The best hair day I ever had was the morning I walked into the AWHONN office with my newly grown out, close-cropped hair. It felt luxurious to me after losing my hair to chemo even if it was less than an inch long.

A breast cancer diagnosis is scary. Treatment is intense and nerve-wracking. To me, the hardest part was when treatment was over. Even when breast cancer is found early, as mine was, there’s a chance it can come back. I’ve been blessed to be healthy for 13 years.

Catherine “Cathy” RUHL, DNP, CNM, is the Director of Patient Education and Outreach at AWHONN.

I was two months away from my 50th birthday, and I had decided that I was going to have a big birthday celebration. What would I do now? I decided I’m not going to spend the money on a party — I’m going to celebrate living. So, I went on with preparing myself with MRI’s and more biopsies and finally on to meet the surgeon. I asked my best friend, April, to go with me to meet the surgeon. I’m so glad that I did. There was so much information given, and under the circumstances with my nerves on edge, all I could think about was when my mother had breast cancer. She had to have chemotherapy and was very sick, and I watched her hair fall out. I was afraid that I would need the same treatment. How thankful was I when the surgeon said that because of the type of cancer, I would be having a lumpectomy and 37 treatments of radiation with a five-year plan of hormonal therapy. So, at the end of the conversation with the surgeon, he said to me, “Why are you delaying your surgery?” I told him one reason was that I was scared and the second was that I wanted to celebrate my birthday. He responded by asking when my birthday is, and I said, “It’s December 15 — I turn 50.” He said, “Oh, well you can celebrate up to 12:00 am and after that, no food or beverages. I will meet you for surgery at 7:30 am on December 16.” We had a good laugh, but I did as he instructed.

I had my surgery, and it was a huge success. He removed the cancer and 27 lymph nodes. I started my recovery process at home. I had six weeks to recover before I started my radiation treatment. After six weeks, I was ready to start my treatment. My best friend, who had been with me to every appointment, surgery, and follow-up appointment, said to me on my first day of treatment, “Do you want me to go with you to radiation?” “No,” I responded, “I think I can manage this by myself.” As I was walking up to the building, I read the sign on the building that reads Cancer Treatment Center — it stuck out like a neon sign to me at this point! Mind you, I have been going to this same building the entire time. I stop walking, and it seemed like I was frozen in time as I was looking at this sign thinking to myself: I have cancer. Why was it hitting me so hard now? I have had the surgery, which was the hard part, but now I am alone. I realized that I’m here alone, and I need to do this. So, I got myself together, stopped the crying, and went into the building for my treatment. During the surgery prep, the doctor marked the locations where the radiation would be focused and would leave three permanent tattoos. Once I had collected myself and went through with the radiation, the experience wasn’t bad at all.

I will be celebrating 10 years of being cancer-free on December 16, 2019 — the day after my 60th birthday this year. I will never forget the love and support that AWHONN showed toward me during my journey, and I am still here with such a wonderful association after 24 years.

Pearl Thorpe is a Senior Graphics Manager within the Strategic Partnerships, Communications and Meetings Department at AWHONN. Pearl has been with AWHONN for 24 years.

Have you often thought when you find out a co-worker is working on a graduate degree, “That’s not for me — I don’t have the time or the money and besides I enjoy what I am doing now”? I did not seek a graduate degree until my children were in high school and after beginning; I wish I had started on that journey earlier! Let’s address some of the myths.

• I do not have time in my life right now.
  I delayed a pursuing graduate degree because I thought I would be on campus as much as undergraduate classes require. Many graduate nursing programs offer online and on campus options or a combination. I often advise nurses, just stick your toe in the water and try one class. You can fit the assignments in your life no matter what shift you are currently working. Just trying one class a semester is “doable”

• I am not sure I can afford the tuition
  There are many options-private and public colleges. There are scholarships and some employers offer tuition reimbursement. It is an employee benefit-check it out!

• I have not been in school in years. I am not sure I am smart enough for graduate school.
  I hear this one a lot. You are smart-you are a RN and passed boards! Hands down for most nurses, our first program is the most difficult whether it was a BSN, diploma or AD program. You will be pleasantly surprised that a graduate degree builds on your existing knowledge and you will be encouraged to focus on your specialty area for assignments. You will often be able to combine an assignment with a project you wanted to do at work anyway. Plus for all of us “seasoned” nurses, when we have to use an example from practice, we have years of case studies and examples to use in assignments.

