The Journal of Continuing Education in Nursing

Original Article 

Increasing RN Perceived Competency With Substance Use Disorder Patients

Regina Russell, MBA, MSN, RN-BC; Maria M. Ojeda, DNP/PhD, MPH, ARNP, NP-C, BC-ADM; Barbara Ames, BS, RN, CMSRN

Abstract

Background:

Although behavioral health and substance use disorder patients visit hospitals in significant numbers, nurses are often ill-prepared to care for them.

Method:

The purpose of this quasi-experimental preclass–postclass design was to determine the effects of an educational intervention on the perceived competency of 57 nurses who care for patients with behavioral and substance abuse disorders. The nurses who chose to participate were asked to respond to a demographic questionnaire and a survey designed to measure perceived competency. Survey data were analyzed to determine whether any differences (alpha = .05) existed between participants' attitudes and knowledge preclass and postclass.

Results:

Immediately following the educational intervention, a statistically significant increase was found in perceived competency related to self-confidence, attitudes, communication, and knowledge of resource availability among participating nurses.

Conclusion:

Nurses working in acute care hospitals, particularly those without addiction and psychiatric services, may benefit from continuing education on this important topic.

J Contin Nurs Educ. 2017;48(4):175–183.

Abstract

Background:

Although behavioral health and substance use disorder patients visit hospitals in significant numbers, nurses are often ill-prepared to care for them.

Method:

The purpose of this quasi-experimental preclass–postclass design was to determine the effects of an educational intervention on the perceived competency of 57 nurses who care for patients with behavioral and substance abuse disorders. The nurses who chose to participate were asked to respond to a demographic questionnaire and a survey designed to measure perceived competency. Survey data were analyzed to determine whether any differences (alpha = .05) existed between participants' attitudes and knowledge preclass and postclass.

Results:

Immediately following the educational intervention, a statistically significant increase was found in perceived competency related to self-confidence, attitudes, communication, and knowledge of resource availability among participating nurses.

Conclusion:

Nurses working in acute care hospitals, particularly those without addiction and psychiatric services, may benefit from continuing education on this important topic.

J Contin Nurs Educ. 2017;48(4):175–183.

Large numbers of individuals visit hospitals each day because of substance use and behavioral disorders (Substance Abuse and Mental Health Services Administration, 2014). Individuals with mental illness have significantly higher rates of substance use disorders than the general adult population, thus presenting to emergency department with a dual diagnosis (Funn & Woodruff, 2011; Jane-Llopis & Matytsina, 2006). The World Health Organization (2010) arrived at a set of key global strategies to reduce the detrimental use of alcohol, including increased referrals to mutual help initiatives such as 12-step groups. Alcoholics Anonymous and Narcotics Anonymous activities, such as attending daily meetings, having a sponsor, and helping others, empower substance abusers to maintain abstinence (Majer, Jason, Aase, Droege, & Ferrari, 2013; Singer, 2016; Vederhus, Timko, Kristensen, & Clausen, 2011). However, some studies have found that nurses without a background in psychiatric nursing are generally unaware of the availability, effectiveness, and extent that 12-step groups have on decreasing substance abuse and providing an ongoing sense of connectedness, support, and empathy (Dadich, 2010; Kingree & Thompson, 2011).

Clinical nurse educators working in a rural general community hospital noted that patients with behavioral health and substance use disorders frequently visit the emergency department and often require admission. Lacking the availability of hospital-based mental health services, staff nurses were faced with the challenge of caring for behavioral health and substance use patients hospitalized for medical and surgical issues, resulting in dissatisfaction for both nurses and patients. With the goal of improving nurse competency in caring for these often unfunded patients, educators formed a task force to seek a low-cost solution. The purpose of this study was to determine the influence of a 2-hour interactive educational intervention on the perceived competency of nurses who care for patients with behavioral and substance abuse disorders.

