1859 when Florence Nightingale first published Notes on Nursing: What It Is and What It Is Not (ANA, 2015b).

Furthermore, as the profession evolved and professional organizations formed, the ANA published the first Standards of Nursing Practice in 1973 (ANA, 2015b). The advancement of nursing excellence accelerated in the 1980s and 1990s with nursing shortages causing research into nurse practice environments and the incorporation of decentralized leadership styles in nursing practice. Research completed by Coulon, Mok, Krause, and Anderson (1996) concluded that nurses desired to provide excellent nursing care that was holistic, humanistic, professional, and improved outcomes. Nursing excellence is not a recent concept but one that has been woven throughout our profession for decades.

The ANA nursing standards evolved over the decades into their most recent iteration, published in 2015. The current Nursing Scope and Standards of Practice, 3rd Edition provides standards of practice and professional performance (ANA, 2015b). The standards of practice focus on the nursing process (assessment, diagnosis, outcomes identification, planning, and implementation) related to clinical nursing care. The standards of professional performance serve as the foundation of and the blueprint for advancing

nursing excellence. The standards of professional performance include: ethics, culturally congruent practice, communication, collaboration, leadership, education, evidence-based practice and research, quality of practice, professional practice evaluation, resource utilization, and environmental health (ANA, 2015b). These standards are prevalent throughout nursing and healthcare literature. Each standard of professional performance containing its own extensive research and strategies for advancing based on the current healthcare climate. Collectively, the standards are actively driving nursing excellence in 2019 and into the future.

Nursing Excellence Today: What is it and why have it?

Nursing excellence is not a project or program; it is the “result of a long-term organizational strategy that builds a healthy culture around staff engagement and empowerment” (Gelinas, 2017, p4). Nursing excellence in current healthcare delivery areas is complex, dynamic, and co-dependent upon many environmental and interpersonal factors. Nursing excellence doesn’t just live in one department, in one leader, or in one geographical area. Nursing excellence lives intrinsically within each licensed nursing professional, whether providing direct patient care or leading thousands of nurses in one healthcare system. Nursing excellence starts with self-reflection and self-accountability for decisions made every day. Nurses are held accountable to the provision of nursing care by themselves and through evaluation of peers (ANA, 2015b; Williams et al., 2016). Nurses practice as expert clinicians in the art and science of nursing while applying the standards of professional performance to lead the rapid and necessary changes in healthcare settings. This serves as the foundation of what nursing excellence is today.

The “why” behind nursing excellence today is simple: nurses are the largest segment of the healthcare workforce (IOM, 2010). It has become evident and imperative for nurses to leverage our numbers and adaptive capacity to effect wide-reaching changes in the healthcare system (IOM, 2010). Nurses retain the closest proximity to individuals, families, communities, and populations and possess a scientific understanding of health, illness, and suffering across the care continuum (IOM, 2010). In the landmark 2010 report from the IOM, The Future of Nursing: Leading Change, Advancing Health, nursing excellence was demanded through advanced education; nurses practicing to the top of their education, training, and licensure; and strong, collaborative partnerships – all standards of professional performance in nursing (IOM, 2010; ANA, 2015b).

Nursing excellence will continue to be demanded in future practice and leadership as the National Academy of Medicine (NAM) seeks to map out the

Christopher Otto obtained his Associate Degree in Nursing from Delaware Technical & Community College – Stanton Campus, Bachelors of Science in Nursing from Wilmington University, and Masters of Science in Nursing with a concentration in nursing innovation and health systems leadership from Drexel University. He is board certified in heart failure, progressive care, and critical-care nursing. Chris is currently the Manager of Nursing Professional Excellence at Christiana Care Health System and provides direct patient care nursing in heart failure and cardiovascular critical-care nursing. He is an advocate for nursing professional governance, relationship-based care, and cultures of nursing excellence. Chris is currently serving as the Secretary for the Delaware Nurses Association. Chris is also a member of the Delaware Organization of Nurse Leaders, Diamond State Chapter of the American Association of Critical-care Nurses, American Nurses Association, American Association of Heart Failure Nurses, American Organization of Nurse Leaders, and American Association of Critical-care Nurses. Chris has presented and published locally and nationally on topics related to cardiac and heart failure nursing, strategic planning in nursing, and strategic communication. Chris can be reached by email at cotto@christianacare.org or directly at 302-733-1583.

