Joining is easy! Alabama’s Nurse LeadersThe family of Rebecca Sloan District 3 Member (formerly...

current resident or

Non-Profit Org.U.S. Postage Paid

Princeton, MNPermit No. 14

Inside this IssueAlabama Board of Nursing . . . . . . . . . . . . . . . . . . 1

ASNA Board of Directors . . . . . . . . . . . . . . . . . . . . 2

ASNA 2013 Convention . . . . . . . . . . . . . . . . . . . . . 9

CE Corner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

ED’s Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Legal Corner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

LPN Corner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Membership News . . . . . . . . . . . . . . . . . . . . . . . 12

President’s Message . . . . . . . . . . . . . . . . . . . . . . . 3

Save These Dates . . . . . . . . . . . . . . . . . . . . . . . . . 1

Volume 40 • Issue 4 December 2013, January, February 2014

Circulation to more than 79,000 Registered Nurses, Licensed Practical Nurses and Student Nurses in Alabama 334-262-8321 ~ alabamanurses.org ~ [email protected]

Provided to Alabama’s Nursing Community by the Alabama State Nurses Assoication... Are You A Member?

Alabama State Nurses Association ~ 360 North Hull Street ~ Montgomery, AL 36104

Joining is easy!Benefits far exceed dues...

JoinASNA!

Scanning this QR code takes you to the Quick Application

• Duesare77%taxdeductible• FreePersonalLegalCounsel(1 hr=$300

value)• ANCCDiscountsSave$120onCertification

Exams

Preparing the next generation of Alabama’s Nurse Leaders

Apply now to be a part of ASNA’s 2014 Leadership Academy

The next ASNA Leadership Academy will beginonMonday evening, April 21, 2014, and continue thenextdayattheElizabeth A. Morris Clinical Education Sessions –FACES‘14 inMontgomery,AL.Asummerone-dayretreatwillbescheduledandtheAcademywillconcludeattheASNA’s2014ConventioninTuscaloosa.

Please see theASNAwebsite formore informationabouttheLeadershipAcademyandtoapplyforthe2014cohortofnurseleaders.

Dr.MarilynRhodes,Dr,EllenBuckner

Capstone College of Nursing Well-Represented in National Nursing Leadership

University of Alabama Capstone College of Nursing (CCN) Dean Suzanne S. Prevost(picturedatright)andSeniorAssociateDeanMarshaHowellAdams(picturedbelow)occupythe highest offices in two of nursing’smost prestigious organizations. Dr. Prevost serves asPresidentofSigmaThetaTauInternationalandDr.AdamswasrecentlyinstalledasPresidentof the National League for Nursing (NLN). Prior to her appointment as Dean of CCN inAugust 2013, Dr. Prevost held positions at the University of Kentucky College of Nursing,MiddleTennesseeStateUniversityandtheUniversityofTexasMedicalBranch.Dr.AdamsisSeniorAssociateDeanofAcademicProgramsatCCNandhasservedtheCollegeinkeyrolesfor30years.

Both Drs. Prevost and Adams are well-recognized for theirachievements in nursing. Dr. Prevost is a Robert Wood JohnsonExecutive Nurse Fellow. She received a Lifetime MembershipAwardfromtheAmericanAssociationofCriticalCareNursesandtheKentuckyStateAwardfor Excellence from the American Association of Nurse Practitioners. Dr. Prevost has alsoreceivednationaland internationalawardsfor researchfromSigmaThetaTau, theAmericanAssociation of Critical Care Nurses and the Hospice and Palliative Nurses Association. Dr.Adams is recognized as anAcademyofNursingEducationFellowand aNursingAcademicFellowbytheAmericanAssociationofCollegesofNursing.ShehasbeentherecipientoftheCCNBoardofVisitorsCommitmenttoTeachingAward,theUniversityofAlabamaNationalAlumniAssociationOutstandingCommitmenttoTeachingAwardandtheAlabamaLeagueforNursingLamplighterAward.

IfyoumissedASNA’s100thConvention,youmissedoutonthefun!

Formorehighlightsvisitthepulloutsection.

NOTICE!

Stateagencieswillbeclosedonthefollowingdates:Tuesday,December24,2013

Wednesday,December25,2013Tuesday,January1,2014.

The Alabama Board of Nursing is a state agencyandwill be closedon thesedates aswell.RegisteredNurses who have not renewed should carefully notethe dates. Following the Christmas holiday, the last day the Board office will be open is Tuesday, December 31, 2013.

The law states that any LPNs license not renewed as of December 31, 2013 (at midnight) shall automatically lapse. Online renewal is available 24 hours per day, 7 days per week at www.abn.alabama,gov. There is a late fee for those LPN’s who wait until December 2013 to renew.

SAVE THE DATES:Feb.12,2014—NursesDayattheCapitolMarch1,2014—End-of-LifeWorkshop

ElizabethA.MorrisClinicalEducationSessionsFACES‘14April22,2014

THE ASNA OFFICE WILL BE CLOSED FOR BUSINESS

DECEMBER 24, 2013 THROUGH JANUARY 1, 2014

OurnormalofficehoursareMonday–Friday8a.m.until4p.m.

Happy Holidays

Don Charlene

John

Betty April

From the ASNA Staff

• The Alabama Nurse December 2013, January, February 2014

Published by:Arthur L. Davis

Publishing Agency, Inc.

www.alabamanurses.org

PUBLICATION TheAlabamaNursePublicationSchedulefor2014

Issue Material Due to ASNA OfficeMar/April/May January27,2014June/July/Aug April28,2014Sep/Oct/Nov August4,2014Dec/Jan/Feb2015 October27,2014

Guidelines for Article DevelopmentThe ASNA welcomes articles for publication.There is no payment for articles published inThe Alabama Nurse.1. ArticlesshouldbeMicrosoftWordusinga 12pointfont.2. Articlelengthshouldnotexceedfive(5)pages 8x11.3. Allreferenceshouldbecitedattheendofthe

article.4. Articlesshouldbesubmittedelectronically.

Submissionsshouldbesentto:[email protected]

orEditor,The Alabama Nurse

AlabamaStateNursesAssociation360NorthHullStreetMontgomery,AL36104

ASNA Board of Directors

President. . . . . . . .ArleneMorris,EdD,MSN,RN,CNEPresidentElect . . . . . BrianBuchmann,BSN,RN,MBAVicePresident. . . . . . . DianeBuntyn,RNC,MSN,OCNSecretary. . . . . . . . . . . . . DonnaEverett,BSN,RN,CICTreasurer. . . . . MarilynRhodes,EdD,RN,MSN,CNMDistrict1. . . . . . . . . . . . . . . . . .ColinTomblin,BSN,RNDistrict2. . . . . . . . . . . . . . . . . . AbbyHorton,MSN,RNDistrict3. . . . . . . . . . . . . . . RebeccaHuie,MSN,ACNPDistrict4. . . . . .MarilynSullivan,DSN,RN,CPE,FCNDistrict5. . . . . . . . . . . DianeBuntyn,MSN,RNC,OCNCommissiononProfessionalIssues. . . . . . . .GenniferBaker,MSN,RN,CCNS,ChairSpecialInterestGroup:AdvancePracticeCouncil:CharlotteWynn,MSN,CRNP,Chair

ASNA STAFF

ExecutiveDirector,JohnC.Ziegler,MA,D.MINDirectorLeadershipServices,

CharleneRoberson,MEd,RN-BCASNAAttorney,DonEddins,JD

AdministrativeCoordinator,BettyChamblissProgramsCoordinator,AprilBishop,BS,ASIT

VISION STATEMENTOur Vision

ASNA is the professional voice of all registered nurses in Alabama.

OUR VALUES

• Modelingprofessionalnursingpracticestoothernurses

• AdheringtotheCode of Ethics for Nurses• Becomingmorerecognizablyinfluentialasan

association• Unifyingnurses• Advocatingfornurses• Promotingculturaldiversity• Promotinghealthparity• Advancingprofessionalcompetence• Promotingtheethicalcareandthehumandignityof

everyperson• Maintainingintegrityinallnursingcareers

OUR MISSION

ASNA is committed to promoting excellence in nursing.

ADVERTISING

For advertising rates and information, please contactArthur L. Davis Publishing Agency, Inc., 517Washington Street, PO Box 216, Cedar Falls, Iowa50613, (800) 626-4081, [email protected]. ASNA andthe Arthur L. Davis Publishing Agency, Inc. reservethe right to rejectanyadvertisement.Responsibility forerrorsinadvertisingislimitedtocorrectionsinthenextissueorrefundofpriceofadvertisement.

Acceptance of advertising does not imply endorsementor approval by the Alabama State Nurses Associationof products advertised, the advertisers, or the claimsmade. Rejection of an advertisement does not imply aproductoffered foradvertising iswithoutmerit,or thatthemanufacturerlacksintegrity,orthatthisassociationdisapproves of the product or its use. ASNA and theArthur L. Davis Publishing Agency, Inc. shall not beheldliableforanyconsequencesresultingfrompurchaseor useof an advertiser’s product.Articles appearing inthispublicationexpresstheopinionsoftheauthors;theydo not necessarily reflect views of the staff, board, ormembershipofASNAor thoseof thenational or localassociations.

The Alabama Nurse is published quarterly everyMarch,June,SeptemberandDecemberfortheAlabamaState Nurses Association, 360 North Hull Street,Montgomery,AL36104

© Copyright by the Alabama State Nurses Association.Alabama State Nurses Association is a constituent member of the American Nurses Association.

Condolences to:The family of

Rebecca SloanDistrict 3 Member

(formerly Mid South Home Health)

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December 2013, January, February 2014 The Alabama Nurse •

The President’s Message

Arlene Morris, EdD, MSN, RN, CNE

During Oct. 10-12, nursesfrom across the state gatheredat theMontgomeryRenaissanceHotel forASNA’scelebrationofaCenturyofService!Attendeesrepresentedavarietyofpracticesettings, levels of practice,ages, geographic areas, andparticipationinASNAatdistrictandstatelevels.Thevarietywasthrilling as lively discussionswere held during both theMable Lamb ContinuingEducationDayandaroundtheeventsof the100thHouseof Delegates. Governor Bentley congratulated ASNAon 100 years of service to Alabama nurses and citizens,relatingcontinuingimportantrolesofnursesinthecurrenthealthcaredeliverysystem.Dr.DebbieHatmaker,recentlyappointed Chief Professional Practice Officer of ANA,presented the keynote address, discussing challengesnurses face across all levels of practice. The AlabamaAssociation of Nursing Students’ concurrent conventionallowed interaction with practicing nurses and manyvendors.