Literature Review

Health care providers in medical–surgical, emergency, and critical care units are trained to treat acute illness, injury, and disease, but knowledge of behavioral disorders and other conditions related to mental health may vary greatly among individual providers (Alexander, Ellis, & Barretta, 2016). The nursing care of patients with substance use disorder is hampered by a lack of education (Indig, Copeland, Conigrave, & Rotenko, 2009; Kelleher & Cotter, 2009; Kerrison & Chapman, 2007), as well as frustration with the difficulties that may characterize such patient interactions (Ford, 2011; Morley, Briggs, & Chumbley, 2015; Neville & Roan, 2014). In 2005, the American Society for Pain Management Nursing examined the use of stigmatizing labels in patient care from the perspective of the emergency, medical–surgical, and pain management nurses (McCaffery, Grimm, Pasero, Ferrell, & Uman, 2005). The authors wanted to determine whether experienced pain management nurses differed from other nursing specialties in how they defined drug-seeking behaviors and what it meant to them. Using a convenience sample of nurses attending pain management programs in the United States over a 5-month period, they obtained completed surveys from 295 medical–surgical, 35 emergency, and 39 pain management nurses.

Results from the completed surveys showed that all three nursing specialties agreed that patient who lose their pain medication prescriptions, went to several emergency departments seeking prescriptions, or made up conflicting stories about why they needed the pain medication could be described as drug seeking. More than 80% of the nurses who participated in the study agreed that patients labeled as drug seeking were viewed negatively as being actual or potential drug addicts. Of note, the authors commented on how bringing awareness to the subject of stigmatizing behaviors during the pilot study seemed to lessen their occurrence during the actual study.

In Australia (Indig et al., 2009), researchers conducted a survey of the attitudes and current practices of emergency department clinical staff (42 nurses and 36 physicians) to determine whether improvements could be made in the detection and brief intervention of alcohol-related patient visits. The survey asked whether they formally screened patients for alcohol use and whether they provided brief intervention and referrals to treatment when indicated. The researchers concluded that emergency department doctors and nurses did not possess the required knowledge, skills, self-assurance, and sense of obligation to manage patients with alcohol abuse disorder. Paradoxically, the participants identified the patients themselves as a barrier to the effective management of alcohol-related disorders. Patients were blamed for being inebriated and unmotivated to get better, thereby creating an obstacle to intervention.

In another study, Kelleher and Cotter (2009) identified a pressing need for continuing education and training to address the knowledge gap in managing substance abuse patients. The authors used an adapted survey questionnaire and a Substance Abuse Attitude Survey (Chappel, Veach, & Krug, 1985) to collect data on the knowledge, attitudes, and perceived competency of emergency doctors and nurses in three large teaching hospitals in Ireland. Researchers found that although most of the emergency department staff rated themselves highly in the identification and assessment of substance abusers, they rated themselves poorly in perceived competency regarding care management. Specifically, participants reported low competency in the areas of motivational interviewing, brief intervention, referral to services, and patient education. The majority of participants also reported low perceived competency in managing patients who were substance abusers with co-existing conditions.

More recently, a systematic review focused of studies regarding patient stigmatization by health care workers (van Boekel, Brouwers, van Weeghel, & Garretsen, 2013). The researchers found that negative attitudes are widespread and contribute to marginalized health care for patients with substance abuse disorders. Health care workers were inclined to characterize these patients as aggressive, manipulative, and unmotivated. Health care workers were found to lack the training and expertise needed to effectively promote desirable outcomes, leading to behaviors such as patient avoidance and task-centered versus patient-centered approaches to care.

Most recently, Neville and Roan (2014) conducted a qualitative study exploring the perceptions of medical–surgical nurses toward patients with a substance abuse disorder in addition to a medical diagnosis. Emerging themes included a negative outlook toward the patient, a sense of being unprepared to care for them, and a lack of confidence in their ability to care for the patient's medical and psychiatric needs simultaneously.

Nurse Education and Competency

Nurse competency in the behavioral health and substance abuse patient populations is defined as encompassing both the affective and cognitive domains (Tilley, 2008). Nurse attitudes, beliefs, and values play a critical role in facilitating the patient's self-directed process of recovery (Zolnierek, 2009). Education has been shown to decrease negative attitudes and improve health care workers' confidence and understanding of patients with a dual diagnosis and substance abuse (Cleary, Hunt, Malins, Matheson, & Escott, 2009; Munro, Watson, & McFadyen, 2006).

The ability to teach patients and families in a manner that empowers and supports the mentally ill, addicted, or alcoholic patient is a core competency for health workers. In 2011, Russinova, Rogers, Ellison, and Lyass studied recovery-promoting competencies from the perspective of mental health patients, health care providers, and recovering health care providers. Authors reported that the recovery competencies rated as most valuable were those related to the health care providers' nonjudgmental attitude, hopefulness, and knowledge that recovery is possible. Encouraging and understanding the role of peer support in meeting needs for connection, sense of belonging, and sober fellowship is also critical (Singer, 2016).