• I really enjoy being at the bedside, I don’t want to do anything different right now
  Great! We need advanced degree nurses using their expertise and practicing evidence based practice in every setting. A graduate degree will open doors that you may not even think about right now. There may be an amazing opportunity that will come your way that requires an advanced degree.

• I am not sure I can keep up with the technology now-discussion boards and on line classes.
  I was not confident either, however if you have middle or high school age children or neighbors, they will enjoy helping you. You will quickly adjust just as you have to EMRs.

I share all these myths because this is what I heard as I was working on my MSN and then a PhD. I began my MSN part time at the age of 50 when I was working about 24 hours a week and had all three children still at home. I did not intend to pursue a doctorate degree, however I became fascinated at the opportunity to influence care through research.

I started on my PhD one year after completing my MSN. I worked full-time during my PhD journey and I completed it within 4 ½ years. To add to the craziness, all three of my children got married during this time. It has now been a year since I graduated and I am an assistant professor at a university. I am able to continue to work occasionally in a clinical setting, conduct research, and teach the next generation of maternal child nurses.  I never would have dreamed that this would be my journey when I began taking that first graduate course. Therefore, if you are considering giving it a try, jump in, the water really is great. There are many others ready to encourage you along the way.

Janet Tucker is an assistant professor at the University of Memphis Loewenberg College of Nursing, where she is currently teaching maternal child nursing. She completed her MSN in 2010 and PhD in 2017. Her research interests are expectant women experiencing a fetal anomaly diagnosis.

AWHONN Resources

With generous support from individual and corporate donors, AWHONN’s Every Woman, Every Baby charitable giving program provides the opportunities to AWHONN members to apply for research grants and project grants who work in continue to improve the health of mothers, babies and their families. Additionally, AWHONN’s commitment to support emerging leaders also provides opportunities to apply to academic scholarships and enhance their professional development through attending AWHONN’s Annual Convention and information of education resources. , For more information on AWHONN scholarships and professional development opportunities visit http://www.awhonn.org/page/awards

When I became pregnant with my first child, I did everything I could to prepare—from research on cribs, bottles, breastfeeding, you name it. Having suffered miscarriages in the past, I was very concerned and anxious about SIDS. I made sure that my daughter’s crib had nothing but the mattress and sheet. I even contemplated buying one of those boards that detects movement and alerts you when a baby stops moving.

Once my daughter was born, she slept in the bassinet in our bedroom. I was still recovering from my cesarean, so my husband was there to help put her in and take her out of her bassinet when it was time to nurse. I was very good about following the safe sleep guidelines, but we would sometimes take naps together while I nursed on my side. I knew in the back of my mind it wasn’t the best option, but we were both able to get rest.

Fast forward 2 years, and my son is born. Again, I was cautious as I prepared for a new baby: I purchased a firm mattress and was sure not to have any toys, bumpers, or blankets in his crib. I told myself I was going to be much better with following safe sleep guidelines than I was with my daughter.

He, too, was born via cesarean, and in the beginning I was very good about not allowing him in bed and always putting him back in his bassinet. When he was about 3 months old, it became harder and harder to follow the guidelines. My son wasn’t sleeping at night, he refused any kind of pacifier (I tried six different brands), and the only thing that soothed him was nursing.

Baby Maxwell in his sleepsuit

Around this time, I returned to my full-time job. I found it easier to nurse him while lying down and returning to sleep. He also seemed to sleep better when he was next to me. I knew it wasn’t right, but I just wanted him to sleep—and I wanted to sleep myself. I tried swaddling, sleep suits, white noise… everything. It’s not supposed to be this hard the second time around, I thought. I’d already been through this; they say the second kid is easier!

When he was about 8 months old, I woke up to a boom and a baby screaming: He had fallen out of the bed, and I felt like the world’s worst mother. Luckily he was ok, but it could have been worse. He could have really gotten injured, or worse, I could have lost him. I knew the rules, I knew that babies were supposed to sleep in their own space, but I ignored them because I wanted my baby to sleep during the night and I was exhausted.