Christopher Otto

Christopher E. Otto, MSN, RN, CHFN, PCCN, CCRN

August, September, October 2019 DNA Reporter • Page 9future of nursing through their recently launched “The Future of Nursing 2020-2030” committee and consensus study. The newly formed committee will extend the original vision and chart a path for the nursing profession (ANA, 2019). We can expect that the outcomes of this committee’s work will certainly focus on standards of nursing excellence. Therefore, nurses must position themselves as key drivers, partners, advocates, and experts in the advancement of nursing excellence. This can be accomplished by examining key strategies for advancing nursing excellence based on selected standards of professional performance and additional strategies.

How to Advance Nursing ExcellenceEthical Nursing Practice

The nurse is best positioned to practice ethically when they have fully read, understood and can apply the code of ethics (ANA, 2015b). The current healthcare environment is an ethically challenging place to practice. Nurses and providers are being asked to do more with less which doesn’t necessarily equate to individualized care planning and consideration for unique needs. Nurses must advocate for the development of and regular participation in programs that support ethical decision making in clinical practice (Grace, Robinson, Jurchak, Zollfrank, & Lee, 2014). Ethics training programs are proven to build capacity and resiliency for dealing with ethical dilemmas while decreasing burnout and compassion fatigue rates (Grace et al., 2014). Ethical dilemmas in patient care delivery will continue to surface daily, so equipping nurses with knowledge and skills is imperative for advancing nursing excellence cultures.

Culturally Congruent PracticeAnother way to anticipate and potentially prevent ethical dilemmas is to

provide culturally congruent care for all individuals, families, communities, and populations. Culturally congruent care can prevent misinterpretation of expectations related to illness, health, and care in the health system. Nurses practice with respect and dignity for all individuals regardless of cultural backgrounds (ANA, 2015a). Nursing working a culture of strong excellence recognize that as human beings, we are all inextricably connected to each other through love and caring, regardless of gender, sexual identity/orientation, religion, political affiliation, race, etc. Nurses practice with strong relational skills that connect them to their patients, families, colleagues, and themselves. This culturally congruent practice is necessary in cultures of excellence as enormous healthcare disparities still plague people within the United States of America and the world (Gergely, 2018).

Communication & CollaborationCommunication and collaboration is a dynamic process that must occur within

all levels of an organization (Gelinas, 2015). Communication and collaboration are so essential to nursing excellence and healthcare delivery that the American Association of Critical-care Nurses (AACN) made them two standards in their AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence, 2nd Edition (2016). Strategies to enhance interprofessional communication and collaboration in cultures of nursing excellence include: interprofessional educational sessions, participation on interprofessional decision-making groups, nurse-physician dyad leadership teams, and organizational values that reflect communication and collaboration (AACN, 2016).

Education & CertificationThe body of evidence surrounding the benefits of higher nursing education

degrees and professional certifications is irrefutable and too extensive to discuss or cite in this article. Higher nursing education degrees improve the quality of nursing care delivered and resultant outcomes for individuals, families, communities, and populations (IOM, 2010). Professional nursing certifications validate the competencies needed by nurses to practice within their specialty (Sy, 2010). Nurse leader and organizational support for higher education and certifications among nurses is a hallmark of cultures of nursing excellence today and the future (Adeniran, Bhattacharya, & Adeniran, 2012; Sy, 2010).

Quality, Evidence-based Practice and ResearchProvision 7 of the ANA Code of Ethics for Nurses with Interpretive Statements

focuses on the role of all nurses in advancing the profession through research and scholarly inquiry (ANA, 2015a). Quality improvement, research, and evidence-based nursing practice are hallmarks of thriving nursing excellence cultures. Evidence-based practice empowers nurses to be leaders in their care and profession (Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012). Currently, these practices are still being used inconsistently across nursing and contributing to cultures that lack nursing excellence (Melnyk et al., 2012). To fully advance nursing excellence into 2020 and beyond, nurses at all levels must develop action plans addressing gaps in these practices and measure the outcome improvements obtained, creating a solid business case for more quality improvement, evidence-based practice, and research.