Kane et al. (2016) outlined the implementation of an educational program designed for 134 emergency nurses from five hospitals focused on identifying, motivating, and referring to treatment patients presenting with, or at risk for, substance use disorder. The grant-funded training of emergency nurses utilized the Screening, Brief Intervention, and Referral to Treatment (SBIRT) (American College of Surgeons, U.S. Department of Health and Human Services, & Department of Transportation, 2010; Emergency Nurses Association, n.d.) approach to early intervention taught by local university faculty. Approximately 2.5 months after the training, a competency self-rating scale was given to determine whether the nurses consistently and confidently applied SBIRT in their daily practice. Results demonstrated that as a result of the educational intervention, nurses were better able to screen patients, engage the patients using motivational interviewing techniques, and collaborate with patients to determine the best course of action.

Lakeman (2010) conducted a qualitative study to help delineate the specific competencies most valuable and effective in facilitating recovery in patients with chronic mental illness. A panel of 31 highly experienced mental health experts were recruited from all over the world to participate in an online best practice survey. Beginning with a list of 103 competency statements, the Delphi technique was used to anonymously achieve consensus. The goal was to clarify the top five competencies regarded as most important to recovery and to describe specific examples of that competency in practice. The most highly rated competencies involved the health care worker knowing and understanding that recovery is a self-directed process facilitated through respectful communication and trusting relationships, followed by awareness that recovery requires support from peers, the presence of hope, and the belief that recovery is possible.

Study Goal

The purpose of this study was to increase the perceived competency of nurses caring for patients with behavioral and substance use at a community hospital. The research question was: Will a 2-hour instructor-led course focused on basic aspects of identifying, treating, and referring patients with behavioral and substance use disorders increase perceived competency among direct care nurses?

Conceptual Framework

The concepts outlined in self-determination theory—a theory of human motivation—comprised the underlying framework for the current study (Deci & Ryan, 2000; Ryan & Deci, 2000). According to self-determination theory, human motivation is driven by satisfaction of three human needs: autonomy (i.e., the perception that one's behavior was driven by one's own volition), perceived competence (i.e., a feeling of being effective in producing desired outcomes while exercising one's capacities), and relatedness (i.e., feelings and perceptions of being respected, understood, and cared for by others). When these human needs are supported, motivation and engagement is enhanced, resulting in improved performance and persistence of behaviors over time. Self-determination theory has been successfully applied within the health care domain in studies involving changes in patients' health behaviors (Ng et al., 2012) and, more recently, as the framework for an educational intervention aimed at improving communication between health care practitioners and their patients (Murray et al., 2015).

Method

Study Design

A quasi-experimental, preclass–postclass design was used to compare the perceived competency of RNs in caring for patients with mental/behavioral health and substance abuse disorders before and after participation in a 2-hour class entitled Behavioral Health and Substance Abuse: Increasing RN Effectiveness.

Setting

The study was conducted at a faith-based, nonprofit community hospital within a six-hospital health system located in the southeastern United States. The surrounding population is racially/ethnically diverse, is of low socioeconomic status, and the majority are uninsured or underinsured.

Participants

The minimum sample size to obtain 80% power and detect a medium effect size (.45) was estimated a priori as N = 43. Three hundred fifty nurses were invited to participate. Recruitment was conducted through distribution of a flyer using the internal e-mail system. Inclusion criteria affirmed participants must be RNs employed within our health system; exclusion criteria applied to non-nurses and non-employees.

Educational Intervention

The class was developed by a planning committee of experienced clinical educators, nurse planners familiar with American Nurses Credentialing Center (2013) standards, and representation from direct care nurses from the emergency, medical–surgical, and critical care units. Consultation with a physician who is board-certified in addiction, a licensed clinical social worker experienced in managing drug and alcohol treatment programs, and a psychiatric nurse practitioner helped guide the planning team in the development of educational objectives based on the desired behavioral outcomes. A comprehensive review of the literature was accomplished to insure evidence-based content. The class was awarded 2.0 American Nurses Credentialing Center contact hours, with five class objectives as follows:

  • Discuss the categories of mental disorders and their impact on health care.
  • Summarize current addiction theory, treatment, and recovery models.
  • Examine the nurse's role in providing ethical, evidence-based care.
  • Determine the resources available to patients and methods of referral.
  • Explain how peer support and 12-step groups facilitate recovery.