At the Awards Dinner sponsored by Arthur L. DavisPublishing Agency, scholarships and awards werepresented fromASNA and individual districts. CharlotteWynn was recognized as ASNA’s initial OutstandingLegislative Advocate, reflective use of her leadershipof ASNA’s legislative committee. The Lillian B. SmithAward was presented to Carthenia Jefferson. DianeBuntyn was named Outstanding Nursing Administrator,

Recalling a Century of Service & Looking to ASNA’s Second Century

and Mary Beth Bodin received the Cindajo Overtonaward for Outstanding Nurse Educator. The award forOutstanding Health Care Organization in Alabama wasaccepted by a table full of staff and the administrator ofForest Manor. Amy Southern was named OutstandingNew ASNA Member, and the inaugural Helen WilsonLeadershipScholarshipwasawardedtoChuquitaMartin-Ramey. Excellence in nursing was apparent across allareasofthestate!

The president’s address to the ASNA House ofDelegates recounted both challenges and successes of2013. The analogy of a tree conveyed ASNA’s strengthand vibrancy, continuing growth begun by nurse leadersover the past century. During the president’s addressto the students, soon to be new nurses were challengedto considerways each could leave a legacy for nurses inAlabama to look back on during thenext 100 years.AnASNA100thConventioncanvasdepictedatreeonwhichnames of past presidents formed roots, signatures ofdelegates (representing current members) comprised thetrunk, and student signatures formed the leaves of newgrowth for ASNA. View it and other historical letters,documents,andphotosatASNA’soffice!

ASNA’s Centennial Birthday Celebration dinner wasenjoyedbymembersandguestswhorelishedreminiscencewith past ASNA presidents and executive directors. Abrief overview of ASNA depicted the initial charter in1913, closely followed byAlabama’s first Nurse PracticeAct in 1915. Photos of nurses in each decade revealedthe tremendous impact of Alabama nurse leaders acrosswars, natural disasters, and times of change, in settingsincluding health promotion, acute and rehabilitative care.Each of the five districts provided a moving historicalpresentation of nurses’ actions across the state during

ASNA’s first century. The evening revealed efforts ofnurses inASNA to address issues of across the past 100years.

Delegates were asked to envision the next 10, 20 and100yearsofASNA inwriting.One stated, “In20years,my son will be ASNA president and my daughter willbe governor.”With vision like this, ASNA is poised forstrength! Both numbers and involvement are essentialto produce new growth for ASNA to move into a newcentury. The profession of nursing in our state and thehealthofourcitizensdependonit.

Thank you to the employees of Forest Manor. Your hard work and dedication led

to our designation as the Alabama State Nurses Association’s

“Outstanding Health Care Organization” of 2013!

www.forestmanorinc.com

205.339.5400

Blue Cross and Blue Shield of Alabama is seeking nurses to join

our Health Management division.

To apply, visit www.bcbsal.jobs and click on “Search Careers”

Blue Cross and Blue Shield of Alabama is an independent licensee of the Blue Cross and Blue Shield Association.

Care CoordinatorDedicated Group Care Coordinator

RN Medical Coding/Reimbursement Analyst

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The E.D.’s Notes

John Ziegler, M.A., D.,MIN

Nursesareamongthebusiestfolks in the professional world.Trying to juggle family (orrelationships), work, financesand time can be exhausting!As I’ve traveled around thestate talking to nurses, mostnon-members have no strongobjections to joining ASNA.They understand that manyvoicespromotingandprotectingthe profession in MontgomeryandD.C.aremuchlouderthanafew.And,when they see thevalueofbenefits far exceeddues in realdollars…the less than$25monthlydues forASNA/ANA is a non-issue. So why don’t more nursesjoin?You guys can helpmewith this by emailingme atedasna@alabamanurses.organdgivingmeyouranswertothatquestion.UntilIgetyourinputandabsentacompleteprofessional survey of RN’s in the state, I’m going tomakeaneducatedguessaboutwhysomedonot/havenotjoined.(Althoughwearegrowing)

Herearemyassumptions:

FOUR POSSIBLE OBJECTIONS AND ANSWERSTOTHOSEOBJECTIONS:

1. It costs too much. Answer:Benefitsfarexceedduesinreal$$$.

2. What can ASNA/ANA do for me? Answer:Abunchofthings…includingprofessional

development,makinglife-longfriends,careernetworking,communityserviceandlegislativeadvocacythatcanshapethefutureofyourjob!Whenyoucheckoutthebenefits,youwillseeanabundanceofcostssavingsonCE’s,personallegalcouncil(onehourFREEforanytopic…likeyourWillorissuessuchasjobbullyingordiscrimination,familyandpersonalstuff…anytopic).Heavenforbid…butifyoueverhavetogobeforetheABN,yourASNAlawyerwillresearchyourcase,representyouandgowithyouasyoustandbeforetheBoard.Thathashappened.YouwouldhaveASNAFREElegalcouncilforlegalservicesthatwouldotherwisecostyouaround$5,000!

3. I don’t have time to participate. Answer:YOUCANBEWHEREYOUCAN’T

BE…ATTHESAMETIME!HereiswhatImeanbythesomewhatweirdtitleofthisarticle.BybecominganASNA/ANAmember,youcansupportotherswhodohavetimetowork“inthetrenches”onyourbehalf.ThebestexampleIcanthinkofisthetraditionaluseofmissionariesbychurchesandfaith-basedgroups.Supposeamemberofachurchhadadeepdesiretofeedthepoorinathirdworldcountry,buttheycouldnotbecauseofpersonalobligations.Byvirtueofbeingamember,

YOU CAN BE, WHERE YOU CAN’T BE…AT THE SAME TIME!

thatpersoncansupportmissionariesthatareouttherefeedingthepoor.Inasense,themembercanvicariously“be”wheretheycan’tphysically“be”throughtheirparticipationasamember.Iknowthatbeingpartofaprofessionalorganizationisnotequivalenttofeedingstarvingpeople.Itsimplyillustratestheprincipalofgrouppowerandrepresentation.Youcanhaveanimpact…todayevenifyourcircumstanceswillnotallowyouTIMEtobe“physically”presentatDistrictmeetings,parties,thestateconventionorlegislativerallies.

4. I’m just not interested. Answer:??? Ihavenoanswerforthatone.Whysomeonewould

havenointerestinpromotingandprotectingtheprofessionisamysterytome…Maybethey’vejustnotthoughtaboutit.I’vemetanumberofnursesthatdidn’tevenknowASNA/ANAexists!MEMBERSCANRELLYHELP…tellthemaboutASNA/ANAand/orinvitethemtogowithyoutoameetingoralegislativerally…Whennursesknowwhat’sinitforthemandwhat’satstakeintherapidlychanginghealthcaresystemfortheirprofession,Ibelievetheywillbeextremelyinterested.

As an organization representing all specialties ofnursing, ASNA has a proven track record (for over 100years)ofstandingupfortheprofession.Sincethepassageof the first AlabamaNurse Practice Act in 1915, ASNAhas worked to instigate/influence legislation and policyexpanding the scope of nursing practice and promotinghigh standards (and higher rewards) for nursing. Therearemany examples over the decades ofASNAmemberssacrificing to help shape and preserve the sanctity ofyour profession, nursing.Remember, therewas a time inour history when nurses were not even allowed to takebloodpressure!Aprocedurethatcouldonlybepreformed“correctly” by a doctor. Please consider joining. “Manyhandsmake lightwork” “Thebundle of sticks, harder tobreak”“Chainisonlyasstrongasit’sweakestlink”Howmanyclichésdoyouneed!YOU…mattermorenowthaneverbefore.

Conclusion:ASNA/ANA benefits exceed the cost of dues in real

dollarsnotjustcouponsanddiscounts…althoughwehavethosetoo.

ASNA/ANA membership can do a lot for you, aspointedoutabove.

TIMEisnotanexcuse.Mostmemberswillbeengagedand benefit professionally from networking, servingon committees and boards and developing life-longfriendships.But, if you don’t have time you can still BEWHEREYOUCAN’TBEbysimplybecomingamember.Your fellow members, along with the ASNA staff, willrepresentyourexpressedinterestsandbeastrongvoicefornursing.Justdoit!Joiningiseasy.SwipetheQRcodeonthecoveroftheAlabama Nurseforthequickmembershipform. Want more info? Surf www.alabamanurses.org.Nurses,let’sjoinhands,lockarmsandbeatthetable…notonthemenu!

Legal CornerDon Eddins, BS, MS, JD

Admittedly I am biased,but in my opinion one of themost important advantages ofmembership in the AlabamaState Nurses Association is thelegalservicesprogram.

The program is two-pronged–onepertainingtolicensure/jobperformance matters, while theother relates to consultation onabroadspectrumoflegalissues.

On the licensure/jobperformance part of theprogram, I should state at the outset that anyone can benegligent.Anotherwayof stating that is that anyone canmakeamistake.

As your ASNA attorney, I have dealt with issuesranging from a nurse practitioner’s failure to check theadvancedpracticeboxonthelicenseformtomishandlingofnarcotics.Ihavedealtwithanursepractitioner’sfailuretohaveacollaboratingphysicianaftersheforgottoupdateher form when a doctor retired, to lapses in judgmentpertainingtochartingofmedications.

Sometimes therewasnomistake.I’vedealtwithcasesinvolvingnursingschoolprofessorsexperiencingdifficultywith a student who didn’t make a good grade. In manycases, the family of a patient who did not have a goodoutcome needs someone to blame and turns to the nurseonduty.

And even when there were mistakes made in themajority of the cases, the CRNP or RN who made themistakewas a good, competent, caring professionalwhojustexperiencedalapseinjudgment.

However, the Board of Nursing staff often does notshare my admiration for the RNwho has committed anerror. Moreover, when the dedicated RN receives thatdreadedletterfromtheBoardinforminghim/herthathis/herlicenseissubjecttoaninvestigationhe/shenormallyisjustaboutfrightenedoutofhis/hermind.

That iswhere thenurse’smembership in theAlabamaState Nurses’ Association pays off. If your license issubjecttoaninvestigationbeforetheBoardandyouwerea member of the ASNA when the event complained ofoccurred,IwillrepresentyoubeforetheBoardofNursingat no charge to you.My services comewith yourASNAmembership.

Legal representation that would normally cost you$2,500or$5,000isyourswithoutchargebecauseofyourASNAmembership.AndthepeaceofmindknowingthatyouwillhaveonyoursideanAssociationandanattorneywhohasdealtwithallkindsoflicensureissuesisequallyimportanttothemonetarysavings.

Tobeeligibleforthebenefit,youmustbeamemberofASNAwhentheBoardraisestheissuewithyourlicense.

The second part of the program is broad-based.Your membership in ASNA entitles you to an hour’sconsultation eachyearon any legal issueonwhich I feelqualifiedtoprovideaconsultation.