After my son’s fall, I knew something had to change; my son could no longer sleep in my bed at night. I decided to move his crib from our room into another room, and I gave the pacifier another shot. While sleep training hasn’t been successful, he is now taking a pacifier. Instead of bringing him into my bed when he wakes up at night, I offer him his pacifier if it’s before 3 a.m. If he wakes up again, I stay in his room to nurse him and then place him back in his crib. In addition, I had to make the decision to go to sleep earlier to ensure that I got my rest, too.

This got me thinking: What are some ways to help moms follow safe sleep practices after the baby is home? I enlisted the help of nurse Sharon Hitchcock, DNP, RN-C and some fellow moms.

Sharon is an obstetrics nurse and teaches at the University of Arizona. She is quite passionate about the topic of SIDS and safe infant sleep as she now knows why most of these deaths occur and, more importantly, how to prevent them (at least most of them).

She routinely talks about the American Academy of Pediatrics (AAP) safe sleep recommendations to students as well as parents and nurses. She’s also gotten a recent taste of some of the struggles, as she’s the happy grandma of a 9-month-old!

Naomi is mom of 9-month-old Samuel and became a safe sleep advocate long before having her baby. Heidi is almost finished with nursing school and has two kids, 3-month-old Eli and 4-year-old Sophia. Melanie, a mom of three, teaches obstetrics at the University of Arizona and is a childbirth educator at the local hospitals.

I shared with them my struggles of following safe sleep practices with my son and asked several questions about how parents can better follow safe sleep guidelines. Here’s what they had to say:

1. Night feedings can be exhausting, especially when breastfeeding. What are some best practices to help resist the urge to nurse while lying down?  

NAOMI: I resisted the urge to nurse while lying down simply because I didn’t want to bring the baby into bed with me. There were some times when I nursed while sitting up in bed, but I also nursed in a rocking chair in my son’s room, just next to his crib, so I could immediately put him back to bed when he finished eating. I’m a light sleeper and didn’t worry much about falling asleep while feeding him, but I’ve heard it’s a good idea to use a timer, like the one on your phone, if you’re worried about falling asleep.

HEIDI: I was aware of the risks of breastfeeding while lying down from my OB classes in nursing school and had heard the horror stories of parents falling asleep with their infants and accidently suffocating them during their sleep. This was enough to make me take precautions the majority of the time that I was breastfeeding at night. I would feed him in my bed, sitting up, with him in the cross cradle position. I would set alarms just in case I did fall asleep with him, as studies have shown that the longer you are asleep with your infant, the greater the risk of SIDS. If mothers are truly so exhausted that they feel like they need to lie down while nursing, they should remove all pillows and blankets from around the baby and set alarms that will wake them should they fall asleep

2. What are some ways to keep baby warm at night without using blankets?

NAOMI: Our son was born at the end of November, just when it really started to cool down here in southern Arizona. We kept the room warm and comfortable, and he wore footed pajamas.

HEIDI: For both of my children, I used sleep sacks that are available to buy online or in any baby store. They have worked well for me both times. I made sure the house was kept warm enough that they would be comfortable throughout the night.

MELANIE: It is recommended to keep the bedroom at a temperature that is comfortable for a lightly clothed adult. Overheating a baby is very dangerous, as they cannot just push the covers off.

3. The risk of SIDS goes down once a baby turns 6 months—is it okay to bed-share then?

HEIDI: No. The baby can still roll over and suffocate on the softer mattress, pillows, and thick blankets that we have. In addition to the suffocation risks, I believe that getting the baby into a routine of sleeping in their parents’ bed will be one that is hard to break. Neither of my children have been able to sleep in my bed with me, mostly due to my concern for their safety. I am a hard sleeper and would not wake up if I rolled onto them. I also always wanted them to be able to sleep in their own rooms, once old enough.

MELANIE: It is true that most SIDS deaths occur before 6 months, but the infant is still at risk for SIDS until 12 months of age, and adult beds are not designed for infants. Most babies are rolling over by 6 months, and adult beds are usually too soft and have too many blankets and pillows. The other risks include the parents rolling onto the infant or the infant falling out of the bed.

4. My baby has reflux and spits up during the night. Can I place a wedge or pillow in his crib?

HEIDI: No. This is another thing that infants could suffocate on if they rolled over. My son spits up a lot, too, but thankfully I knew from my OB class that it was safer for him to be on his back when he sleeps than on his stomach or wedged if he spits up. A baby is less likely to choke when on their back if they spit up because their airway sits above their esophagus (the tube going to their stomach), making it easier for the fluid to stay away from the airway and easier to swallow.