Twelve live classes scheduled from 8:30 a.m. to 10:30 a.m. on weekdays over a 3-month period were made available for registration through the internal learning management system. Two members of the study team who were clinical learning instructors obtained consent for participation in the study, taught the class, and collected the data. The class was offered free of cost to attendees, and participation in the survey was not required.

Instrumentation

The nurses who choose to participate in the study were asked to respond to a demographic questionnaire and a survey designed to measure perceived competency. The demographic questionnaire consisted of three multiple choice questions regarding practice location, highest level of educational attainment, and practice specialty.

A review of the literature did not identify any valid or reliable instruments aimed at measuring the perceived competency of direct care nurses (i.e., not specializing in psychiatric, mental health, or addiction) in providing care to patients with substance use disorders. Thus, the planning committee developed the perceived competency survey questions based on the five competencies outlined by Lakeman (2010) as most effective in generating positive mental health outcomes. The competencies were translated into statements depicting measureable behavioral and affective terms to create the survey questions. Face validity for the survey questions was obtained by requesting 21 unit-based educators to review and comment on each question's relevance and representation of competency among RNs caring for patients with mental/behavioral and substance abuse disorders. When consensus was reached, the final survey consisted of four items, each containing a statement to which nurses attending the class were asked to rate themselves on a 5-point Likert scale (strongly agree = 5 points to strongly disagree = 1 point). The range of possible scores if all questions on the survey were answered was between 4 and 20 points; the higher the overall score, the greater the perceived competency.

Data Collection Procedures

Prior to institutional review board submission, the hospital's research and evidence-based practice council reviewed the study protocols for completeness and scientific integrity. Approval from the institutional review board was granted, and the classes and data collection began on March 23, 2015. On arrival to class, participants were informed that if they completed the class, continuing education credits would be awarded regardless of participation in the study.

Consent to participate in the study was obtained by the principal investigator (R.R.) at the beginning of class, prior to the presentation of any class content. The consent was obtained via a cover letter; two copies of the cover letter were distributed to each participant, one to keep and one to return to the researcher obtaining consent. A data collection packet including the cover letter, demographic questionnaire, and the preclass and postclass surveys were distributed to each potential participant. At that time, potential participants were given the opportunity to ask questions regarding the study. The cover letter, demographic questionnaire, and preclass and postclass surveys were clearly labeled with a matching pseudo-identification number assigned to each data collection packet to enable statistical analyses of matched pairs. The pseudo-identification number was not linked to any identifiable information. At the bottom of the cover letter, potential participants were asked check a box indicating agreement or refusal to participate. Time was then provided for the completion of the preclass survey by those who had agreed to participate in the study, and those who chose not to participate in the study were instructed not to answer any of the demographic, preclass, or postclass survey questions. After the presentation of class content, study participants were afforded the opportunity to complete the posttest survey. Class participants were asked to place the researcher's copy of the completed consents, the demographic questionnaire, and preclass and post-class surveys into an envelope, seal it, and then place it in a secured box located next to the classroom exit. At the conclusion of each class session, the study data were transferred to a double password-protected electronic spreadsheet to which only researchers had access.

Data Analyses

Descriptive data are presented as response rates, percentages, and medians. Cronbach's alpha was used to test for internal consistency reliability of the survey items. The level of statistical significance was set at alpha = .05. Differences between preclass and postclass scores on the survey were assessed using nonparametric statistics. All analyses were conducted using SPSS® version 19 software.

Results

Invitations to attend the class and participate in the study were sent to 350 hospital nursing staff through an e-mail distribution group. Of those, 57 nurses completed the course and participated in the study, generating a response rate of 16.3%. Demographic characteristics can be found in Table 1. Of the 57 nurses who participated, 78% held either an associate degree or a baccalaureate degree in nursing, 56.8% worked at one of three hospitals within the system, and 56.4% were either medical–surgical or emergency department staff. Sixteen nurses did not answer the demographic questions, whereas an additional two nurses did not indicate their specialty. This made it impossible to explore the relationship between specialty area and perceived competency.


