Honoring the difficult

The first time I met Grace she was sitting in the music room, her eyes closed, her lips quivering to the lyrics of “Be Thou My Vision.” It was late afternoon, the time the nursing assistants felt it would be best for me to see Grace, before her behavior changed and she refused any company. Grace had fired her doctor, whom she’d known for more than 25 years but no longer recognized. She also fired the next doctor, with whom her daughter had worked for 15 years and Grace had sat next to at her daughter’s wedding. And she had fired the nurse practitioner who specialized in geriatric care and with whom she seemed to have made a connection, convinced that her husband Roger and the rest of the family were plotting to get rid of her and leave her to die in the assisted living facility against her will.

A fall for Grace

On the surface, Grace’s story was not unlike so many I’d heard before. A retired accountant with the federal government, she had been living at home with her husband, a university professor, before an unexpected ice storm caused her to slip, fall, and break her hip. Her daughter Marianne, an administrator at the university hospital, knew exactly whom to call upon for her surgery. Everything went well, and Grace’s wound healed quickly. Anxious to get back to her gardening and volunteer work at her parish, Grace agreed to a short stay in rehab and was usually up and ready to walk before the physical therapists even arrived at her room.

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But it was one morning that Grace was not up and ready that the nursing assistants found unusual. She was disoriented, disheveled, argumentative, and nearly combative. Grace had a urinary tract infection that, as it often does with older adults, affected her ability to think clearly. A round of antibiotics was all it would take, so the doctors promised. She’d be back to herself in no time, and soon she’d be able to go home.

What no one knew—other than Roger and Marianne—is that Grace would not go home. Not even a week before her fall, Roger and Marianne had spoken about Grace’s unusual behavior. She had accused Roger of taking her checkbook from her purse when, in fact, she’d left it on the dining table the night before. She had written a check for $5,000 to the lawn service and then fired them, accusing the owner of trying to steal from her account.

Roger had not told his daughter that it wasn’t really the ice that had caused her mother to fall. She had also fallen in the middle of the night, right outside her bathroom. As a matter of fact, Grace had fallen three other times, each time trying to get to the bathroom, only to forget how she had gotten there. Even at the rehab, although the nurses had laughed it off and chalked it up to her wry sense of humor, Grace had said Roger was not really her husband but a federal agent who needed to be IDd before coming on the unit.

Making a connection

Now, my job was to connect to Grace and convince her to take her medications, particularly one she had taken for many years for anxiety and mild depression. It had taken weeks and several rounds of antibiotics to clear up Grace’s infection but her memory seemed worse, and it was clear from a series of neurological and psychological tests that it was exactly as Roger and Marianne suspected. Grace had dementia.

I started things off as I always do.

“Hello, Grace. My name is Angel,” I said, extending my hand. “May I sit and talk to you for a moment?”

Grace’s soft hands curled into tightly clenched fists, her shoulders hunched forward, her lips pressed into a tight, thin line.

“What do you want? Who are you, anyway?”

“My name is Angel. I’m wondering if I can talk to you for a few minutes?”

Grace sealed her eyes shut, clenched her fists tighter, and pressed her shoulders in toward her chest. I told Grace why I was there, choosing first to let her know I was a nurse practitioner and that I was there to check on how she was feeling—her appetite, her sleep, her mood.

“How do you think I feel?” Grace spat. She leaned forward, the skin on her knuckles turning pale white. “How would you feel if you were me?”

“I’m not sure how I would feel, Grace. But what I want to know, really, is how you feel.”

Give or take a few details, much of what Grace shared with me that day was true: No one had ever really told her she wasn’t going home from the rehab. Roger and Marianne had taken the facility tour by themselves and decided that, since it was on the side of the Beltway nearest to Marianne’s office and not too far from Roger’s, it would be convenient for both of them.

Silent treatment

The view at night from Grace’s room was picturesque. The small but beautiful assisted living facility was costing Roger a pretty penny, but, after 35 years of marriage, he knew the sacrifice he was making for his wife was worth it. It was also true that Roger had spoken to Miriam—Grace’s best friend—because he had been so distraught about what to do. But what wasn’t true, and what Grace was convinced of, was that Roger had “dumped” her there and was having an illicit affair with Miriam; that Roger was taking her retirement money and spending it on fancy overseas vacations for himself and Miriam; and that the medications I was there to convince her to take were coming out of her life savings, all for the sake of getting her out of the way of Roger and Marianne. Grace had all but stopped speaking to Roger. When he came, she just sat quietly in the day room, ignoring his every word.

In geriatric practice, we often quip about always having at least two patients: the person we are there to care for and the relative or family unit to which they belong. Our work is part detective, deciphering what is fact and what is perception, and part historian, wading through family histories that are often messy, convoluted, and very complicated. We are the insider and the outsider all at once, paying close attention to little nuances that don’t often make clear which side of the fence we should be on for any given day. We are also the bearer of news that, many times, isn’t good. People get older. Body parts stop functioning. Diseases set in and get worse over time. Cures don’t always happen. Hope falls short, and expectations crash to the ground. Anger is quick and acceptance slow, especially in cases of dementia.

What most people don’t know—and what many providers have difficulty explaining—is that dementia changes the brain in ways clinicians can rarely predict. It changes the ability to complete not only the ordinary functions of bathing and toileting and walking, it can also create drastic changes in mood, behavior, and personality. In addition to struggling with the mechanical tasks of caring, caregivers grieve the loss of the person and personality they used to know. For some, like Roger, the changes become unbearable over time.

The plan

Getting Grace to take her medications had less to do with talking to Grace than it did with talking to Roger. Because her behavior was so emotionally taxing, Roger had given up on coming to see her. My work was not only to manage Grace’s medications but to help Roger understand the full scope of her illness and how his presence alone might help. He understood parts of the science; where he needed help was in understanding his emotions.

"Holding space" for caregivers is as important as the work we do for our patients; in fact, it is central. In holding space, we strengthen caregiver coping skills by helping them process feelings of anger, frustration, and fear. We help normalize emotions, clarify perceptions, and set realistic expectations for what we know is likely to come. Most of all, we help caregivers learn how to honor the difficult.

My conversations with Roger led to creation of a new visiting schedule at an earlier time in the day when Grace was far more rested and less likely to be tired, irritable, and suspicious. His visits would be brief and focused.