Leadership, Professional Practice Environments & Resource UtilizationLeadership and professional practice environments are uniquely connected and

through extensive research it has been demonstrated that outcomes for patients, nurses, and health systems are improved with healthier practice environments (AACN, 2016; Bowles, Batcheller, Adams, Zimmermann, & Pappas, 2019). For nursing excellence to advance, nurse leaders must have a current pulse on the health of the practice environment they support. To complete this, leaders must know and understand how factors like staffing, morale, engagement, access to resources, civility, communication, and collaboration impact the practice environment. Leaders must create psychologically safe environments and support decentralized leadership models (i.e. shared governance) to engage all nurses and staff in identifying, developing, and sustaining professional practice environments where nursing excellence thrives (Swihart & Hess, 2014).

Engagement in Professional OrganizationsThere are dozens of nursing professional organizations that have emerged as

nursing practice has evolved and became more specialized. Professional nursing organizations exist at state, regional, national, and international levels. The consistent theme of all of them is to improve nursing practice and excellence. Nursing organizations are critical for generating collaboration, ideas, innovations, and advocacy around the nursing profession and healthcare (Matthews, 2012). To impact cultures of nursing excellence across the state, country, or world,

nurses must be engaged in the work of professional nursing organizations. Active membership in these organizations develops a broader, systems-thinking view that nurses can utilize to advocate for advancements in health, illness, and wellbeing.

Go FirstNursing excellence is a complex and dynamic journey, not a destination.

It takes strong leadership, engaged nurses, commitment, and courage. The payoff for commitment to cultures of nursing excellence include healthier work environments, higher job satisfaction among nurses, and less nurse burnout (Kelly, McHugh, & Aiken, 2011). The outcomes are worth the journey, so you are invited to take the first step towards creating a culture of nursing excellence wherever you may be practicing nursing. After all, as Mark Twain stated: “to stand still is to fall behind.”

ReferencesAdeniran, R. K., Bhattacharya, A., & Adeniran, A. A. (2012). Professional excellence

and career advancement in nursing: A conceptual framework for clinical leadership development. Nursing Administration Quarterly. 36(1), 41-51. DOI: 10.1097/NAQ.0b013e31823b0fec.

American Association of Critical-care Nurses (2016). AACN standards for establishing and sustaining healthy work environments: A journey to excellence, 2nd edition. Aliso Viejo, CA: AACN

American Nurses Association (2015a). Code of ethics for nurses with interpretive statements. Silver Spring, MD: ANA.

American Nurses Association (2015b). Nursing: Scope and standards of practice, 3rd edition. Silver Spring, MD: ANA.

American Nurses Association (2019). Future of nursing 2020-2030: Extending the vision. American Nurse Today. 14(5), 64-66.

Bowles, J. R., Batcheller, J., Adams, J. M., Zimmermann, D., & Pappas, S. (2019). Nursing’s leadership role in advancing professional practice/work environments as part of the quadruple aim. Nursing Administration Quarterly. 43(2), 157-163. DOI: 10.1097/NAQ.0000000000000342.

Brenan, M. (2018). Nurses again outpace other professions for honesty, ethics [web log post]. Retrieved from: https://news.gallup.com/poll/245597/nurses-again-outpace-professions-honesty-ethics.aspx

Coulon, L., Mok, M., Krause, K. L., & Anderson, M. (1996). The pursuit of excellence in nursing care: What does it mean? Journal of Advanced Nursing. 24(4), 817-826.

Excellence. (n.d.). In English Oxford Living Dictionaries. Retrieved from https://en.oxforddictionaries.com/definition/excellence

Gelinas, L. (2015). Creating the environment for nursing excellence. American Nurse Today. 10(5), 4-5.

Gelinas, L. (2017). Characteristics of nursing excellence. American Nurse Today. 12(9), 4. Gergely, S. W. (2018). Cultural competency matters: Calling for a deeper understanding of

healthcare disparities among nurse leaders. JONA: Journal of Nursing Administration. 48(10), 474-477. DOI: 10.1097/NNA.0000000000000654

Grace, P. J., Robinson, E. M., Jurchak, M., Zollfrank, A. A., & Lee, S. M. (2014). Clinical ethics residency for nurses: An education model to decrease moral distress and strengthen nurse retention in acute care. JONA: Journal of Nursing Administration. 44(12), 640-646. DOI: 10.1097/NNA.0000000000000141

Institute of Medicine (2010). The future of nursing: Leading change, advancing health. Washington, D.C.: The National Academies Press.