Demographic Characteristics of Participants (N = 57)

Table 1:

Demographic Characteristics of Participants (N = 57)

All of the study participants (N = 57) answered the preclass and postclass survey questions. Preclass and postclass descriptive statistics for individual items may be found in Table 2. Internal consistency reliability for the preclass was alpha = .654, which is an acceptable result due to the small number of items (n = 4) in the scale (Eisinga, te Grotenhuis, & Pelzer, 2013; Streiner & Norman, 2008); on the postclass, the alpha was .857. Before the class, the competency statement the nurses agreed with most was “Feel confident to care for them and believe recovery is possible” (50.9%), followed closely by “Refer them to resources in the community and motivate them to seek help” (43.9%), then “Know what questions to ask if I suspect drug/ alcohol use” (29.9%). The competency statement rated lowest in agreement was “Make the approach with a positive, nonjudgmental attitude” (3.5%), with 26 (45.6%) of the nurses disagreeing with the statement. The greatest impact of the educational intervention was reflected in the postclass rating of the latter competency statement, with 56 (98.3%) of the nurses reporting that they agree or strongly agree. Further, when compared with preclass surveys, the median scores (Mdn) for each item were significantly higher postclass (Mdn Q1 = 4 versus 5, Mdn Q2 = 4 versus 5, Mdn Q3 = 3 versus 4, and Mdn Q5 = 3 versus 5). The results of Wilcoxon signed ranks test confirmed these findings, indicating that postclass scores for each item were significantly higher when compared with preclass scores (Table 2). Similarly, the preclass median score on the overall survey was 13 (range = 8 to 17), whereas the postclass median score was 19 (range = 12 to 20); Wilcoxon signed-rank tests confirmed that the overall distribution of survey scores was also significantly higher on postclass surveys compared with preclass surveys (Z = 6.599, p < .001).


Descriptive and Analytical Statistics for Responses to Individual Survey Items (N = 57)

Table 2:

Descriptive and Analytical Statistics for Responses to Individual Survey Items (N = 57)

Discussion

Previous studies have demonstrated that the nursing care of patients with a substance use disorder is hampered by a lack of education (Indig et al., 2009; Kelleher & Cotter, 2009; Kerrison & Chapman, 2007). The current study's results reflect congruence with these findings and other study findings described in the literature review—primarily that substance use and behavioral health education can help shift negative attitudes, reduce stigma, and increase knowledge and understanding; most importantly, it has the potential to improve outcomes for patients with dual diagnosis (Cleary et al., 2009; Munro et al., 2006). This study's results were similar to findings by Kane et al. (2016), in that the nurses showed an increase in self-reported competency as a result of an educational intervention. Although these studies differ greatly in target audience, learning objectives, and health care setting, the educational outcomes show an improvement in participant knowledge, skill, and attitude when caring for patients with substance use disorders.

Over time, incorporating substance use disorder recovery-focused care as a core competency for all nursing specialties may help alleviate this global concern. The problem extends well beyond the boundaries of psychiatric and addiction treatment programs; we cannot always depend on limited mental health resources to intervene. Educational activities such as those used in this study may facilitate improved patient and family education related to substance use disorders, help address denial and other barriers to recovery, and guide patients to practical treatment options. Empowering the direct care nurse with education could change practice and help promote recovery outcomes.

This study suggests that providing direct care nurses with basic substance use disorder training is a positive step toward providing quality patient and family-centered care to this vulnerable population. Immediately following the educational intervention, the authors found a statistically significant increase in perceived competency among nurses who participated. Consideration should be given to making the education mandatory for hospital staff, ensuring that those who need it most will benefit.

Limitations

Several limitations to this study exist. First, the sample size was relatively small—350 staff throughout the hospital system were invited to participate, but 57 actually participated in the study. For that reason, the possibility of self-selection bias or that study participants were somehow different than the considerable proportion of invitees who chose not to participate in the study cannot be ruled out. Difficulties involving work schedules, the voluntary nature of the class, and potential variations in the prevalence of substance use disorders between system hospitals may have contributed the low response rate of 16.5%. Second, despite the fact that no identifiable information, such as names, ages, gender, dates, or e-mail addresses, was collected, 16 participants (28% of the sample) failed to answer any of the demographic questions. This prohibited the researchers from examining the potential associations between demographic variables and pretest and posttest survey scores. Although a slight possibility exists that these individuals may have failed to answer those questions through simple oversight, there is a greater possibility that refusal to answer the demographic questions may have been the result of concerns over the possibility of identification. Finally, this study did not attempt to link increases in perceived competency to actual practice changes or improvements in patient outcomes.