Under the new arrangement, Roger became increasingly helpful to the nurses during the morning medication time. Roger and Grace shared meals together and morning coffee, activities that hadn’t been erased from Grace’s memory. Grace loved art, so we devised a calendar art project that involved cutting, pasting, and coloring, which gave her a goal and kept her busy in the same way her work as an accountant had.

Her condition did deteriorate over time, but, by then, she, Roger, and Marianne had accepted hospice and palliative care, and Grace was able to live her final few days back at home. There were days she still refused her medication, something we all learned to accept. And that, I’ve found, is the essence of geriatric practice: providing care through acceptance; making peace with even the smallest and slowest of progress even as the end of life looms near. It’s learning to honor the difficult.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.

Now is the time!

“You cannot solve problems with the same level of thinking that created them.” — Albert Einstein

It’s April, and I can only imagine the collective sigh of relief heard around the country. Those of us in the Northeast region of the United States—the New England and Middle Atlantic states—can finally be assured that our snowplow and shovel days are over. Clinic closures and school cancellations are unlikely and, thank goodness, the darkest days are behind us. Summer vacations for those of us who reside in the Northern Hemisphere are being planned, and, though we’re a little more than three months deep into the New Year, it actually feels like a new beginning.

April, for me, marks the beginning of planting season. As a gardener, I’m poring through seed catalogs and testing the quality of my soil to determine if it needs a few cups of nitrogen here or there to even out the acid-alkaline imbalance. I’m checking Farmer’s Almanac predictions to get a sense of just how hot and dry the growing season will be. I’m thinking about what I want to eat this summer and whether or not I want to stay on the tried and true path, growing what is familiar to me, or be a bit more bold and ambitious with heirloom seeds and varieties yet untried.

I’m checking my compost—a pile of rich, dark soil filled with worms and their egested casts, perfect for growing. And most importantly, I’m thinking about ways to improve irrigation. With an early start and late finish most days of the week, and hot temperatures sure to come, I can hardly imagine having enough time to make sure each crop row gets thoroughly watered to ensure that all of my hard work pays off with delicious meals composed of my own plantings.

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Interestingly, April also marks the convergence of two observances critical to our nation’s health: National Minority Health Month and National Public Health Week (6-10 April). Both are times of sowing new ideas for harvests of better health.

National Minority Health Month

Spearheaded by the U.S. Department of Health and Human Services’ (HHS) Office of Minority Health, the theme of this year’s National Minority Health Month—“30 Years of Advancing Health Equity”— commemorates HHS efforts, mobilized by findings of the Report of the Secretary’s Task Force on Black and Minority Health, commonly referred to as the Heckler Report, to eliminate health disparities among racial and ethnic minorities. Despite significant advances in medical science and disease-awareness campaigns, health disparities continue across racial, ethnic, gender, and socioeconomic lines.

Incidence rates of noncommunicable diseases such as diabetes, hypertension, and kidney failure remain disproportionately higher in African-American and Latino populations, and the United States continues to have an infant mortality rate that is higher than 25 of its wealthy counterparts. According to an alarming report in the Washington Post, in which data from the Centers for Disease Control (CDC) is analyzed, “A baby born in the U.S. is nearly three times as likely to die during her first year of life as one born in Finland or Japan. That same American baby is about twice as likely to die in her first year as a Spanish or Korean one.”

National Public Health Week

While we observe National Minority Health Month, the American Public Health Association (APHA) is marking—this week—National Public Health Week with five days’ worth of shifting themes that also emphasize the importance of addressing health disparities.

Monday kicked off the week with “Raising the Grade,” which, in an attempt to understand the overall state of America’s public health, examined public health data. Tuesday’s focus on the social determinants of health, particularly “zip code” health inequities, opened doors for very necessary conversations about ways in which health care access and services differ from neighborhood to neighborhood, city to city, thus further marginalizing the already marginalized. Wednesday and Thursday offer opportunities to discuss means for building a stronger public-health infrastructure through engaged leadership, interdisciplinary collaboration, and partnerships. And Friday will mark the 20th year of APHA’s National Public Health Week with a celebratory remembrance of major achievements in public health.

Nurses on front lines
No matter the setting in which we find ourselves, nurses are, more often than not, on the front lines of the very health delivery systems that are central to these week- and month-long observances. Nurses are the first and last points of contact for direct and indirect care. We are responsible for educating the largest segment of the health care workforce in the United States. For these reasons—and more—it is our responsibility to not only tune into these observances but to establish a direct relationship between public health and clinical practice.

By now, most of us have read the headlines about police shootings, tensions between local police and civilians, and spousal abuse at the hands of prized athletes. Tragedies all, it is time to speak publicly about the psychological toll that violence—particularly structural violence—has on individuals and whole communities. It is time to speak publicly about powerlessness and disengagement as a result of rape, abuse, repeated exposure to violence, and lack of protection and justice for victims of violent crime.

Those of us in clinical practice who know firsthand the financial struggles our patients have paying for medicine, healthy food, and the most basic necessities must give voice to the harsh realities of poverty and the social determinants of health. No more can we remain silent about the existence of food deserts—entire communities bereft of access to quality food markets but with easy access to the cheapest and most nutrient-poor foods one can imagine. No more can we ignore the roles of poor literacy and numeracy, placing blame for nonadherence on our patients without examining our responsibilities as providers to properly identify these deficiencies and to treat them as we would any other obvious health condition.

Now is the time

Knowing that these issues exist—and will continue to exist long past the five days in which we observe National Public Health Week and the 30 days in which we observe National Minority Health Month—underscores the importance of planting ourselves now in the events and discussions that are forthcoming. Now is the time for checking the soil and telling the truth about root causes of health disparities and inequities. Now is the time for collaboration, planting seeds of ideas that are bold and creative and getting out of silos that use outdated methods and theories that won’t solve new and more complex problems.

In the words of Einstein: “You cannot solve problems with the same level of thinking that created them.” Now is the time for improving irrigation, for ceaselessly watering, through advocacy and lobbying for improved and long-overdue health policies, seeds that will germinate into healthy “plants.” There is no better moment than the present to say what needs to be said and to do what needs to be done. Now's the time and the season, because, in the words of a treasured public-health colleague, at the end of the day all policy is health policy and all health is public health.