Nurses call me regularly about matters pertainingto their jobs,aswellasall typesother issues–fromrealestate matters to estate planning. I always am pleasedto share my limited legal knowledge with any ASNAmember.

There are many good reasons to join ASNA – fromcontinuing education opportunities, to our lobbyingefforts,toprofessionalnetworking,tomemberdiscounts…Thelistislengthyandcannotbeexhaustedhere.

The ASNA legal services program is among thoseimportantmembershipadvantages.

HIRINg IN TUSCALOOSAApplications are currently being accepted for

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WALLACE COMMUNITY COLLEGEDothan, AL

2014 Continuing Ed Courses (Call 334-556-2414 to register)

Train the Trainer $399.00February 11-12 August 12-13May 13-14 November 11-12

All classes Tuesday and Wednesday, 8:00 A.M. - 3:00 P.M.• Location: Wallace CEWD Bldg. (5565 Montgomery Hwy)

• CEUs: 1.2 • Course limited to 12 nurses.

ACLS Recertification Course $75.00February 10-11 August 11-12April 14-15 October 13-14June 9-10 December 8-9

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Greg Howard, LPN

The role of the nurseis established in the verybeginning of the nursestraining. This training focuseson the psychological and theinternal nature of the nurse.It challenges the nurse to dothe right thing nomatter what,and meeting the expectationsof those who rely on the nursefor their care. The expectationsare that the nurse will meet orexceed the Standards of Care,State Nurse Practice Acts and Codes of Ethics. If thenurseviolatestheStandardsofCare,thereisadisciplinaryprocessinplace.

It is the expectation of the public that nurses willmake wise, ethical decisions in caring for the sick. It isalways acceptable to seek advisement when in doubt.Collaborationiskeyinusinganydecisionmodelstoreachadesiredoutcomeorgoal.

Andifbychance,awrongdecisionismade,“right”thewrong.Therearethreestepstodoingthat:

1. Claimthewrong2. Apologizetotheappropriatepeople,and3. Makeamendsifpossible

LPN Corner

Professional Conduct: The Role of a NursePlacingtheblameoncircumstancesisa“copout”.The

bucks always stop with the Nurse or person in charge,Doctor,ExecutiveDirector,RNorLPN.

It isok toshowregretor shame,butunprofessional toblameothersordenyyourroleinthewrongdoing.

Therearedecisiontreesandmodelstousethatcanhelpwithdecisionmaking,suchas:

The “Stop” Model

S is for Standards of care as set forth by the NursePracticeAct.

T is forThorough and challenges us to consider ourdecisions including, but not limited to, past history, rulesspokenandunspoken,personalitiesandsheerfacts.

O is for Outcomes and reminds us to check andrecheckourdecisionsforthebestresults.

P is for Personal value, which guides us to makeconsistentdecisionswhichreflectone’sowncharacterandpersonalvalues.

Find your tool, and make it your Bible for the careyougive.Thisapplies tonursesandstudentnurses.Withmodifications this applies to our everyday lives, whetheryouareanurseorhavesomeotherprofession.

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Professional Issues

Ellen B. Buckner DSN, RN, CNE, Leigh Anne Minchew, DNP, RNC, WHNP-BC,

Erica Elkins-Little, BSN, RN

Thisisthesecondinamulti-partseriesonthe80x20CalltoAction.Basedonthe2010InstituteofMedicinelandmarkreportonThe Future of Nursing: Leading Change, Advancing Health, there have been nation-wide initiatives to supportprogress toward the goal of having the registered nurseworkforce 80%BSN prepared by the year 2020. Followingthis report from the Robert Wood Johnson Foundation(RWJF) and Institute for Healthcare Improvement (IHI),individual states undertook initiatives to advance the goals.Some of these activities in Alabama are described in thisarticle. This part discusses the magnitude of the challengeinAlabama,groupsandchanges thathavebegun toaddressthesechallenges,andresolutionsbytheAlabamaStateNursesAssociation(ASNA)supportingtheprocess.

The Magnitude of the Challenge in AlabamaCurrently in Alabama we have over 68,000 registered

nurses(ABON,2013).Itisestimatedthatlessthan40%holdaBSN.Thatleavesover27,000nursesinAlabamawhowouldneedtocompletetheBSNby2020tomeetthenationalgoals.In2011-2012AlabamacollegesanduniversitiesparticipatingintheAmericanAssociationofCollegesofNursing(AACN)survey of schools of nursing reported slightly more than1100 RN-BSN students were enrolled (AACN, 2011-2012 Data Report-Alabama). Those Alabama schools providingRN to BSN and/or RN to MSN programs are: AuburnUniversity at Montgomery, Jacksonville State University,Oakwood University, Samford University, Stillman College,The University of Alabama, The University of Alabama inHuntsville, Troy University, Tuskegee University, UniversityofAlabamaatBirmingham,UniversityofMobile,Universityof North Alabama, and the University of South Alabama,(AACN,2013).Inadditionotherliveandonlineprogramsareavailablewithinoroutofstate.EvenifeveryAlabamaschoolwas at capacity, the need could not be completelymet.Therate limiting factor right now is enrollment. RN/BSN/MSNtracks are actively recruiting and space is available! This isnotanenvironment forcompetitionbut forcollaboration.Tothatendnationalandstatewidegroupshaveformedtoaddressthe needs for educational advancement and the processes ofcurriculardevelopmentsupportingeducationalprogression.

Initiatives to Address these ChallengesAACN Position Papers on RN-BSN/MSN Education and Expectations

The American Association of Colleges of Nursing(AACN) has long supported educational progression for

80 x 20: A Call to Action! Part 2 – Alabama Initiatives

registerednurses, supporting the clinical ladder concept andstatingthateducationenhancesbothclinicalcompetenceandpatientcare(AACN,2012a).Bridgeprogramsbuildonpriorlearning and credentials as licensed RN’s and provide forcareer advancement.Nationwide there aregrowingnumbersavailable with 173 programs of RN to Master’s and 646programsofRN-BSNnationwide(AACN,2012a).Ingraduatelevel curricula, baccalaureate course work is embedded inorder to prepare students for graduate level courses and tomeet accreditation standards. RN to MSN programs canlead to preparation for faculty roles and future doctoralstudy, potentially reducing the faculty shortage. EducationalprogressionhasbeensupportedthroughaJointStatementonAcademicProgressionforNursingStudentsandGraduatesbytheAmericanAssociationofCommunityColleges (AACC),the Association of Community Colleges Trustees (ACCT),the AmericanAssociation of Colleges of Nursing (AACN),the National League for Nursing (NLN), and the NationalOrganization for Associate Degree Nursing (N-OADN)(AACN,2012b).

In 2012 a task force was created by AACN to addresswaystocreateadynamiccurriculum,responsivetotheneedsof registered nurses. This task force studied, discussed, andmade recommendations to give exemplars for definitionsof practice experiences in RN to Baccalaureate Curricula(AACN, 2012c).The task force addressedways tomeet theexpectation for varied practice opportunities to meet The Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 2008). Practice experienceswere described as “experiential learning in any settingwhere healthcare is delivered or health is influenced thatallows forand requires the student to integratenewpracticeknowledgeandskills(AACN,2012c).Dr.Bucknerservedasamemberofthistaskforce,andinpreparationconsultedwithcolleagues inseveralAlabamauniversities todeterminebestpractices in RN-BSN/MSN education. Practice experiencesare typically integrated across RN-BSN/MSN experiencesin several different courses. These may include courses inhealth assessment, leadership, evidence-based practice, andcapstone practice integrated projects. Practice experiencesinclude activities requiring collaboration with health caresettingsoragencies,andaddresshealthneedsofindividuals,families,andcommunities.Practiceexperiencesrequireclearobjectives, outcomes, and evaluation by a faculty member.Practiceexperiencesoftenincorporatelearningofleadership,organizationalsystems,andinterprofessionalcommunication.Examplesweredrawnfromnumerousexamplesgivenbytaskforcemembers(AACN,2012c),suchas:

• Participateininterprofessionalperformanceimprovementteamcurrentlyworkingonimplementation/evaluationofnationalpatientsafetygoals.

• Evaluatetheeffectivenessofcontinuityofcarebyassessingtheneedsofanindividualpatientandfamilyandthenreviewingthedischarge,referral,andcasemanagementprocessesandplansforthatpatient.

• Collaboratewiththequalityimprovementdepartmenttoimplementanintentionalroundsinitiative.Thestudentcompletedtheinitialtraining,createdatrainingvideoofexemplaryrounds,thenservedasacoachtootherswhowereimplementingthisonseveralfloors.

Alabama colleges and universities have led the way inincorporatingthesetypeexperienceswithcurricularprogramsbuiltontheabilitiesofregisterednursesfurtheringtheircareerdevelopment.

Nursing Education and the Alabama 80 x 20 Task ForceInAlabama several initiatives are underwaywith one of

these focusing specifically on curricula. Nurse educatorshave come together in an 80 x 20 task force to examine

Professional Issues continued on page 7

pre-nursing requirements to facilitate seamless articulationin nursing education. This task force began through theCapstone College of Nursing at the University of Alabamaand is currently chairedbyMichelleCheshireRN,MSN. ItengagedRN/BSN/MSNeducatorsacrossAlabamatodiscussissues related to curriculum and the Statewide Transferand Articulation Reporting System (STARS) curriculumrequirements(STARS,2013).Institutionswereencouragedtomakeeveryefforttoreducemandatorycorerequirementsbyoptimizingcredits,includingAPandCLEPcredits,whilestillcomplyingwiththe120hoursrequiredbySTARS.Consensuswassoughttoworktowardacommonsetofprerequisitesandacceptabletransfercredits.Communitycollegerepresentativeswere supporting of changes in prerequisites that wouldfacilitateprogression.Furthermeetingsareplannedtoaddressadditionalissuesconfrontingeducationalprogression.

University initiativesIn several cases academic institutions have reduced

total hours and increased flexibility. Educators have builtcurricula that address the specific nursing experience andeducational background of the ADN-RN with a) flexibleschedulingforonlinecourses,repeatedofferings,partorfulltime, concurrent enrollment in outstanding prerequisites, b)leadership and collaboration emphasis, c) activities focusedon clear and relevant outcomes for career development, andd)seniorplacementand/orseminarsforcourses tostimulateengagementandprofessionaldevelopment.Specialcurriculardevelopmenthasalsobeendonereplacingclinicalpracticumhours with practice integrated experiences as describedabove (AACN, 2012c). Specialized advising is available inmanycollegeswithpreliminaryreviewdonebyprofessionaladvisorsfromunofficialtranscripts.