Kelly, L. A., McHugh, M. D., & Aiken, L. H. (2011). Nurse outcomes in magnet and non-magnet hospitals. JONA: Journal of Nursing Administration. 41(10), 428-433. DOI: 10.1097/NNA.0b013e31822eddbc.

Matthews, J. H. (2012). Role of professional organizations in advocating for the nursing profession. OJIN: Online Journal of Issues in Nursing. 17(1), 3. DOI: 10.3912/OJIN.Vol17No01Man03.

Melnyk, B. M., Fineout-Overholt, E., Gallagher-Ford, L., & Kaplan, L. (2012). The state of evidence-based practice in US nurses: Critical implications for nurse leaders and educators. JONA: Journal of Nursing Administration. 42(9), 410-417. DOI: 10.1097/NNA.0b013e3182664e0a.

Swihart, D. & Hess, R. G. (2014). Shared governance: A practical approach for transforming interprofessional healthcare, 3rd edition. Danvers, MA: HCPro

Sy, V. (2010). Enhancing professional excellence. Nursing Management. 41(3), 17-18. DOI: 10.1097/01.NUMA.0000369492.84605.43.

Williams, T. E., Baker, K., Evans, L., Lucatorto, M. A., Moss, E., O’Sullivan, A.,…Zittel, B. (2016). Registered nurses as professionals, advocates, innovators, and collaborative leaders: Executive summary. OJIN: Online Journal of Issues in Nursing. 21(3), 5. DOI: 10.3912/OJIN.Vol21No03Man05

NursingALD.com can point you right to that perfect NURSING JOB!

NursingALD.com

E-mailed Job Leads

Easy to Use

Privacy Assured

Free to Nurses

Page 10 • DNA Reporter August, September, October 2019

Membership Activation Form

LPN Member Benefits LPN members enjoy discounts to DNA educational activities and events, receive the quarterly DNA Reporter, nursing updates via the DNA E-News, and networking opportunities.

Web Join online. Visit us at www.denurses.org

Mail Delaware Nurses Association 4765 Ogletown-Stanton Rd, Suite L10, Newark, Delaware 19713

Essential Information

First Name/MI/Last Name Credentials

Mailing Address Line 1 Highest level degree earned

Mailing Address Line 2 Phone Number Home Work

City/State/Zip Email Address

Professional Information

Employer Current Position Title: (ie: staff nurse)

Type of Work Setting: (ie: LTC, Ambulatory Center)

What is your primary role in nursing?

Administrator/supervisor staff

Discharge planner/case manager

Educator

Office nurse

Researcher/consultant

Quality assurance/infectious control

Staff nurse

Not currently working in nursing

Other nursing position

Practice Area: (ie: pediatrics)

Current Employment Status: (ie: full-time nurse)

The annual membership fee is $154/annually.

LPNs TO THE DELAWARE NURSES ASSOCIATION!

WE

LC

OM

E

Delaware Today Magazine’s

Excellence in Nursing Gala

Making an impact in the lives of Others...

Every Day we work as One.• Work in a new TCU

• State of the art equipment & technology

• Faith Based Organization

Apply On-Line / Call 302-744-3510

1175 McKee Road, Dover, DE 19904

wmvdover.orgE.O.E.

August, September, October 2019 DNA Reporter • Page 11

Web Join online. Visit us at www.denurses.org

Mail Delaware Nurses Association, 4765 Ogletown-Stanton Rd, Suite L10, Newark, Delaware 19713

Ways to PayAnnual Payment

Check Credit Card

If paying by credit card, would you like us to auto bill you annually?