In late 2014, Angel Shannon was elected to serve on the Maryland Community Research Advisory Board (MD-CRAB) at the University of Maryland Center for Health Equity. “The overarching goal of MD-CRAB is to make a meaningful contribution toward the elimination of racial and ethnic health disparities by building trust between minority communities and health science researchers.” To learn more.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.

Cultural competence: More than numbers

“We see the world, not as it is, but as we are—or, as we are conditioned to see it. When we open our mouths to describe what we see, we in effect describe ourselves, our perceptions, our paradigms.”  — Stephen Covey

There’s an old saying that we see the world not as it is, but as we are conditioned to see it. This thought often comes to mind when I think of the latest national shift in the paradigm of health care. The current focus of discussion is “cultural competence” and the need to build a workforce that recognizes and appreciates the myriad factors that shape an individual’s definition of health and his or her experience in the health care system. While many organizations and institutions struggle to define exactly what cultural competence means, nowhere is the understanding of its importance more clear than in day-to-day clinical practice.

Case in point. Late one afternoon, in walks Shaye,* an 18-year-old male with diabetes. The youngest of four children, Shaye wears a low-hanging necklace with a beautiful gold pendant of a laughing Buddha. Shaye’s wide, bright smile is framed by a set of cheeks that look like two round apples. His shirt pokes out at the belly, which he rubs constantly in a way that conveys a touch of nervousness about our first visit.

Judging by the way his body has felt recently, Shaye knows the news of his latest lab results will not be good. He is right. His hemoglobin A1C is over 10. His LDL and triglycerides are double and triple what they should be. And, unfortunately, he has gained weight since his last visit nearly eight months ago. He has a short list of reasons for why things are wrong: He hasn’t been eating right, and, when he eats, he eats too much. He hasn’t been exercising, and what he does find time to do—a little soccer here and there—just isn’t enough. He didn’t pick up the new prescription the previous nurse practitioner gave him, despite the fact that he has prescription-insurance coverage. He even has a manufacturer’s savings card, which would have made it available at no charge.

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Contrary to instructions, he has stopped checking his blood sugars daily, because he ran out of lancets, and the prescription didn’t authorize a refill. Instead, every other week or so, he reuses the one he has if he feels bad and senses that his sugars are too high. It could be argued that Shaye is simply noncompliant and full of excuses.

A week later, Nick,* a 54-year-old accountant who hasn’t had time to come to the clinic in nearly nine months, shows up. First, it was the holidays, and he, his wife, and their four children were caught up in planning the family’s annual Christmas and New Year’s Eve parties, and he had simply forgotten. Then, it was spring break, tax season, and a slew of board meetings that he could not afford to miss. With all his responsibilities, he didn’t realize he had run out of one of his diabetic medications and, for some reason, hasn’t even thought to refill it.

As with Shaye, insurance coverage is not an issue for Nick. He came to the clinic partly to get “caught up” and partly because he senses that the news will not be good. Between the numbness and tingling in his feet and his increasingly blurry vision, he knows his condition is uncontrolled. Unlike Shaye, he hasn’t been checking his blood sugars at all, because there is simply no time in the mornings and definitely no time at night when he finishes work not completed earlier in the day.

At home, his elliptical exercise machine is, admittedly, covered with dust, and yes, he has gained a few pounds since his last visit. But, in his estimation, those few pounds don’t exactly qualify as being unhealthy, per se. He is proud of the fact that he has a wife at home who makes sure a balanced meal and a glass of after-dinner gin are ready for him to come home to every night. It could be argued that Nick, too, is full of excuses—some understandable, but excuses nonetheless. For some clinicians, it would be much simpler to cut losses, rewrite prescriptions, and send both of these patients on their way. Both Nick and Shaye illustrate why it’s so important to take the long view when it comes to population health and improving health outcomes—a view that must include foundational awareness and knowledge of the intersections of culture, ethnicity, and linguistics in the health experience of patients and health-care delivery by providers.

In its 2013 Enhanced Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (CLAS), the Office of Minority Health seeks to “advance health equity, improve quality, and help eliminate health care disparities by establishing a blueprint for individuals as well as health and health care organizations to implement culturally and linguistically appropriate services.” The enhanced standards offer a comprehensive approach to integrating culturally and linguistically appropriate practices into health-professions education, as well as clinical practice. Culture, in the standards, is broadly defined “in terms of racial, ethnic and linguistic groups, as well as geographical, religious and spiritual, biological and sociological characteristics.” In clinical practice and in teaching, I like to think of cultural competency as the discipline of and commitment to getting to know our patients’ stories.

Shaye’s story is a reflection of culture and socioeconomics. He and his family are recent immigrants from Thailand. His meals, cooked by his mother, are often hearty servings of rice and root vegetables, drenched in thick, spicy sauces unique to Thai culture. Shaye, who is still in high school after being put back a grade upon arriving in the United States, gets little exercise. After school, he works part time at a local Thai restaurant alongside his mother, whose English fluency is limited. Not only does Shaye help bring in additional income, he helps cover his mother’s embarrassment when interacting with customers at the store. Between school and his part-time job, there is little time for formal exercise or after-school participation in sports. This doesn’t bother him. In his culture, he explains, it is understood that families work together. He considers it honorable to help his parents maintain what is needed for their household.

Back home in Thailand, it never occurred to Shaye or his parents that he was obese or that obesity negatively affects a person’s health. Big babies are considered healthy babies. They never heard of the word “diabetes” until they arrived in the States. Most importantly, because the meals he grew up eating—vegetables, stews, and rice—were assumed to be loaded with vitamins and nutrients and were not the same as junk food, he finds it terribly confusing that those things make him feel worse. Shaye’s parents teach their children the value of conserving by reusing what can be reused. Anything less is considered wasteful. He sees no problem in reusing his lancets, because it saves the family money.