Financial Issues Affecting ProgressionOften the most significant barrier for nurses pursuing

educational progression is financial. In a recent meeting oftheAlabamaNursing80x20 task force, financialconcernswere discussed including: a) Students must be seeking adegree or certificate at the school for which they wish toobtainfinancialaid,b)Financialaidwillonlypayforclassesthatcounttowardstheirspecificdegree,c)PellGrantswillnotapplyafterthestudentisworking,d)ThereisalackofRN-BSN scholarship money, e) Most scholarships require full-time enrollment, and f) Students can only receive financialaidatoneinstitution.Possiblesolutionsinclude:a)establishingadvising tracks for RN-BSN students, b) encouragingADNgraduates to continue immediately to BSN in order to takeadvantageoffinalyearofeligibilityPellGranteligibility,andc)establishingRN-BSNspecificscholarships.Manyhospitalsoffer tuition reimbursement or other financial incentives.Financial supportmaybe available andprofessional supportfor educational progression is growing with employersseekingbetterpreparationinhiringandpromotiondecisions.NursesshouldalsoconsiderthefinancialincentivesforBSNcompletion as some hospitals give a per hour differentialwhichwould affect decisions about pace of part-time study(AlabamaNursing80x20TaskForce,MinutesofApril23,2013).

Alabama Health Action Coalition (AL-HAC)ThiscoalitionisheadedbyKathleenA.LadnerandCarol

J. Ratcliffe, both of the Alabama Organization of NurseExecutives and Alabama Nurse Leaders in Education andPractice, in collaboration with Jane Yarbrough, Manager,BlueCross andBlue Shield ofAlabama, andLacyGibson,DirectorofHumanResources,AlabamaHospitalAssociation.ThecoalitionhastakentheleadtorespondtotheIOMcalltocreatetheAlabamaHealthActionCoalition(AL-HAC).Thiscoalition seeks to “transformhealth care throughnursing inourstate(AL-HAC,2012).”TheyhaverepresentedAlabamato the nationalRobertWood JohnsonFoundation supportedCampaign for Action. They have a strong agenda forsupporting nurses’ educational progression with congruencywithAlabamaStatewideTransferandArticulationReportingSystem (STARS), congruencywith SouthernAssociation ofColleges and Schools (SACS) requirements, and flexibilityin allowing transfer of course credits (AL-HAC, 2013).This summer AL-HAC submitted a State ImplementationPlan (SIP) proposal with the primary focus to increase thepercentage of Registered Nurses in Alabama with BSNdegrees(Figure1).TheplancontributestomeetingtheIOMrecommendations toward increasing educational preparation

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and removing the barriers to so thatRN’s andAPRN’s canfunction to the fullextentof theireducation,experienceandcompetence.Theoverallgoalof theAL-HACis to improvethe health status of all Alabamians by increasing access tocost-effective, high quality through inter-professional andcommunity collaboration. The AL-HAC project will beaccomplished by four activities: 1) collecting, analyzing andtracking RN workforce data, 2) working with health careagencies to provide tuition support so AD graduates canenteraBSNprogrampost-graduation,3)workwithstateADandBSNprograms,schoolsandcolleges todesignseamlesseducation progression pathways, and 4), design outreachprogramstopromotenursingasacareerchoice tochurches,civic organizations, elementary, junior and high schoolsstudents. A central strategy to these four activities includesaddressing geographic and diversity workforce needs (K.Ladner,personalcommunication,August1,2013).

The ASNA 80 x 20 Resolution: Alabama’s Future of Nursing

2012 and 2013 ASNA Resolutions At the ASNA 2012 Convention a resolution was offered

byamemberoftheInauguralClassoftheASNALeadershipAcademy, Dr. Leigh Minchew. This resolution was for thecreation of a Task Force fromASNA tomove the 80 x 20planningforward.Theresolutionlistssomeofthebackground

supporting educational progression and identifies actions forASNAtofurtherawarenessandfacilitateachievingthe80%x2020goal(Figure2).Asimilarresolutionwasapprovedin2013 demonstrating ASNA’s commitment to this ongoingprocesswithoneadditionalactionitem:RESOLVEDThattheASNAwillpromoteeducationaladvancementthroughoutthedistricts topromote thehighestqualityofhealthcarefor thecitizensofAlabama(ASNA,ConventionResolutions,2013).

ConclusionThrough these and other initiatives, nurses and

stakeholders in Alabama have joined forces with otherscommitted to educational advancement for nurses. Alreadynumerous hospitals and healthcare agencies are offeringtuition reimbursement for RN-BSN courses. Graduates ofRN-BSN/MSN tracts are encouraging their colleagues andfriendstostartthejourney.Fromruralhospitals,tostatewideprofessional organizations, the call to action is clear!Nursesmust advance their educational level for the dynamic,collaborative,andengagedpracticeoftomorrow.

To contribute to the discussion, email correspondence toDr. Ellen Buckner, [email protected], Dr. [email protected],[email protected].

ReferencesAlabamaBoardofNursing[ABON].(2013).Daily Statistics.Retrieved

fromhttps://www.abn.alabama.gov/.Alabama Health Action Coalition [AL-HAC] (2013). State Action

Coalitions-Alabama.http://campaignforaction.org/state/alabama.

Alabama Health Action Coalition [AL-HAC] (2012).Alabama Action Coalition Status Report. Retrieved from http://campaignforaction.org/sites/default/files/AL-StatusReport-3Q.pdf

American Association of Colleges of Nursing [AACN], (2008). The Essentials of Baccalaureate Education for Professional Nursing Practice.Retrieved from http://www.aacn.nche.edu/publications/order-form/baccalaureate-essentials.

AmericanAssociationofCollegesofNursing[AACN],(2012a).Degree Completion Programs for Registered Nurses: RN to Master’s Degree and RN to Baccalaureate Programs.Retrievedfromhttp://www.aacn.nche.edu/media-relations/fact-sheets/degree-completion-programs.

AmericanAssociation of Colleges ofNursing [AACN], (2012b). Joint Statement on Academic Progression for Nursing Students and Graduates. Retrieved from http://www.aacn.nche.edu/aacn-publications/position/joint-statement-academic-progression.

AmericanAssociationofCollegesofNursing [AACN], (2012c).White paper: Expectations for Practice Experiences in the RN to Baccalaureate Curriculum. Retrieved from http://www.aacn.nche.edu/aacn-publications/white-papers/RN-BSN-White-Paper.pdf

AmericanAssociationofCollegesofNursing[AACN],(2013).SchoolsOfferingRN toBaccalaureatePrograms,Fall 2012.Retrieved fromhttp://www.aacn.nche.edu/research-data/RNBSN.pdf

Institute of Medicine [IOM]. (2010). The future of nursing: Leading change, advancing health.Washington,D.C.:NationalAcademiesPress.

StatewideTransferandArticulationReportingSystem(STARS).STARSUnofficialandOfficialTransferGuide.Retrievedfromhttp://stars.troy.edu/

Figure1&2areavailableatalabamanurses.org.Clickon80x20.

Professional Issues continued from page 6


Excellent Nurse Opportunity

The Alabama Department of Public Health is now hiring for the position of:

Licensure and Certification Surveyor – classification number 40726, nurse option. This involves professional work surveying health care providers to determine compliance with state and federal regulations. To qualify you must have a Bachelor Degree in Nursing and two years of direct patient care nursing experience OR an Associate degree in Nursing or diploma in Nursing and five years of direct patient care nursing experience.

This position offers competitive compensation, generous paid time off and excellent benefits. Extensive overnight travel is required. For more information and to apply please go to:

http://www.adph.org/employment/index.asp?id=474 or http://personnel.alabama.gov/Default.aspx.

If you have questions please contact Peggy Norrell at (334) 206-5297

or email [email protected].

The Alabama Department of Public Health is an Equal Opportunity Employer

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of applications will begin immediately and continue until the positions are filled. Minimum Qualifications: MSN degree from an accredited institution, RN license in Alabama. A doctoral degree is preferred. For a complete job description and to apply for a position visit the Troy University Employment System website at https://www.troyuniversityjobs.com/

For questions about the positions, contact Dr. Latricia Diane Weed, Director of the School of Nursing, at334-670-3745 or email [email protected] University is an Equal Employment Opportunity and Affirmative Action employer.

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2013 Alabama Nurses Association Annual Convention

DedicationThe 2013 Alabama State Nurses Association (ASNA) Annual Convention was dedicated to two outstanding members, both of whom died in early 2013. They both became actively involved members from the day they transferred membership to the association.

Janet Donoghue , BS, RN, SANE-A

Janet‘sfirstandlifelonginvolvementinASNAwaswith continuing nursing education committee. ShewasoneofthemostprolificactivityreviewersontheApproval Committee.Along theway she became anASNAPresident.Members ofDistrict 1describeheras “self-starter and passionate about everything shetouched”. She was a pioneer in the field of forensicnursing and became one of the first SART/SANENurses. She assumed leadership of the AlabamaCoalition Against Rape and led the legislativecampaigntomakestrangulationafelonyinAlabama.InadditionshewasaleaderintheASNAEthicsandHumanRightsCommitteeand became a champion for prevention of hazing and bullying. Janet was anactivememberoflocal,stateandnationalRepublicanwomenorganizations.She‘led the fight’ tohaveAlabama recognizedas a strongpolitical force atANAwithherinvolvementwiththeANAPoliticalActionCommittee.InadditiontoallofthisJanetremainedinthePRNPoolatHuntsvilleHospitalintheCriticalCareUnit.Despite all of her non clinical nursing activities, shenever stoppedworkingintheICU.Janetwasoneofthosenurseswhotalkedthetalkbutalsowalkedthewalk.Shewillbemissed.

Helen Wilson, MSN, RN

HelenmovedtoAlabamain1989andimmediatelytransferred her membership and became activelyinvolved in all aspects ASNA. She started as acommittee member in the continuing nursingeducation Approval Unit, approving activities andlater transferred to the Provider Unit and becametheLeadNursePlanner. For the past 15 yearsHelenwas involved with the planning of every ASNAeducational activity. Shewas actively involved at theMontgomery, Autauga, & Elmore County NursesSociety as well as District 5. She is credited withmentoringanumberofaspiringmembersintoleadershippositions.SheassumedleadershipoftheASNAEnvironmentalTaskForce.HelenbecameknownbothnationallyandinternationallyforherworkwiththeASNAEnvironmentalTaskForce.ShealsoservedastheASNAparliamentarian.AndalongthewayHelenbecame an Interim Executive Director at ASNA. Helen represented ASNAonmany state-wide committees almost all dealingwithwellness. Shewill bemissed.

Resolutions Passed at ASNA 2013 Convention

Resolution #1 Emergency Preparedness

RESOLVED TheAlabamaStateNursesAssociation(ASNA)willchallengenurses acrossthestatetocompletedisastertraining,andbeitfurther

RESOLVED ThattheASNAwillreportparticipation,providedbythedistricts,of certificationcompletionthroughoutthestate,andbeitfurther

RESOLVED ThattheASNAwillpublishanarticleinThe Alabama Nurse andwill providealinktoinformationaboutDisasterTrainingand CertificationsontheASNAwebsite.