Yes

Authorization Signatures

______________________________________________Monthly Electronic Deduction | Payment Authorization Signature*

______________________________________________Automatic Annual Credit Card | Payment Authorization Signature*

Monthly Payment Checking Account

Attach check for first month’s payment. Credit Card

*By signing the Monthly Electronic Payment Deduction Authorization, or the Automatic Annual Credit Card Payment Authorization, you are authorizing ANA to change the amount by giving the above signed thirty (30) days advance written notice. Above signed may cancel this authorization upon receipt by ANA of written notification of termination twenty (20) days prior to deduction date designated above. Membership will continue unless this notification is received. ANA will charge a $5 fee for any returned drafts or chargebacks. Full members must have been a member for six consecutive months or pay the full annual dues to be eligible for the ANCC certification discounts.

DNA Membership Activation Form

DNA is centrally billed through our national organization, the American Nurses Association. This means ANA manages the billing on behalf of the Delaware Nurses Association.

Monthly PaymentsYou can choose to pay your dues on a monthly basis – making your dues no more than your lunch out! ANA will either charge a credit card of your choice or deduct from your bank account 1/12 of your annual dues and any additional service fees. Bank accounts are debited on or about the 15th and credit cards are charged the first week of each month.

Annual PaymentsIf you choose to pay annually, you can pay by credit card or a check payable to ANA. If paying by credit, you also have the option to have ANA automatically bill your annual dues each month on your anniversary.

OnlineYou can join DNA instantly online. Visit DNA at www.denurses.org

Essential Information

First/MI/Last Name _____________________________________________ Credentials ____________________

Mailing Address Line 1 _________________________________ Highest level nursing degree earned ________

Mailing Address Line 2 ___________________________________________ Phone Number

Home _____________________

Work ______________________

City/State/Zip ________________________________________ Email Address __________________________

Professional Information

Employer ___________________________________________________

Current Position Title: (ie: staff nurse) ___________________________

Type of Work Setting: (ie: hospital) _____________________________

Practice Area: (ie: pediatrics) __________________________________

Currently Employment Status: (ie: full-time nurse) _________________

What is your primary role in nursing?

Advanced Practice Registered Nurse

Clinical Nurse/Staff Nurse

Nurse Manager/Nurse Executive

(including Director/CNO)

Nurse Educator or Professor

Not currently working in nursing

Other nursing position

Full DNA/ANA MembershipEmployed full-time/part-timeEnjoy discounts and participation at the state and national levelsPrice: $247/annually or $21.09/monthly, electronically

DNA State-Only MembershipEmployed full-time/part-timeEnjoy discounts and participation at the state levelPrice: $159/annually or $13.75/monthly, electronically

ANA National-Only MembershipEmployed full-time/part-timeEnjoy discounts and participation at the national levelPrice: $191/annually or $16.42/monthly, electronically

Reduced MembershipFull-time student, new graduate from basic nursing education program (within 6 months of graduation, first year only), 62 years or older not earning more than social security allows, not employedEnjoy discounts and participation at the state and national levelsPrice: $123.50/annually or $10.79/monthly, electronically

Special Membership62 years or older and not employedEnjoy discounts and participation at the state and national levelsPrice: $61.75/annually or $5.64/monthly, electronically

Dual MembershipRN holding membership in ANA through another state; proof of membership is requiredEnjoy discounts and participation at the state and national levelsPrice: $101/annually or $8.92/monthly, electronically

Select Which Membership is Right for You Choose the way to pay that’s right for you!

Welcome New & Returning Members

Nanaawawu Adeoye DoverAmy Balasus DagsboroMichelle Belile MagnoliaSteven Beltran NewarkStephanie Bolden DoverMichelle Bryan HartlyBreanna Clinton Amityville, NYLori Davis-Palmer MagnoliaAngeline Dewey FeltonErin Dignan NewarkDorothy Eyong MagnoliaJennifer Haines MilfordLaurie Judy FeltonMelissa Kestler DelmarJessica Krause MiddletownChristina Krupka DoverStephanie McClellan DoverRebecca McKenna TownsendFredeline Menard SmyrnaAmanda Newland LewesOluwaseun Ogunyemi DoverArhonda Osborne New CastleNancy Parsons New CastleDenene Richardson ClaytonMary Stirparo NewarkMichael Szeliga Media, PARenee Westmoreland New CastleAmanda Williams NewarkKaren Williford Rehoboth Beach

To access electronic copies of the DNA Reporter, please visit

http://www.nursingald.com/publications