Nick’s story is strikingly similar. He grew up in a large Italian family, and a meal without pasta, bread, and wine is simply not a meal. He recalls how his mother and both sets of grandmothers would stand over the table waiting for nods of acceptance from his father, grandfather, and uncles, and how dinner wasn’t finished until every morsel was eaten—a sure sign of a good cook. Even today, Nick and his wife insist that their children finish meals in their entirety. Nick’s liking for wine and other alcoholic beverages, akin to a deep desire, is ingrained from childhood as such drinks were part of the meal as much as vegetables and dessert. As in Shaye’s family, a chubby baby was considered a healthy baby, and a few extra pounds around a man’s midsection at midlife are a sign he is well taken care of.

Critical to effective health care delivery is understanding that the concept of “culture” is far broader than skin color and ethnic origin. Each patient represents a collection of personal histories that includes a full range of biological and sociological influences. Understanding my patients’ personal narratives—their lifestyles, family histories, and health beliefs—helps me better understand their levels of health literacy and identify where there are gaps in their knowledge about their health in general and, more specifically, their diabetes.

In Nick’s case, talking about nutrition and the meaning of food at a level beyond calorie counting and carb elimination was time well spent, a chance to discuss work-life balance with him and help him set healthier boundaries that would allow time for exercise, glucose monitoring, and basic self-care. More importantly, it was an opportunity for me to see my work in diabetes prevention through a broader lens than just numbers.

* Names have been changed to protect identities.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.

Nurse practitioners as public health leaders

Some time ago, when my daughter was younger, I stumbled across a website that introduced the concept of life-goal mapping. Aptly named “43 Things,” the website functions like a bucket list—a place to house all the goals, aspirations, and dreams of a lifetime. Rather than fill it with my own “to-do’s,” I chose to use it as a catalog of all of the experiences I wanted my daughter to have and the life skills and competencies I wanted to pass on. The list was one part basic, two parts “womanly” personal, including such things as learning how to swim, having (and using) a passport, traveling abroad, knowing how to change the oil in her car, rotate the tires, and balance her checkbook. Back then, I thought of these life skills only in the context in which they existed—equally attainable by anyone who had the mindset to achieve them.

Over time, I came to realize that my list was not as unique as I thought it was. Through sleepover parties and swim classes, I met other parents who—regardless of race, ethnicity, or demographic background—had goals for their children that almost mirrored mine. I recognized, but at the time did not give much consideration to, the shared underlying premise: These were lessons and skills we considered a necessary part of a healthy childhood that would lead, we hoped, to a healthy adulthood. Fifteen years would elapse before I thought of that list again. And then came a local news report of a fatal accident and a tragic national news story.

In early July, news outlets in my area carried a story about a group of teenage campers caught in a violent and rapidly moving storm. According to the report, the day had unfolded as normally as any other. The young campers had participated in their usual activities and, later that day, “sang songs, read stories and prayed in open-air pavilions,” just as they did every evening at the camp. At some point, when signs of an impending storm became evident, the camp leaders decided to cut the evening’s activities short. As the sky darkened and the wind picked up, they led the children on a wooden path, single file, to a nearby shelter, but already trees had fallen and power lines were strewn about. Eight children were injured, and one—a 12-year old—died.

A week later, while commuting to work, I tuned into a radio news report about the growing number of children crossing the southern U.S. border, seeking to escape violence in their Central American countries. With only coins in their pockets and the clothes on their backs, children as young as 5 years old had traveled across Mexico clinging to the rusted bars of freight trains, “risking death, rape, or abuse” by the hands of drug lords on one side and arrest and deportation by border agents on the other. Children carrying children had crossed muddy, snake-ridden rivers on inner tubes and ridden dusty roads on stolen bicycles. Many of those who survived and were lucky enough to make it to a migrant shelter or federal holding center have well documented stories of lives they left behind: unemployed parents, prostitution, rape, sex trafficking, poverty, closed schools, illiteracy, and whole communities left to their own devices for the most basic of health needs. According to some statistics, more than 70,000 unaccompanied minor-age children are expected to cross the border this year, double the number who came across in fiscal year 2013.

It would be easy to label this an immigration issue and leave it to the high court of the land to figure out, but in any part of the world where there is heightened danger, political instability, and mass numbers of individuals risking lives to cross borders to escape abuse, rape, murder, prostitution, ethnic cleansing, human trafficking, famine, or any other inhumane set of conditions, we call them what they are—refugees—and we call the situation what it is—a humanitarian crisis.

Conditions at migrant shelters and holding facilities in U.S. border states are a far cry from optimal. Makeshift warehouses are overcrowded with detainees lying on chilly concrete floors or wall-to-wall mattresses. Language barriers make it nearly impossible for the most basic communication. Amidst the tangled web of legal procedures involved in processing unaccompanied minor children—whether locating U.S. relatives or placing them in the juvenile foster-care system—a significant number of health needs go unaddressed. Many children lack basic immunizations and routine preventive care. Pregnant teenage girls, often housed in separate facilities, wait days for prenatal exams. Worst of all, given the language barriers, there are significant mental health issues, such as depression, panic disorder, and PTSD—either directly or indirectly related to the refugee experience—that we can ill afford to ignore.

Strangely absent from the larger media are the voices of nurses. Where are our work groups and think tanks? Who are our public health leaders? What do we know about overcrowded living conditions, mental illness, teenage pregnancy, and poor prenatal care? In this crisis, what can we, as nurses, do that we’ve done before?

Whether it is a rural migrant health center, a busy inner-city ER, or a campground clinic in our own backyard, nurses are in a key position to shape discussion about population health and implementation of safe public-health practices. Nurses, by far, are the single largest body of health care providers nationwide and, more often than not, are the first point of contact in a health-related encounter. As of 2011, more than 2.7 million registered nurses were employed in the United States, and the number continues to grow. As of 2013, according to the American Association of Nurse Practitioners, more than 192,000 nurses in the United States are nurse practitioners.

Given provisions in the Patient Protection and Affordable Care Act, there is greater potential than ever before for nurse practitioners to lead policy development that strengthens public health practice and networks, improves availability of primary care, and eliminates disparities and inequities in the health care delivery system. From nurse practitioner-led clinics to community-based disease prevention programs, nurse practitioners have the skill and competencies needed to advance care, expand delivery, and improve health outcomes at all levels of our society—especially, and most importantly, at our own borders, where there is a humanitarian crisis.