Resolution #2 Safe Patient Handling and Mobility

RESOLVED ThattheASNAwilladvocateforsafepatienthandlingandmobility, andbeitfurther

RESOLVED ThattheASNAwillpromotecontinuingeducationonthetopicofsafe patienthandlingandmobilitythroughFACES,andbeitfurther

RESOLVED ThattheASNAwillpublishanarticleinThe Alabama Nurseandwill providealinktoinformationaboutSafePatientHandlingandMobility ontheASNAwebsite,andbeitfurther

RESOLVED ThattheASNAwillchallengethedistrictstopromoteandeducate SafePatientHandlingandMobility.

Resolution #3 Alabama’s Future of Nursing Support of the Institute of Medicine’s 80/20 Recommendation

RESOLVED ThattheASNAwillpromoteeducationaladvancementthroughoutthe districtstopromotethehighestqualityofhealthcareforthecitizens ofAlabama,andbeitfurther

RESOLVED ThattheASNAwillpublishanarticleinThe Alabama Nursetofurther educatenursesandthepublicaboutTheIOM80/20recommendation.

Resolution #4 Hazardous Waste

RESOLVED That the Alabama States Nurses Association (ASNA) will publish anarticle in the Alabama Nurse and provide an educational opportunityto increase awareness of hazardouswaste landfills in theState and thepotentialhealthimpactonthepopulation,andbeitfurther

RESOLVED ThatASNAwilladvocateforstrengtheninglawsthatregulateandlimithazardouswasteintheStateofAlabama.

Resolution #5 Workplace Bullying in Nursing

RESOLVED That ASNA, through bullying education, programs and projects fornurses, continues to encourage an atmosphere of zero tolerance forbullyingbehavior;and

RESOLVED ThatASNAprovideseducationonverbalandbehavioralactionstotakewhenbullyingoccurs;and

RESOLVED ThatASNAchargeseachdistrictwithhostingapresentationonbullyingintheworkplace(powerpointprovidedbyASNA);andbeitfurther

RESOLVED That ASNA surveys its constituents to assess for the occurrenceand prevalence of bullying in the Alabama nursing workplace anddisseminatetheevaluationsbytheendof2014.

Resolution #6 Cardiopulmonary Resuscitation (CPR) Training for Faculty and Staff in Our Schools

RESOLVED That ASNAwill challenge districts to partner with schools to provideeducationandcertificationandbeitfurther

RESOLVED That ASNA will promote community awareness throughout the statetopromoteCPRcertificationandmaintenance of CPR certification forschoolfacultyandstaffandbeitfurther

RESOLVED That ASNA advocate for strengthening laws that require CPRcertificationoffacultyandstaffintheschools


2013 Alabama State Nurses Association Annual Convention

American Nurses Association Executive DirectorDebbie Hatmaker, speaks on national issues.

CE sessions on relevant issues such as identifyingvictims of sex-trafficking in ER’s.

Representative greg Wren, Montgomery

Dr. Robert Bentley, the firstgovernor to do so, brings openingremarks at the ASNA Convention.

House of Delegates considers resolutions, By-lawchanges, elections and other ASNA business.

Representative April Weaver, Alabaster

Rep. greg Wren,speaking at Convention and Rep. April Weaver,speaking at Nurses Dayat the Capitol, receivedthe first ASNA LegislativeCitation of AppreciationAwards. The Award,originating in 2013,commends outstandingservice to healthcareissues and to theprofession of nursingspecifically.


2013 Alabama State Nurses Association Annual Convention

All Award recipients are listed on page 12 in The Nurse and all Convention photos may be viewed in“Convention Album” at www.alabamanurses.org.


Membership News

End of the Year Savings!IfyouareamemberofASNA,youcandeduct77%ofyourdueson2013’staxes.Here’saneasycheatsheet:• FullDuesMembers(ASNA/ANA)$225.61• ReducedDues(ASNA/ANA)$112.81• SpecialDues(ASNA/ANA)$56.40• StateOnlyMembers$134.75

If you are in the process of taking your ANCC certification exams, don’t forget all dual members (ASNA/ANA)receivea$120discountonexamfees.

ANAannounced thatonJanuary1,2014 itsautomaticdues escalatorwould take effect.ANA’s dues adjustmentis implemented every three years, based on the policypassedbytheANAHouseofDelegatesinJune2004,andmodifiedinJune2010toremovethesunsetclause.ANA’slastdueschangeoccurredJanuary1,2011.

Although ANA’s 2014 incremental dues increase is$8 annually, ASNA has requested that ANA/ASNA combined member increase be limited to $6 annuallyfor an employed ANA/ASNA total membership costof $299 annually ($25.43/month), thereby keepingmembershipduesinAlabamabelow$300.

State-only ASNA membership dues are NOTincreasingandremain$175annually($15.08/month).

Otherdiscountedrateoptions:ANA/ASNA New RN Grad/Full-time Student/

UnemployedNurse:$149.50($12.96/MO)ANA/ASNAAge62orover,retired,ordisabled:$74.75

($6.73/month)Non-RNmembers:$95annuallyor$50biannually

Members who join prior to January 1, 2014 and payinfullwillbeabletojoinatthe2013rate.Ifthememberchooses to pay bymonth, themonthly ratewill increaseon January 1, 2014. If paying monthly, the ANA/ASNAincrease is 50 cents per month. Another ANA inflationadjustment in dues is not scheduled to take effect untilJanuary1,2017.

ThankyouforbeingamemberofASNA.Ourmembersreachouttoothers,andASNAisgrowinginbothnumberandinfluence!

[email protected].

JohnZieglerExecutiveDirector,ASNA

An Important Dues Announcement for

Members:

2013 Alabama Nurses Association Annual Convention

2013 Award WinnersOutstanding Legislative Advocate of the Year Award -

CharlotteWynn,MSN,CRNPOutstanding Health Care Organization Award -

ForestManor,Inc.Outstanding New Member Award -

AmySouthern,BSN,RN-BCCindajo Overton Outstanding Educator Award -

MaryBethBodin,DNP,CRNP,NNP-BCOutstanding Nursing Administrator Award -

DianeBuntyn,MSN,RN-BC-OCNLillian B. Smith Award -

CartheniaW.Jefferson,JD,BSN,RN

2013 Scholarship Winners

Vice President–DianeBuntyn,RNC,MSN,OCN

Secretary–DonnaEverett,RN,BS,CIC

Commission on Professional IssuesAnnBales,MSN,CCRN,CNN

DebbieLitton,DNP,RNCordeliaNnedu,PhD,

JackieWilliams,DNP,MSN,RN

Nominating CommitteeDebbieFaulk,PhD,RN

BobbieHolt-Ragler,DNP,RN

Thank you to the Table Sponsors for ASNA’s 100th Birthday Party

HuntsvilleHospitalUniversityofSouthAlabama

ITTTech-MobileBreckinridgeSchoolofNursing&HealthScience

ITTTech-BirminghamBreckinridgeSchoolofNursing&HealthScience

AlabamaNursingHomeAssociationVirginiaCollege

AU/AUMSchoolsofNursingRunkie&AssociatesofMerrillLynch

Fortis-Birmingham

A Special THANK YOU to all our Exhibitors and Sponsors

Sponsors:SILVER

ArthurL.DavisPublishingAgency,Inc.

BRONZEHurstReview

2013 Convention Exhibitors:AARP

Alabama\NWFloridaGideonsInternationalAlabamaOrganCenterAlabamaEyeBank

ALACAREHomeHealth&HospiceAuburnUniversity/AuburnUniversityMontgomery

SchoolsofNursingBlueCross/BlueShieldofAlabama

E-ZWay,Inc.HurstReview

JacksonHospitalJohnR.WhiteCompany(AmericanRedCross

RepresentativeJamesRomett)

ASNA Scholarships Winners:

•ChuquitaMartin-Ramey$1,500.00

•WendyDuBose$1,500.00•DeniceDavis$1,500.00

District 2 Scholarship Winners:

•BriannaMartin$300.00•KileySmothers$300.00

KramesStaywellADPHFITWAY

KaplanMiddleTennesseeSchoolofAnesthesia

MoviMedicalSamfordUniversity

SylviaRayfield&Associates/ICANPublishingRinehartandAssociates

TroyUniversityUniversityofAlabama,CapstoneCollegeofNursingUniversityofSouthAlabamaCollegeofNursing

UAHCollegeofNursingUABHospital

VanderbiltUniversityZoll

Exhibit and Sponsorship Information

District 3 Scholarship Winners:•HeatherWalker$500.00•ClaireAngell$500.00

•AshtonTuteaud$500.00

2013 Election Results


CE Corner

Adult Celiac DiseaseAuthor: Charlene Roberson, MEd, RN, BC,Directorof

LeadershipServices,ASNA.

Goal:ExplorethepotentiallongtermeffectsofuntreatedCeliacDisease

Target Audience: Nurses, nursing students, health careproviders,orconsumersinterestedinthepoliticalprocess.

Attheconclusionofthisactivitythelearnershouldbeableto:

1. RelatethetypicalpatientprofileofapersonwithCeliacDiseaseaftertheyingestglutencontainingfoods.

2. ExplainthelongtermeffectofmalabsorptionwhenCeliacDiseaseisuntreated.

3. Giveexamplesofglutenfreeandglutencontainingfoods.

Disclosures: TheAuthorandPlanningCommitteedeclarenoconflictsofinterest.

Contact Hours: 1.5 contact hours (60minutes equal 1.0contacthour)or1.8contacthours(50minutesequal1contacthour)

Activity is valid through Nov. 1, 2015.Accreditation: Alabama State Nurses Association is

accredited as a provider of continuing nursing education bytheAmericanNursesCredentialingCenter’sCommissionofAccreditation.

AlabamaBoardofNursing(exp.30March2017)Cost:$10ASNAmembers $15NonmembersIf we mail this program to you, postage and processing

fee is $3.Directions:Completethewrittenmaterialasdirectedand

theanswer/evaluationformandsendto:Contact Information:AlabamaStateNursesAssociation360N.HullStreet,Montgomery,Al36104Fax: 334-262-8758 or Email scanned documents to

[email protected].

AContinuingEducationCertificateofCompletionwillbesenttoyouuponsuccessfulcompletionofboththeevaluationandposttest.Youmustscoreatleast80%ontheposttestforsuccessfulcompletion.Shouldyoufailtheposttestyouwillbeofferedtheopportunitytoretaketheposttestforanadditional$5.00 fee.Allowat least three (3)weeksafter receiptof thecertificate of completion for course to be placed on yourofficialAlabamaBoardofNursingtranscript.