Conclusion

Substance use disorder can be described from a multitude of perspectives; it is a biological and mental illness, a harmful and destructive behavior, a dysfunctional emotional response, and finally a social and spiritual concern. This study provides some interesting insight to these perspectives. Within the authors' organization, for example, staff nurses frequently acknowledge the need for more mental health services to treat behavioral health and substance use disorders and the need for staff education and training, yet the modest number of voluntary participants who made the effort to attend the class suggests that they do not see themselves as primarily accountable for providing that care. This may suggest that acute care emergency and medical–surgical nurses view mental health as a segregated specialty rather than an integral part of acute care services. Communicating the importance of the staff nurse's role in the holistic care of patients with substance use disorders presents a substantial challenge to educators wishing to address this important issue.

Contemporary research is needed to determine the best teaching strategies for optimizing the acute care nurses' knowledge, competency, and attitude toward substance use and behavioral health patients with medical comorbidities. Both qualitative and quantitative research is needed to validate recovery-based ongoing education and training of acute care nurses is a cost-effective method of improving the quality of care for this population. Opportunities exist for research investigating the effect of improved nurse competency on patient outcomes, such as patient follow-through on referrals to treatment or 12-step groups made by nurses. Evidence-based content would assist nurse educators in designing more targeted and effective educational programs.

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Demographic Characteristics of Participants (N = 57)

Variablen (%)a
Hospital43
  One11 (25)
  Two3 (6.8)
  Three8 (18.2)
  Four14 (31.8)
  Five7 (2.3)
Highest level of education41
  Diploma4 (9.8)
  Associate's degree8 (19.5)
  Bachelor of Science in Nursing24 (58.5)
  Master of Science in Nursing4 (9.8)
  Doctorate in Nursing Practice1 (2.4)
Practice specialty39
  Medical–surgical10 (25.6)
  Perinatal2 (5.1)
  Emergency12 (30.8)
  Intensive/progressive care6 (15.4)
  Other9 (23.1)

Descriptive and Analytical Statistics for Responses to Individual Survey Items (N = 57)

ItemPreclass ResponsePostclass ResponseZbp


n (%)aMdnn (%)aMdn
Feel confident to care for them and believe recovery is possible.455.9743.001*
   Strongly agree3 (5.3)30 (52.6)
   Agree26 (45.6)22 (38.6)
   Neutral20 (35.1)5 (8.8)
   Disagree8 (14)0 (0)
   Strongly disagree0 (0)0 (0)
Make the approach with a positive, nonjudgmental attitude.456.2563.001*
   Strongly agree0 (0)31 (54.4)
   Agree2 (3.5)25 (43.9)
   Neutral29 (50.9)1 (1.8)
   Disagree22 (38.6)1 (0)
   Strongly disagree4 (7)1 (0)
Know what questions to ask if I suspect drug or alcohol use.346.4303.001*
   Strongly agree1 (1.8)27 (47.4)
   Agree16 (28.1)27 (47.4)
   Neutral21 (36.8)3 (5.3)
   Disagree16 (28.1)0 (0)
   Strongly disagree3 (5.3)0 (0)
Refer them to resources in the community and motivate them to seek help.356.6233.001*
   Strongly agree1 (1.8)35 (61.4)
   Agree24 (42.1)21 (36.8)
   Neutral20 (35.1)1 (1.8)
   Disagree12 (21.1)0 (0)
   Strongly disagree0 (0)0 (0)
Authors

Ms. Russell and Ms. Ames are Clinical Learning Educators, Department of Clinical Learning; and Dr. Ojeda is Nurse Scientist, Nursing/ Health Sciences Research, Baptist Health South Florida, Miami, Florida.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank the Baptist Health South Florida CE Council of Nurse Planners of Yvonne Brookes, Barbara Blanco Marchante, Judy Bowling, Sally Bonet, Vivian Fuentes-Sanchez, Tania Napoles, Marrice King, Diane Carol Kramer, Katherine Tryon, and Kayce Kathleen Tugg.

Address correspondence to Regina Russell, MBA, MSN, RN-BC, Clinical Learning Educator, Department of Clinical Learning, Baptist Health South Florida, 8500 SW 117th Avenue Road, 3rd Floor Box #6, Miami, FL 33183; e-mail: reginar@baptisthealth.net.

Received: May 17, 2016
Accepted: October 26, 2016

10.3928/00220124-20170321-08

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