Looking back on the list I compiled a decade and a half ago, I’m reminded of its basic underlying premise and the hope that unites every parent, regardless of race, ethnicity, or nationality—the desire for opportunities, experiences, and competencies that make for a healthy childhood and healthier adulthood. These are not just bucket-list ideas, and they are not universally attainable by all—yet.

Nurses, regardless of political affiliation, have a moral and ethical responsibility to make opportunities for health available to all. The loss of a child’s life—whether through accidental death or otherwise—is a matter of public health. Ensuring emergency preparedness and safety in our communities, providing care for those who are medically underserved, and figuring out ways to care for those who are “not our own” are matters of public health. We can do better than turn our backs, nod our heads, and fall silent. And nurse practitioners are well prepared to lead the charge.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.

Trading places

The conversation started simply, the way most conversations with my patients do.

Me: Good afternoon, Ms. Jones, Mr. Jones. What can I do for you?

Son (Mr. Jones): I’m worried about my mother. I know we’re here for her regular blood-pressure checkup, but I think she’s depressed and want to know if she can just get a little medication for it today.

It was late afternoon, the time of day when most clinicians struggle to gather their last bit of steam to make it to the day’s end. It was my first time meeting Ms. Jones (not her real name) and her son—a visit I now say was sheer serendipity. The story was pretty straightforward.

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Ms. Jones was 79 years old, widowed, and slightly forgetful, but not so much as to be a threat to anyone else’s safety or her own. She and her husband, an electrician, had raised three successful children, the eldest of whom lived nearby and had come with her for her checkup. She had a short list of basic medications: a daily aspirin, a pill for blood pressure, and a calcium-with-Vitamin-D tablet for her bones. While I could have easily stuck to the script of the scheduled visit and given into what Mr. Jones asked for, the body language and distance between mother and son demanded something more.

Me: OK. Well, how about we talk about what’s going on?

Mr. Jones: She’s depressed. She just doesn’t want to go anywhere anymore. She doesn’t want to do anything anymore, and it’s just not like her. I know she needs medication. I think most people do at this age.

There’s an old saying that, between two people, there are always three sides to every story: his side, her side, and the right side. His side was that, when it came to family functions that she had, for years, enjoyed and even helped plan, his mother’s answer lately was a resounding and resolute “No!” When it came to exercise, such as taking Zumba classes at the local senior center, her answer was “No.” And when it came to get-togethers with neighbors in the community, her answer again, quite predictably, was “No.” All in all, her days were starting to add up to nothing; and nothing, in Mr. Jones’ estimation, meant depression. He and the rest of the family were sure of it.

Her side was quite the opposite. Her days did add up to something. Every morning she got up and made breakfast, the same way she had done for all 36 years of her marriage, even though, now, she was only cooking for one. After breakfast and maybe a Sudoku puzzle or two, she crossed the street and headed to the nearby park. If she remembered her container of day-old bread, she would feed the birds, and if not, she’d simply sit, quietly reminiscing through one or another memory of her husband, the children, and their old friends. From time to time, she might bring along her crocheting, if the weather was nice.

By 2, before school let out, she’d start making her way back to her apartment to catch her favorite afternoon game shows on cable TV. Sometimes, depending on how good the reception was in her apartment, she’d pull out her “transistor” radio and tune into the AM station, where she’d find a treasure trove of nonstop, swing-style jazz. In her mind, and in that soft afternoon space, she remembered every skirt that had swung too high when they danced, every kiss that had lasted far too long. It was true she had no interest in get-togethers, no desire to go to the senior center for exercise classes, and surely no interest in community goings-on. No matter what it looked like to the rest of the family, and whether they believed it or not, it didn’t add up to depression, and there was nothing more that she wanted to hear or say about it.

Despite popular opinion, clinical care of elderly people is not much different from that of any other population. There are signs and symptoms to listen for, specific tests to order, and treatment options to consider. There are medications to prescribe, and adverse reactions and side effects to monitor. What makes older members of society unique, however, is their vulnerability.

In a world dictated by 15-minute slots, addressing vulnerability as a clinician is no easy task. Helping relatives understand the very natural changes associated with aging takes time and skill. What was missing in this equation was the third side. Mother and son were in the midst of trading places, and they needed help in finding balance. Ms. Jones needed to acknowledge the validity of her son’s concerns. Mr. Jones needed to understand differences between true depression and natural developmental changes. And, to pull this off successfully, I needed to carefully set the stage.

Me: Ms. Jones, so what is it that you don’t like anymore about the family get-togethers, and why don’t you want to go?

Ms. Jones: I just don’t want to. All they do is gossip and talk about stuff I don’t care anything about.

Me: Who are “they"? And what do they talk about?

As Ms. Jones explained it, “they” were a series of husbands, wives, grandchildren, and great-grandchildren whose lives centered around Facebook announcements, Instagram photos, and round-the-clock text messages, transmitted via a bunch of gadgets they never seemed able to put down. They danced to music that was nothing more than noise, as far as she was concerned. And what little conversation they did have always centered on speculation about celebrities, politicians, and issues that had nothing to do with their day-to-day lives. While Ms. Jones had always been in reasonably good health—with the exception of the blood pressure—many of her lifelong friends had not been so lucky and had long since passed away. The people at the senior center weren’t people that she knew, had any relationship with, or even cared about. In a word: Every moment spent with any of them was a moment disconnected from the life she once knew.

As with most clinical visits with adult children and their senior parents, the remainder of our time was centered around helping Mr. Jones remember the passage of his own developmental stages so that he could better understand his mother’s—stages marked by his pulling away from family, outgrowing certain interests, losing friends, and making new ones. And, of course, there was the inevitable post-college experience of starting a family, with a life full of new interests, passions, and opportunities to make memories of his own.

We talked about the sadness associated with outliving friends and finding oneself alone in a world entirely different than one has known. Rather than concluding all that his mother needed was another medication, we talked about activities and outings that might help her remain connected to fond memories she seemed determined to hold onto. Surely trips to museums and libraries, where time stands still, would be far more therapeutic than any pill could ever be.

Slowing down long enough to trade places with our seniors is not only good clinical care; it’s a much-needed act of compassion. Our task as nurse practitioners is to remember that our work is far more than pumping out prescriptions on demand. It’s holding space for discussion and clarification. It’s ensuring that the care we give, particularly for older adults, is safe and sensible. And more than anything, whether we understand it or not, it’s about protecting the health of those who are most vulnerable and honoring their right to hold onto a personal meaning of life.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those the promote products or services will not be posted.