Introduction – Celiac Disease (CD) is an immunemediated disease (tissue damage caused by body’s own immune system) that principally affects the gastrointestinaltract. It seems to result as interplay between genetic,immunologic, and environmental factors. The individualwithCDhasachronic inflammation in their small intestinewhichusuallyresultsinatrophyorflatteningoftheintestinalvilliwithaccompanyingmalabsorption.Commonsymptomsincludediarrhea,abdominalcrampingand/orpain,abdominaldistention and if untreated vitamin andmineral deficienciesaswell as osteoporosis.Most of the symptoms subsidewiththe exclusion of gluten from their diet. It is believed thatapproximately 2millionAmericans haveCD.Until recentlyit was believed that this disease was predominately locatedin Europe because the majority of research into CD wasconductedinEuropeinthedecadesfollowingWorldWarII.In recentyearsCDhasbeen locatedaround theglobe.ThispaperwillconcentrateonAdultCD.

Historical Overview –Other names for CD are gluten-sensitive enteropathy and nontropical sprue. The cluster ofsymptoms that today health care providers refer to as CD,was first recorded in literature by Aretaeus of Cappadocia,a Greek physician who practiced in Rome and Alexandria,duringthesecondcenturyAD.TheactualtermCDwasfirstused in1888byDr.SamuelGee,aLondonphysician in thepaper On the Coeliac Affection.ThepapercontrastedCDtotuberculosis and dysenteric enteritis. However, the greatestadvances in the diagnosis and treatment of CD occurred

immediatelyfollowingWorldWarIIintheNetherlandsbyaphysiciannamedDr.Willem-KarelDicke.Heiscreditedwithdeveloping theglutenfreedietas treatmentandprovingthatcertaintypesofglutencausesrelapsesinindividualswithCD.From the 1890s numerous physicians have proposed dietsconsistingofbananas,othervariousfruits,tomatoes,potatoes,beefsteak,andmilkforthetreatmentofCD.Thesedietsmetwithvaryingsuccess.Dr.Dickeusedthisdatainhisresearchexperimenting with gluten free diets for individuals withCD.Hemadetheconnectionbetweentheingestingofbreadandcerealsandreoccurringdiarrhea.Duringthe“WinterofHunger”(1944-1945)intheNetherlands-especiallyintheWestern area, food became scarce and different food items,such as tulip bulbs were consumed. Wheat/bread was notavailableandindividualswithCDimproveddrastically.ThenAlliedplanesstarteddroppingbreadandindividualswithCDdeterioratedrapidly.Thisdiscoveryledtomultiplecontrolledstudies in childrenbut the resultswere transferred to adults.Childrenwerefeddefinedglutenfoodsourcesandthentheirstoolsweremeasured for fecalweight and fecal fat and thiswasusedasameasureofmalabsorption.Theseexperimentsidentifiedthegreatestoffendersaswheat,barley,ryeandtoalesserextentoats.

Manifestations: Theclassicformisdiagnosedininfancyand is evidenced by failure to thrive, diarrhea, abdominaldistention, anddevelopmental delay and at times becomes amedical emergency.The clinical symptoms arevariable andmay be noticed at any age.A prolonged delay in obtaininga diagnosis is common. Often individuals wait becausethey realize that limitinggluten in their diet decreased theirsymptoms.Itisamultisystemdisorderandmaypresentwithno gastrointestinal symptoms and selected examples includethe following: dermatitis herpetiformis (blisters on buttocks, elbows, and knees which may be burning , itching, or painful in nature), iron deficiency anemia, unexplained short statue,delayed puberty, osteoporosis, recurrent fetal loss, vitamin/

Adult Celiac Disease continued on page 14

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mineral deficiencies, fatigue, protein malnutrition, recurrentaphthous stomatitis (canker sores), elevated transaminases,dental enamel hypoplasia, endocrine disorders such asthyroiditis, depression, anxiety, and peripheral neuritis Thisarticle will focus more on CD diagnosed in adulthood.Anywherefrom3-8%ofallindividualswithType1Diabeteshave CD and about 5-12% of individuals with Down’sSyndrome haveCD.There is also a prevalence ofCDwithindividuals diagnosed with Turner Syndrome, WilliamsSyndrome, selective IgA deficiency, and autoimmunedisorders.

CDisclassifiedinthefollowingtypes:1. ClassicalCD–gastrointestinalmalabsorptionand

diagnosisisestablishedbyserologictests,positivebiopsiesofvillousatrophy,andimprovementwithaglutenfreediet

2. AtypicalCD–fewornogastrointestinalsymptoms,extraintestinalsymptomspredominate.ThistypeisresponsibleformuchoftheincreasedprevalenceofCDtoday.ItisdiagnosedthesamewayasclassicCD.

3. SilentCD–personisasymptomaticbuthaspositiveserologictestsandbiopsiesarepositiveforCD.Theseindividualsareusuallydetectedbyscreeninghighriskfamilymembers.

4. LatentCD–positiveserologictestsbutnovillousatrophyonbiopsy.Personisasymptomaticandmaylaterdevelopsymptoms.

Management –There are six keymanagement elementsfollowedbyallhealthcareprovidersasfollows:

C–consultationwithaskilleddietitianE–educationaboutthediseaseL–lifelongadherencetoagluten-freedietI–identificationandtreatmentofnutritionaldeficienciesA–accesstoanadvocacygroupC–continuouslongtermfollowupbyamultidisciplinary

teamBeforetreatmentbeginsthepersonshouldhaveacomplete

diagnosticworkupwhich should include serologic tests and

an intestinal biopsy.Management of CD is simple and it isthe exclusion of all gluten for life – specificallywheat, rye,andbarley.Thesegrainscontainagentsknownaspeptidesorglutenswhichhavebeendetermined tobe thecauseofCD.EvensmallquantitieshaveanimpactontheoverallhealthofsomeonewithCD.Inmostindividualsoatsaresafe;however,thereisoftencontaminationwithglutenduringprocessingoffooditems.Therefore,apersonwithCDshouldconsumeoatproductswithcaution.IndividualswithCDcaningestsome/smallquantitiesofglutenwithoutharmand thisvariesfromindividual to individual. There is no realistic scientificallybased formula to determine what a safe amount is or howmuchglutenisineachfoodproduct.Thusacompleteornearcompletegluten-freedietisrecommended.

Improved self care management is enhanced withknowledgeaboutthediseaseandparticipationinanadvocacygroup is a positivemeans of adhering to a gluten-free diet.Often individuals with CD have nutritional deficienciesand the healthcare provider should evaluate for and treatboth vitamin and mineral deficiencies. The most commondeficiencies include B12, calcium, folate, iron, phosphorus,and fat-soluble vitamins. Another essential evaluation is forosteoporosisasthereisahigherincidenceinindividualswithCD. Periodic visits to their healthcare provider are essentialfor the assessmentof symptoms anddietary adherence (and in children evaluation of growth and development).Thisisatimeforthehealthcareteamtooffersupportandbenefitsforlifelongadherencetotheglutenfreediet.

Initial serologic testing is essential if there is a suspicionthat thepersonhasCD.All testsshouldbepreformedwhilethepatientisonaglutendiet.Theyshouldbetestedforboththe IgA antihuman tissue transglutaminase (TTG) and IgAendomysial antibody immunofluorescence EMA) tests.These 2 tests have the best equivalent diagnostic accuracy.Another recently developed specialized serologic test is theantideamidated gliadin peptide utilized predominately inchildren. After the initial evaluation the continued use ofserologic testing is questionable by somepractitioners.Oncethepersonhas agluten freediet the testsmaynot return tonormal for at least a year andmay never correlatewith theimproved histology. Elevated serology levels do indicate alack of adherence or unintended gluten ingestion. But someindividualsdonotimproveonaglutenfreediet.Alsothetests

donotreflectpotentialcomplicationofCDsuchaslymphomaoradenocarcinomaofthesmallbowel.Healthcareproviderscontinue to debate the best practice regarding continuedserologic testing. At this time there is just no establishedtreatmentprotocolforserologictests.

Whenthetestsarepositiveaproximalsmallbowelbiopsyis indicated – except for those who have biopsy provendermatitis herpetiformis. Multiple biopsies should be takenas all areas may not be sensitive to the CD changes. It isimportant that the pathology report include the 1.) degreeof crypt involvement, 2.) hyperplasia, 3.) villous atrophy,and 4.) the number of intraepithelial lymphocytes. As eachperson is different in their physiologic response to gluten asecond opinionmay be neededwhen the biopsy report andserologic findings do not correlate.A definitive diagnosis ismadewhen gluten is removed from the diet and the personimproves. Some individuals have suggestive symptoms(breadintolerance)butanegativeserology.Inthiscasethereare 3 different possible scenarios as follows: 1.) selectiveIgAdeficiency&inthiscaseadditional laboratorytestingisneeded– IgT-TTGor the IgE-EMA(tests havevery similarresults), 2.) a false negative and if so the test should berepeated and/or a small bowel biopsy should be preformed,and3.)thepersondoesnothaveCD.

TherearegeneticmarkersforCDandtheseareimportantif the diagnosis is uncertain. Greater than 97% of allindividualswithCDhave theDQ2 and or theDQ8markercomparedto40%ofthegeneralpopulation.Thereforeif theDQ2and/orDQ8markersarenegativetheindividualprobablydoesnothaveCD.Aswithallgeneticteststheseareexpensiveandmayormaynotbecoveredwiththirdpartypayers.

There is no one best plan of care for patients who havepositiveserologic testsandnormalbiopsyresults.Theyhaveachoiceoffutureserologytests,additionalbiopsies,orgoonaglutenfreediet.

Dietary Support – The hallmark treatment for CD is alifelonggluten-freediet.Thisisfareasierstatedthenpracticedespeciallysincesomeindividualscantoleratesmallamountsofgluten.Nowheat,rye,orbarleyshouldeverbeconsumedand oats should be carefully monitored to include nomorethan 2oz/day. Safe alternate grains include buckwheat,

Adult Celiac Disease continued from page 13

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corn, potatoes, rice, and tapioca flours - all of which maybemadeintobread.Mostpreparedfoodsandmixescontaingluten, so labels should be carefully examined. Names forhidden additives containing gluten include “stabilizers” and“emulsifiers.” Safe beverages include distilled alcoholicbeverages, vinegars, and wine. Ale, beer, lagers, and maltvinegars are made from grains and not permitted. Glutenfree beer is widely available in Europe and available on alimited basis worldwide. Many individuals with CD alsohave lactose intolerance so the use of dairy products needsto be individualized. The followi8ng list of gluten sourceswasobtainedfromtheCeliacDiseaseFoundationandPublixSupermarketbrochure“glutenfreeguide.

SOURCES OF GLUTENThe following grains and their derivatives are sources

of gluten:Wheat - Varieties and derivatives of wheat such as:

wheatberries durumemmer semolinaspelt farinafaro grahamKAMUT®khorasanwheat einkornwheatrye barleyTriticale

Malt in various forms including: malted barley flour,malted milk or milkshakes, malt extract, malt syrup, maltflavoring,maltvinegar,chocolateandchocolatecandymadewithmalt.

Therearemanyfooditemsthatmaycontainthesesourcesofgluten,often inhiddenorunexpectedways.Always read the labelsofanyfoodproductsyouarebuyingifgluten-freeisnotspecifiedonthelabel.

Products labeled wheat-free are not necessarily gluten-free. Theymay still contain spelt (a formofwheat), rye, orbarley-based ingredients that are not gluten-free (GF). Toconfirm if something is gluten-free, be sure to refer to theproduct’singredientlist.

Common foods that contain gluten:• Pastas:raviolis,dumplings,couscous,andgnocchi• Noodles: ramen,udon,soba(thosemadewithonly

apercentageofbuckwheatflour)chowmein,andeggnoodles.(Note:ricenoodlesareglutenfree)

• BreadsandPastries:croissants,pita,naan,bagels,flatbreads,cornbread,potatobread,muffins,donuts,rolls,etc.)

• Crackers:pretzels,goldfish,grahamcrackers,etc.• Baked Goods:cakes,cookies,piecrusts,brownies,

etc.• Cereal & Granola:cornflakesandricepuffs(malt

extract/flavoring),granola• Breakfast Foods:pancakes,waffles,frenchtoast,

crepes,andbiscuits.• Breading & Coating Mixes:pankobreadcrumbs• Croutons: stuffings,dressings• Sauces & Gravies(manyusewheatflourasa

thickener)• flour tortillas• Alcoholic beverages (unlessexplicitlygluten-free)

andanymalt beverages–beer,ale,lager,mostgin,whiskey,andvodka.

• Sweets and special treats–candiescontainingcerealextract,commercialcakefrostings,icecream,rootbeer.

• Processed meats(wholegrainsareusedin

manufacturing)–coldcuts,liverwurst,hotdogs,bologna.

• Other common food –potatochips,frozenorcannedvegetablesinsauces,restaurantorfastfoodfries,cannedsoup.

Foods that may contain gluten (Must be verified):• energy bars/granola bars(somebarsmaycontain

wheatasaningredient,andmostuseoatsthatarenotgluten-free)

• fries(becarefulofbattercontainingwheatflourorcross-contaminationfromfryers)

• potato chips(somepotatochipseasoningsmaycontainglutenormaltvinegar,whichisnotgluten-free)

• processed lunch meats• candyandothercandybars• soup (payspecialattentiontocream-basedsoups,

whichhaveflourasathickener.Manysoupsalsocontainbarley)

• multi-grain or “artisan” tortilla chips or tortillasthatarenotentirelycorn-basedmaycontainawheat-basedingredient

• salad dressings and marinades• “starch”unlessspecified,labelsincludingstarch

asaningredientcouldmeananytypeofstarch,includingwheat.

Unexpected sources of gluten:• brown rice syrup• meat substitutessuchasvegetarianburgers,

tempeh,vegetariansausage,imitationbacon,imitationseafoodetc.(Note:tofuisgluten-free,becautiousofsoysaucemarinadesandcross-contaminationwheneatingout,especiallywhenthetofuisfried)

• soy sauce• self-basting poultry• pre-seasoned meats• cheesecake(somerecipesincludewheatflour)• eggs served at restaurants (somerestaurantsput

pancakebatterintheirscrambledeggsandomelets,butontheirown,eggs are naturally gluten-free)

• baking powder(somecommercialbrandsofbakingpowdercontainstarchtopreventclumpingthatisderivedfromwheat)

**Althoughsome individualsmay tolerate small amountsofglutenbestpracticeindicatesastrictaspossibleadherenceto a gluten free diet. Reasons stated include 1.) some mayhave micronutrient deficiencies such as Vitamin D causingbone loss,2.) individualswithCDhavean increasedoverallrisk of gastrointestinal malignancy, 3.) there is a possibilityof developing a concurrent autoimmune disorder {Type 1 Diabetes, connective tissue diseases, Hashimoto’s thyroiditis, Graves Disease},and4.)motherswithuntreatedCDappeartobeat riskof lowbirthweightbabiesandpre termbabiesascomparedtomotherswithCDandfollowingaglutenfreediet.

Thereare traceamountsofgluteninglutenfreeproductsprobably from grain contamination. Most medication hastrace amounts of gluten and trace amounts generally donot post hazards to individuals with CD. Gluten free drugsare available and information may be obtained at www.glutenfreedrugs.com.

Follow up monitoring is an essential aspect of bestpractices. About 70% of all patients with CD experiencenoticeableimprovementofsymptomswithin2weeksofbeing

gluten free. Generally the clinical symptoms show greaterimprovement than the histology (as noted on biopsies). Theproximal intestine improves slower than the less severelydamaged distal intestine and according to a ‘best guess’in the scientific community this is due to increased/longerexposuretoglutens.Mostcliniciansrecommendreevaluationoflabstudies6weeksfollowingaglutenfreediet.Theusualtests are B12, complete blood count, folate, iron studies,liver chemistries, and maybe serological testing. (NOTE: serologic tests may not return to normal for a year following the beginning of treatment.) Women should be advised thatbreasttendernessiscommonforthefirst3monthsfollowinginstitutingaglutenfreediet.AfollowupglutenchallengetovalidatethediagnosishasbeendeemedunnecessarybyboththeNationalInstituteofHealthandtheEuropeanSocietyofPaediatric Gastroenterology and Nutrition if the person isshowingimprovementclinically.

Cross contamination commonly occurs • Factorywhenbothglutenandnonglutenfoodsare

produced• Homekitchenwhentoolsandsurfacesareshared

whenpreparingfooditems–cuttingboards,toasters,flourshifters,deepfriedfoodswithsharedoil.Itisbesttohaveaseparatecuttingboardforglutenfreefoods.

• Wheatflourmayremainairborneformanyhoursinabakeryorathome

• Condimentssuchasbutter,jam,peanutbutter,mustard,mayonnaisewhentheutensilis‘doubledipped’

Foods best to avoid as they are easily contaminated• Oats• Frenchfries• Pizza• Non-certifiedbakedgoods

Special attention with children – make sure children wash their hands after playing with the following gluten containing items and teach the child not to place hands in mouth while playing with the following:

• Playdough• Paint• Glue• Papermache• Play-dough

Non food items that should be evaluated for gluten prior to use:

• Lipstickandgloss• Lotions(usuallynotanissueunlesshypersensitivity

orunlessaccidentlyingested• Herbalsupplements• Nutritionalsupplements• Overthecountermedications(vitamins,pain

relievers,etc.)AboveitemsobtainedfromtheCeliacDiseaseFoundation

website

Safe Gluten Free Foot Items• Beans,legumes• Buckwheatandkasha(checklabels)• Carob• Cheese,plain(checklabelifshredded)

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Post Test - Select the one (1) best answer

1. CommonsymptomsofCeliacDiseaseincludewhichofthefollowing?A. NauseaandvomitingB. BonelossandnauseaC. AbdominaldistentionanddiarrheaD. Diarrheaandexcessivethirst

2. AprolongeddelayinobtainingadiagnosisiscommonbecauseindividualsA. self-medicatetheoffendingsymptoms.B. delaytheworkupbecauseofcost.C. limitglutentodecreasesymptomsD. Alloftheabove

3. AtypicalCeliacDiseasehadfewgastrointestinalsymptoms.A. True B. False

4. SerologictestsshouldbeperformedwhilethepersonisA. consumingglutenintheirdiet.B. maintainingaglutenfreediet.C. Accurateresultsmaybeobtainedwithadieteitherglutenfreeorcontaininggluten.

5. Aproximalsmallbowelbiopsyisindicatedregardlessoftheresultsoftheserologictests.A. True B. False

6. GeneticmarkersforCeliacdiseaseincludeA. DQ2andDQ11B. DQ2andDQ8C. DQ8andDQ11D. DQ3andDQ6

7. Foodsallowedonaglutenfreedietincludewhichofthefollowing?A. TapiocaandgrahamcrackersB. BeansandcroutonsC. MaltvinegarandFrenchtoastD. Eggsandgrits

8. About70%ofindividualswithCeliacDiseaseexperiencenoticeableimprovementofsymptomswith___________weeksofbeingglutenfree.A. 1 B. 2 C. 3 D. 4

9. Improvementindermatitisherpetiformisinusuallynoted____________followingaglutenfreediet.A. 1-2monthsB. 1-6monthsC. 6–7monthsD. 6–12months

10. AdultswhohavelifelonghistoryofuntreatedCeliacDiseasemayexhibitwhichofthefollowingsymptoms?A. PseudofracturesB. PerforatedbowelC. CardiacarrhythmiasD. Cataracts


Evaluation/Post Test~Adult Celiac Disease1.5 (ANCC) 1.8 (ABN) contact hours

Activity #: 4-0.920

Goal:ExplorethepotentiallongtermeffectsofuntreatedCeliacDisease.

Name, Credentials: _______________________________ ___ Member $10.00

Address: ________________________________________ ___ Non Member $15

________________________________________ ABN License#: _____________ City State Zip CC Security Code ___________

Phone: ______________________ Email: ________________________________

______________________ / ________ ______________________________Credit Card Number Exp. Date Signature

1 2 3 4 5 6 7 8 9 10

ACTIVITY EVALUATION Circle all responses using this scale: 3–Yes 2–Somewhat 1–No

Objectives&Goalswereappropriate. 3 2 1

Rateyourachievementoftheobjectivesfortheactivity 1. Relatethetypicalpatientprofileofapersonwith CeliacDiseaseaftertheyingestglutencontainingfoods. 3 2 1

2. ExplainthelongtermeffectofmalabsortionwhenCeliac Diseaseisuntreated. 3 2 1

3. Giveexamplesofglutenfreeandglutencontainingfoods. 3 2 1

Programfreeofcommercialbias. 3 2 1

Onascaleof1–5/1(low)5(high)knowledgeoftopicbeforehome-study 5 4 3 2 1

Onascaleof1–5/1(low)5(high)knowledgeoftopicafterhome-study 5 4 3 2 1

Howmuchtimedidittakeyoutocompletetheprogram?____________ hours_________ minutes.