New NP grad? Some career realities and a little advice

If you live in the northern part of the northern hemisphere, you’re probably ready to pack away anything that comes close to reminding you of winter. Record snowfalls, plummeting temperatures, iced roadways, and closed schools have most of us pining for spring. And if you’re a student nurse practitioner who is coming close to that magical moment of graduation, the urge to pack things up is far greater. It has nothing to do with wanting to hear birds sing or see flowers bloom. It comes down to one simple thing—wanting your life back.

You probably have a countdown app on your smartphone, and every passing day brings you closer to that moment when you can toss those 10-pound textbooks out the window as you pull out of the campus parking lot. There isn’t a night you don’t dream of finally being rid of the preceptor who you’re sure sits up every night thinking of who is the worst possible patient from her caseload she can assign you the next day. You’re reasonably certain you will never, ever want to see your professors again, and, if you do happen to run into them, you’re prepared to put on your best foreign accent and insist they’ve got the wrong person. In a word, you are done, and that official day of completion, with all its pomp and circumstance, can’t come soon enough.

While I agree that navigating a graduate school’s nurse practitioner program is akin to walking a path of burning sand, I often warn those about to exit that path about some hard-to-believe realities they should expect the first year, and I mix that reality check with a little advice.

Michael Jung/iStock/Thinkstock

1. You will miss being a student.

As a student, you always have new and fresh information coming your way in the form of articles, practice guidelines, and late-breaking research findings that your professor has added to your never-ending syllabus. Until now, you may have carried out doctors’ orders to the letter, reasonably confident of the how but not always clear on the why. Your time as a student, I hope, has changed that. With each article and clinical experience, you’ve gained the tools necessary to determine not only what a symptom means but the pathophysiology behind it, how to diagnose it, and how to treat it. Now, you know which antibiotic to choose (or not choose) for a certain condition, and why. Admittedly, it’s pretty interesting stuff!

Career reality: Learning something new every day will be your responsibility. In the real world, no one is going to show up with a syllabus and a list of learning objectives. You will know what you know, but what you don’t know will show up one patient at a time. Part of your role as a clinician is to stay abreast of new developments—to stay current—so you can provide your patients with the best, evidence-based care possible.

Advice: Always be a student. While you may not have the time for daily scouring of journals to learn about the latest and greatest research, plan to keep up on what’s most important in your clinical specialty. Your first year out, keep a daily journal of clinical issues that arise that may stump you or symptoms that have you scratching your head trying to figure out a diagnosis. Make it your homework to read up on those issues, and make notes for yourself so you’re better prepared the next time they come around. Make a list of topics you least understood in school and, little by little, find a CME, workshop, or conference that address those topics or specialties so you’re more adept when they present.

2. You will miss having a preceptor.

As a student, you lived with the expectation that you could—and would—run out of the exam room in a state of sheer panic, not knowing what to do for that patient in front of you who has a rash you’ve never seen before. After all, “derm” is your least favorite specialty, and you were barely awake during the visiting lecturer’s presentation on common skin disorders. As a student, it was okay not to know what to do. Just when you were sure it was leprosy, there, with years of experience, was your preceptor, ready to save you and remind you of a commonly occurring fungal rash that could be cured with a $5 cream.

Career reality: Depending on where you work for your first job, there may or may not be a person willing to follow you down the hall and confirm your suspicions by taking a look at a rash or peeking inside an ear. To complicate matters even more, figuring out which medications to prescribe for which insurance plans will be your job and yours alone, regardless of what clinical guidelines say are “preferred treatments.” In many environments, your degree and certification translate into the assumption that you know what you’re doing and are safe to be on your own.

Advice: When interviewing for your first job, your first and foremost priority should be to inquire about the availability of precepted orientation. Find out how long the company offers orientation and who will be your resource person to go to for clinical questions that arise during your first few months. During your orientation, be honest about your strengths and weaknesses, and use that time wisely to acquire the resources and knowledge needed to make your transition as smooth as possible. Don’t buy into the media hype that doctors don’t want NPs in their territory. There are many environments where nurse practitioners are highly valued and appreciated. Take time to find a practice where this will be true for you.

3. You will miss your classmates.

As a student—part of a cohort—you have come to know one another in ways that you likely take for granted. You have seen each other during moments of extreme stress and gotten by with little or no sleep while consuming dangerous amounts of caffeine, hardly a set of images any of you would want showing up on Facebook later on in life. For some of you, there have been painful divorces and difficult breakups; children have eaten more take-out meals than you care to admit; and friends and family have long given up on you as missing without a trace. You and members of your cohort have studied together, cried together, and supported one another with words of comfort during a very difficult time. It’s an experience that only another person who has traveled the same path can understand.

Career reality: Your new colleagues can relate to some of what you have endured, but will never really understand what you’ve gone through. It is impossible for them to know and, honestly, it would be unprofessional of you to rattle off all your past miseries to people you’ve just met. You’re no longer a student and, early on, it’s important that you establish a confident and professional presence in your new environment.

Advice: Do your best to maintain friendships developed in your cohort. Your first year out of your program will offer a full range of challenges with people you don’t yet know. Having a circle of support is critical to strengthening both your knowledge base and your confidence level. As new graduates, you can network with one another on a pretty even playing field, sharing resources about potential jobs, starting salaries, educational conferences, and a vast array of other opportunities that come along.

4. You will miss having a schedule.

As a student, you always had somewhere you had to be and something you had to do by a certain time. There were exams to prepare for, papers to turn in, and clinical rotations that required you to be on deck and ready to go by a certain time every day—no excuses. Even in the midst of what seemed chaotic, there was order. You set goals for yourself and, to achieve the prized goals of graduation and a degree, you learned to prioritize your time and manage your resources.

Career reality: Prioritizing time and resources will be just as critical in your new career as it was in school, except now there won’t be anyone standing by—red pen in hand—holding you accountable and checking off what you did or didn’t accomplish. Years will pass quickly, and the vision you once held for your new career can quickly turn to dust and disappointment.