ADDITIONALCOMMENTS:

CE Corner

• Coffeeandtea(checklabelifshredded)• Cornproducts-cornstarch,cornflour,cornmeal,

corngrits• Creamcheese,cottagecheese• Eggs• Freshorfrozenvegetableandvegetablesjuices• Freshfruitandfruitjuices• Freshmeatandpoultry,plain(checkingredientsto

makesureithasnotbeeninjectedorbastedwithaglutenproduct)

• Milk,buttermilk,andcream• Millet,quinoa,flax,sorghum,andflowersderived

fromthem• Nutsandseedsandflourmadefromthem• Rice,incbrownrice,basmati,jasmine,andArborio

andriceflour(checklabels)• Soymilk9readlabelifflavoredorisasoybased

beverage)• Tapioca• Tofu(readlabel)AboveitemsobtainedfromthePublixGlutenFreeguide

A personwho follows a gluten free diet for 2 years andshows no clinical improvement is referred to as a NonResponder. Approximately 5% of individuals with CD areNonRespondersandtheyfallintothefollowing5groups:

1. concurrentdisorderwhichhasclinicalfeaturessimilartoCD(LactoseIntolerance,IrritableBowel,bacterialovergrowth,etc.)

2. clinicaldiseaseswithclinicalorhistologicfeaturesofCDbutarenot(smallbowelvillousatrophy)

3. poordietarycomplianceorinadvertentlyingestionofgluten

4. patientswithrefractorysprue5. patientswithulcerativejejunitisorintestinal

lymphoma

Adults often have untreated medical issues due to alifelong history of malabsorption. So they need evaluationand treatment for nutritional deficiencies. Another isevaluation of bone loss especially osteopenia. Most oftenthis is secondary hyperparathyroidism due to a Vitamin Ddeficiency.Patientswithanadvancedstatemayexhibitbonepain, pseudofractures, or deformity. A few patients have anelevated Serum Alkaline phosphatase or hypocalcemia andusually this isnotsevere.AprophylacticpneumoniavaccineshouldbeadministeredasmanywithCDhavehyposplenism.IndividualswithCDoftenhave avarietyof skin issues andthemost common is dermatitis herpetiformis. Improvementisusuallyobserved6monthstoayearfollowingaglutenfreediet.

Family members of individuals with CD should beevaluated as they have an increased risk of also having thedisease. Monozygotic twins have the highest risk at 75%,followedbyHLA-identicalsibling(tissuesimmunologically

compatible)at40%.It is testingof familymembers thathasincreased the numbers of known CD cases. Many of thefamilymembershaveeitherlatentorSilentCD.

Nursing Management: Nursing care is limited withthese patients as most are managed on an outpatient basis.They need support with the strict diets and help locatingsupport groups and essential resources. Emotional supportis especially needed when the individual and family areexperiencing long term effect of untreated CD. Some haveguiltfornotseekingtreatmentsoonerandsomeparentsmayfeel they are responsible for their child’s ongoing sickness.Nursingsupportisalsoneededtoencouragefamilymembers,althoughasymptomatictobetestedforCD.

Selected BibliographyNational Institute of Health consensus Development

ConferenceStatement.CeliacDisease2004availableathttp://consensus.nih/gov/(accessedOctober26,2013).

ShakerJL,BricknerRC,FindlingJW,et.al.Hypocalcemiaandskeletaldiseasesaspresentingfeaturesofceliacdisease.ArchInternMed1997;157:1013.

Pink IJ, Creamer B. Response to a gluten-free diet ofpatientswiththecoeliacsyndrome.Lancet1967;1:300.

HolmesS.Coeliacdisease:symptoms,complicationsandpatientsupport.NursingStandard;2012May;24:35

Barbato M, Maiella G, Di Ccamillo C, et. al. the anti-deamidatedgliadinpeptideantibodiesunmaskceliacdiseaseinsmallchildrenwithchronicdiarrhea.DigLiverDis.2011Jun;43(6)465-9.


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CE CornerASNA’s 2014 Annual End of Life Symposium

Saturday, March 1, 2014Loeb Conference Center ~ Old Alabama Town 301 Columbus St ~ Montgomery, Al 36104

Goal: To explore improved end-of-life care

Cost: $45ASNAmembers $65nonmembers

Contact 6.0(ANCC) 7.2(ABN)Hours:

8 am Registration

8:15 am Tentative Topics Include: • PalliativeCareinLTC–CharlotteWynn,MSN,CRNP,LTCNursePractitioner • LegalIssuesatEOL–DonEddins,JD,ASNAAttorney • EOLCommunications–JenniferVann,DNP,APHRN,PalliativeCareNurse Practitioner • AnalgesicsandPolypharmacy/PainManagementatEOL–MarshaFerrell,RN (invited), Certified Pain Specialist • CulturalIssuesateOL–SueMorgan,PhD,RN,ELNECInstructor • What’sSoFunnyAboutDying?–SueMorgan,PhD,RN,ELNECInstructor

4: 00 pm Evaluation

Accreditation: The Alabama State Nurses Association is accredited as a provider of continuing nursingeducationbytheAmericanNursesCredentialingCenter’sCommissiononAccreditation.

AlabamaBoardofNursingProviderNumberABNP0002 (valid until March 30, 2017).

Refunds: If cancellation is received inwriting prior toFeb. 14, 2014 a refund (minus a $20.00 processingfee)willbegiven.AfterFeb.14,2014norefundwillbegiven.Wereservetherighttocanceltheprogramifnecessary.Afullrefundwillbemadeinthisevent.A$30returncheckfeewillbechargedforallreturnedchecks/payments.

ASNA’s 2014 Annual End of Life Symposium

Name:________________________________________________ Credentials:____________________

Address:_______________________________________________________________________________

DayPhone:(_____)_______________________ Email:_______________________________________

PaymentMethod: ___ASNAMember$45 ___ NonMember$65 After Feb. 14, 2014 add $15

CreditCard#: ____Check–MakePayabletoASNA

Signature:_________________________________ ExpirationDate:__________ SecurityCode:_____

Confirmations by Email Only ~ Licenses Will Be Scanned at the Workshop

Mailregistrationformto:ASNA,360N.HullSt.,Montgomery,AL36104ORFaxto334-262-8578/Registeronlineatwww.alabamanurses.org

ConfirmationbyEmailOnly

Registration Methods:Mail:ASNA360N.HullSt.Montgomery,AL36104

Fax:334-262-8578Online:alabamanurses.org

Research Corner

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Automated Phone Monitoring System Provides Important Information

About Medication DiscontinuationInteractive voice response system (IVRS) technology has the potential to directly

contactlargenumbersofpatientstoassesstheiradherencetotheirmedicationregiment,as well as symptoms experienced while taking the medication. A new study foundthat rates atwhich patients reported by phone their discontinuation ofmedicationwassubstantially higher than those documented in the electronic medical record. Thissuggests that the IVRS may be an important tool for improving physician-patientcommunicationaboutmedicationadherence,nottheresearchers.

Over 1,500 patients from 11 primary care clinics affiliated with the Brigham andWomen’s Hospital agreed to receive an e-pharmacovigilance call that used IVRS.Overall, 3.9 percent of patients who completed the e-pharmacovigilance call and1.0 percent of patientswhodid not complete the call had discontinuation of the targetmedicationrecordedintheelectronicmedicalrecordwithin6monthsoftheireligibilitydate.Thisdifferencewasstatisticallysignificant.Thosewhocompletedthecallalsohadhigheruseofprimaryorspecialtycare(32.8percent) than thosewhodidnotcompletethecall(18.7percent).Theratesofotheroutcomes(acutecareservicesanddeath)weresimilarinbothgroups(12.2and9.8percent).

Eachpatienthadrecentlybeenstartedononeof32medicationsselectedforthestudy.Fourweeksafteraprimarycarevisit,patientsreceivedane-pharmacovigilancecall(i.e.,atelephonecallusingIVRS)aboutwhethertheywerestilltakingthemedicationrecentlyprescribed and, if they had stopped,why?Following the call, the system sent a singleemail to the primary care provider if the patient: (1) reported stopping a medicationintended for chronic use and indicated that they Had not discussed this with theirprovider, (2) reportedapre-defined listofsymptoms,or (3) requested thatanemailbesenttotheprovider.

Among the subgroup of 799 participants who noted at least one symptom, 176(22 percent) attributed their symptom to the medication. Patients who thought thattheir symptomwas related to themedicationweremore likely to report that they hadstopped themedication (13.1 percent) comparedwith thosewho did not think that thesymptomwasrelatedtothemedication(1.5percent).ThisstudywassupportedbyAHRQ(HS16970).

See“Activeparmacovigilanceandhealthcareutilization,”byJenniferS.Haas,M.D.,ElissaKlinger,S.M.,LucasXavierMarinacci,B.X.,andothers in theNovember,2012American Journal of Managed Care 18(11),pp.e423-e428.MWS

Reprinted from August issue of Research Activities

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The Effect of Medication Reconciliation on Medication

Discrepancies is UnclearTransitions in care, such as admission to or discharge from thehospital or between

hospitalunits,putspatientsatriskforerrorsduetopoorcommunicationandinadvertentinformation loss. Unintended medication discrepancies remain common at discharge.The formal process for identifying and correcting medication discrepancies acrosstransitionsofcare,medicationreconciliation,hasbeenwidelyendorsedandismandatedby health care accreditation bodies in the United States and Canada. Yet, mostunintentionalmedication discrepancies foundduringmedication reconciliationhave noclinicalsignificance,according toanewstudy.Theresearchersconductedasystematicliterature review focusing on the effect of medication reconciliation on unintentionaldiscrepancieswiththepotentialforharm.Discrepancieswithonlyconsideredclinicallysignificant if they posed a nontrivial risk of harm to patients. All included studiesreported a category that amounted to “trivial,” “minor,” or “unlikely to cause harm,”with all other unintentional discrepancies deemed to be clinically significant. Theresearchers included 18 studies evaluating 20 hospital basedmedication reconciliationinterventions, with pharmacists performing medication reconciliation in 17 of the20 interventions. Their review suggests that only a few unintended discrepancies haveclinical significance. Furthermore, most patients have no unintentional discrepancies.Therefore,theactualeffectofmedicationreconciliationonreducingclinicallysignificantdiscrepancies in the inpatient setting remains unclear. The researchers point out thatwhilemedication reconciliationaloneprobablydoesnot reducepost-dischargehospitaluse, itmaydosowhenbundledwithinterventionsaimedat improvingcaretransitions.Theyalsocautionthattheremaybeaneedtoconsideralongerwindowofobservationthan30daysinordertodemonstratethebenefitsofmedicationreconciliation.ThisstudywassupportedbyAHRQ(Contracto.290-07-10062).

See“Medicationreconciliationduringtransitionsofcareasapatientsafetystrategy,”by JaniceL.Kwan,M.D., LishaLo,M.P.H.,Margaret Sampson, Ph.D., andKavehG.Shojania,M.D.,intheMarch5,2013Annals of Internal Medicine158(5)Part2,pp.397-403.MWS

Reprinted from August, 2013 issue of Research Activities


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