Advice: Ask yourself where you want to be in one year, three years, five and 10. Set goals for yourself, and work from Day One to achieve them. Take time to find the right “first job”—one that supports your goals and leaves sufficient time to work toward them. If your goal is to have your doctorate, start your own business, or even retire, it’s important that you have a map and a timeline to help you get there. Through frequent check-ins, that circle of friendships you’re continuing to nurture can provide support by holding you accountable.

5. You will miss a professor or two.

As a student, you were certain all of your professors were out for blood—specifically, yours. In the beginning, you took everything that was taught as unparalleled gospel, questioning little—if anything—and hoping one day to be so brilliant. What you’ve learned, over time, is not what to think but how to think. It was never the intention of your professors—really—to force-feed information to you but, rather, to give you the tools to decipher facts and apply knowledge to practice. You now realize the truth in the maxim that what doesn’t kill you makes you stronger.

Career reality: You will find that much of what your professors taught you was true but not absolute. Health care is both a science and an art. No two people practice health care the same way, and you will have to develop a style that works for you. There are thousands of guidelines and algorithms for clinical practice, but how to implement the guidelines in a way that is safe, efficient, and cost-effective for each patient is a skill that comes with time. Your professors have developed their own style of practice, based on experience, and now it is time for you to take the knowledge you’ve gained to develop your own.

Advice: See your professors as colleagues. Stay in touch with the ones you feel most strongly supported your goals as a student and helped you overcome challenges. Ask for suggestions on professional-practice issues, such as getting through the first interview, negotiating collaborative practice agreements, and deciding which professional organizations to join. For those in clinical practice, make a list, and refer your patients accordingly. Tap into their knowledge about certain specialty areas and conditions in which you are not as well versed as they.

In a few weeks, you will join the wonderful world of advanced practice nursing, deserving every gift you receive to honor your accomplishment. But the best gift you can give yourself is a moment to pause and absorb your last few days as a student.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.

Nurse practitioners and the pursuit of social justice

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” — Martin Luther King Jr.

If there’s one question every nurse practitioner is familiar with, regardless of geography, specialty, or number of years in practice, it’s the one that sounds something like this: So, are you a doctor or still a nurse?

I was two months out of my graduate nursing program when an elderly patient posed that question to me. She had come in expecting to see the physician for a routine, post-hospital follow-up visit that quickly became not so routine. Slightly overweight, she presented with the common triad of chronic conditions I was becoming adept at managing—diabetes, hypertension, high cholesterol. Added to that were depression, anxiety, COPD, GERD, and arthritic knee pain. Her scribbled list of medications spanned the alphabet: amlodipine, clonidine, Cymbalta, furosemide, gabapentin, hydrochlorothiazide, K-Lor, lisinopril, Lantus, pantaprazole, Senekot, sliding-scale insulin, Symbicort, and tramadol. After determining that the physician was unavailable, she settled, albeit reluctantly, into seeing me that day, her slightly raised brow indicating lack of confidence in my capability.

We began by reviewing the most obvious: her hospital discharge summary, the list of medications she was supposed to stop taking, those she was supposed to start taking, and, with regard to the latter, a quick but subtle quiz on why she was taking each one. Her answers revealed little to no knowledge of the purpose of the medications, correct dosages, and, least of all but most importantly, potential side effects.

We proceeded into what is known as the ROS, or review of systems, a quick query from head to toe about important systems and any symptoms that may be present. Given her conditions, I asked if she was monitoring her blood pressure at home (Yeah, sometimes it’s as high as 170, 180); if she was monitoring her blood sugar (Not really. I can’t figure out how to work all those buttons); and how often she was using her inhaler (What inhaler? I don’t have an inhaler). I also asked about pain and how much pain medication she had been taking (That stuff never works, so I just sit for most of the day to keep from hurting so bad).

From there we proceeded to her physical assessment, which underscored the majority of her story. Her blood pressure was indeed high, her knees were indeed crackling, and the wheezing in her lungs could be heard without even lifting the stethoscope. I went on to ask how many of the medications she actually had at home, only to discover that she was still waiting for the pharmacy to deliver nearly half of them. From there, the plot thickened even more.

Truth was she lived alone, depended on an untimely cab service to get to and from appointments, had children who, for one reason or another, could not help and had given up on trying to figure out whom else to call. Her funds were limited and, more often than not, she took only half the dose of insulin to “stretch” her supply until the next Social Security check came in. After purchasing food from the corner market (which was as far as she could reasonably walk without getting too tired) and paying the gas bill, she would buy her medicines, if she bought them at all.

Some say it isn’t the primary-care provider’s job to get involved with social issues, such as transportation, food, finances, and physical access to needed services and educational supports. That some individuals live in what we now know as food deserts—communities without access to nutritious, healthy foods—is a personal problem, they say, one beyond our control. Certainly, there are social workers who are better suited—and have the time—to address these issues, and there’s no argument that our payors will not reimburse us for helping individuals find transportation or locate family members to help. But to ignore the social determinants of health—defined by both the Centers for Disease Control and Prevention (CDC) and the Office of Minority Health as the range of personal, social, economic, and environmental factors that influence health status—is to contribute directly to the very health inequities that our care is supposed to eliminate.

The role of the primary-care nurse practitioner—who, yes, is still a nurse—is multifaceted, with good reason for being so. Certainly, he or she is credentialed to provide the same level of care that a physician would provide in the primary-care setting. We can describe, ad nauseum, to our patients and to the world the educational preparation that enables us to do so. We can attain doctorates, perform and publish research, and gain the skill sets needed to perform a number of advanced, highly technical clinical procedures. But, at the end of the day, what matters most is the actual delivery and fulfillment of the work for which our role was created in the first place—the equitable and efficient delivery of comprehensive health care with a focus on health education and disease prevention.

In truth, the foundational premise of our role dates as far back as the 1870s, a time of severe postwar food shortage, rampant spread of contagious disease, and a medical infrastructure inadequate to care for returning wounded soldiers across the rural South. Our role dates back to the early 19th century, a time marked by racial segregation and African-American families migrating to northern cities in search of better living conditions and employment opportunities—only to find themselves in overcrowded, often vermin-infested tenements where unsanitary water supply, high infant mortality, and poor childhood nutrition were the order of the day.

And our role now, in the most contemporary sense, will be defined and shaped by the uncertainties of health care policy reform amidst a struggling economy, a growing demographic of aging, medically underserved citizens and of whole immigrant communities lacking access to the most basic preventive care. In truth, medical care is what we deliver, but social justice and eradication of health inequities are, and always have been, our foundation.

In meeting with that patient that day, the focus was not on my credentials and the myriad differences between my physician colleague, whom I respect and admire, and me. My focus was on doing what I’ve always tried to do best: provide patient-centered, age-appropriate, culturally competent care.

For patients who ask, “But are you still a nurse?” the answer should be evident in the work we do: simplifying medication regimens by eliminating or combining medicines where feasible, thereby reducing costs and the risks associated with polypharmacy; securing home-care referrals for medication teaching, diabetes education and blood-pressure monitoring; collaborating with community pharmacists to find efficacious drugs, particularly those offering financial benefit for the medically underserved; and speaking out wherever and whenever we can for those most vulnerable in our society—the elderly and the young. The nurse and nurse practitioner as continual advocates of social justice, health equity, and comprehensive health care are roles that we should defend and be proud of.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

So you want to be an NP?

No pessimist ever discovered the secrets of the stars, or sailed to an uncharted land, or opened a new heaven to the human spirit.  — Helen Keller

“I want to be a nurse practitioner. I’m going back to school!” As soon as I spoke the words, I felt their weight and intensity.

We were a group of night-shift nurses—weekend warriors, we called ourselves—commiserating over all that seemed to be missing, not only on our unit but in our careers. We were a mixed bunch. Some, fresh out of nursing school, were dismayed by their new reality, an overwhelming set of responsibilities that hardly matched the “Grey’s Anatomy” image of nursing. There were no organized Code Reds with a well-scrubbed physician yelling “Stat,” nor was there a faculty preceptor to lean on. Some, much older, reminisced about the “good old days,” when nursing didn’t involve complicated EMR systems, committee meetings and unit-based research projects.

As soon as I made my declaration, questions and rapid-fire judgments quickly followed. How? With what resources? Why? Who in their right mind would want to take on student loans, late-night studying, clinical rotations and research papers at this stage in an already established career?

These questions, common for nurses who feel the urge to pursue graduate studies, are surely valid. Graduate school is expensive, requires self-directed study and ongoing individual assessment of learning style and learning needs, and it demands focus if one is to successfully juggle multiple tasks, set priorities, and meet deadlines. More importantly, especially for aspiring nurse practitioners who will incorporate unpaid clinical rotations into their schedules, graduate school usually requires students to reduce their employment workload, which lowers personal income over the course of the program.

Bedside nursing has tremendous perks, not the least of which are shorter workweeks; open and continuous opportunities for overtime; and casual “uniforms,” the cost of which pale in comparison to the professional wardrobe required in corporate settings. However, advanced practice nursing has its own share of perks, including opportunities for leadership, scholarship and management, as well as regular work schedules and potential for independent practice.

The barrage of who, what, where, why and when can lead to doubt, worry, and complete derailment of one’s quest for professional and personal growth. Success requires not only a leap of faith but the parachute of careful planning. The following are five key considerations for the journey to becoming a nurse practitioner.

1. Do your research.

Nurse practitioner programs are not all created equal. Speak directly to program directors and admission counselors about the number of credits required, the average length of time for completion, and graduation rates. Assure that the program holds solid accreditation and sufficient faculty-to-student ratios. Check national ratings for each school and the length of time the program has existed. Investigate the experience levels of the program’s faculty members, to ensure you’ll be learning from experienced nurse practitioners, rather than novices. Beware of new programs “awaiting accreditation” and lacking a track record. Speak with other nurse practitioners you know, to be sure you understand the role and responsibilities of a nurse practitioner. Consider “shadowing” an NP for a day or two, to get a clear picture of what the career path entails.

2. Assess your needs.

Carefully consider your learning style and weigh the options between traditional on-campus programs and those designed for distance learning. While distance learning may offer convenience, it also requires discipline, strong commitment, and strict time management. There is no one to hold you accountable for showing up to class, viewing lectures, reviewing content, and reminding you of deadlines. It is very easy to fall behind or become distracted by everyday life responsibilities, family and work obligations, and unexpected emergencies. Because traditional on-campus programs require a reduced employment workload to accommodate classes, clinical rotations and exams, you may need to line up additional financial resources to replace lost income.

3. Create a financial plan.

Add up all costs for the program, including tuition, books, clinical supplies, fees, parking, and commuting costs. To help offset these costs, investigate existing scholarships, graduate assistantships, grants and nursing education loans. When creating your budget, allow a reasonable amount for unplanned expenses such as car repairs, fluctuating gas and commuting costs, and household repairs that may occur. Realistically decide how many hours you will be able to work each week and compare this figure to current expenses. If attending graduate school requires you to move to another city, fully investigate the complete cost of living in the new location. Will you need a car to get to school and clinical sites? Is reasonably priced, safe housing affordable? What are average costs for utilities? Your NP studies will prove difficult enough. Inadequate income will not only create stress; it will distract from the time and focus needed for your studies.

4. Rally support.

If you have a spouse, significant other, or children, be sure you have their support early on in the decision-making process. In all fairness, these are the people who are going to be most affected by your decision. They will endure your late-night studying, early-morning clinical rotations, and perpetual absence at family events and affairs. Openly and honestly explain the time and financial commitments you’re planning to take on. Be realistic about the time you will need to study and the help that others will need to provide for day-to-day household management. If you are an adult learner with children, be sure to include extended family and friends in these discussions, and ask for their support as needed for carpooling and assistance with after-school activities. Once in the program, be considerate of their time, and remember to thank your “village” for helping you succeed.

5. Make your decision and stick with it.

If everything aligns properly, stick to your decision and move confidently in the direction of your passion. Equipped with your research and careful planning, beware of pessimists and naysayers who lack the insight you now have. No matter which direction the economy turns, graduate education in nursing will always yield a high return, and there will always be room for new nursing leaders who seek out opportunities for professional growth and advancement.

Consider every minute and every dollar spent an investment in yourself. Opportunities for nurse practitioners are endless and include such specialties as clinical research, global health, teaching, consulting, independent practice, and much more. Take your leap of faith with passion and optimism!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.