MELANIE: The AAP recommends that infants are always placed on their backs and not on their sides. Infants are quite good at protecting their airways while on their backs (unless they have a swallowing impairment, which your doctor would tell you). The U.S. FDA has stated that infant sleep positioners are not recommended as there have been several cases of infant deaths from the use of side positioners after the baby rolled to the stomach position or when their face got wedged into the positioner. Keeping the infant upright on a parent’s shoulder for 20–30 minutes after a feeding can decrease reflux.

SHARON: Some parents may think it’s a good idea to elevate the head of the crib to help with the reflux. However, multiple studies have shown this does not help and actually puts the baby at risk for sliding down to the foot of the bed and getting into an unsafe sleeping position.

5. If I nurse while lying down, should I remove everything from my bed in case we fall asleep?  

NAOMI: This is what the newest recommendations advise you to do. Make sure all the blankets, pillows, etc., are moved out of the way, so that in the event you fall asleep, the bed will be a little bit safer.

HEIDI: Absolutely. This is the safest practice if you must nurse while lying down. This is what I did. I also asked my husband to adjust his pillow, and if possible, stay awake with me to ensure that I didn’t fall asleep with the baby. We aren’t perfect, though, and there were a couple of times where we dozed off with him, but fortunately I had alarms set to wake me within 15 minutes of beginning nursing. Once I knew he was full and had a clean diaper on, I set him back down in his crib and went to sleep.

6. Sometimes the baby falls asleep on my chest. It’s recommended that babies sleep on their backs, but since he’s on my chest is it okay?

HEIDI: I believe so, as long as you are rested enough that there is no risk of you falling asleep and you are able to monitor the baby while he is asleep on his tummy. I did this a lot with both of my children during the day and think it is the perfect opportunity for skin-to-skin time.

SHARON: Make sure you can see your baby’s face (to make sure it is not covered or does not become wedged into your breasts) and you are awake and attentive to him.

7. The only way to get my baby to sleep is if I nurse him; when I go to transfer him into his own bed, he wakes up and cries. Is it okay to let him cry it out?

NAOMI: This is a hard topic. There are so many opinions out there, and it’s hard not to get discouraged by all the articles in my Facebook newsfeed that highlight how awful it is to let your baby “cry it out.” It became important for me to consider our circumstances and the fact that every baby is different. I didn’t use the formal “cry-it-out” method for sleep training, but there were, and still are, so many times when I have to let my son cry for a while before he’ll give in and go to sleep. He’s fed. His diaper is clean. He has burped. He’s still crying. He’s not comforted by me holding him close. I’m starting to go a little crazy, and my left ear is ringing from his screams. I know he’s exhausted. What he needs is sleep. It’s okay to place him in his crib and walk away. It’s OKAY to let him cry. I had to learn this early on. It’s made a huge difference.

MELANIE: Crying is a baby’s language and the only way they have to communicate. They cry because they are hungry, tired, uncomfortable, and sometimes just because they are fussy and need to get rid of excess energy. If they have burped and their diaper is clean, you can try to console them with rhythmic noise, music, or gently stroking their head. If the baby is tired, they will usually fall asleep quickly.

Safe sleep is harder than it appears, at least for some of the recommendations. This is an extraordinarily complex topic, and we know it’s hard. In order to keep your baby  as safe as possible, learn  the recommendations, start them at birth, do the best you can, and know that you are not alone in your struggle.

Do you have safe sleep tips/advice you want to share with parents? Share them at www.awhonn.org/SafeSleepTips

Resources

• American Academy of Pediatrics Safe Sleep Recommendations – 2016
• American Academy of Pediatrics Safe Sleep Website
• Healthy Mom&Baby article: What’s New with Infant Safe Sleep
• More health4mom.org resources on safe sleep

References

American Academy of Pediatrics. (2016). SIDS and other sleep-related infant deaths: Updated 2016 recommendations for a safe infant sleeping environment. Pediatrics, 138(5), 1–12. doi:10.1542/peds.2016-2938

Centers for Disease Control and Prevention. (2017). Sudden unexpected infant death and sudden infant death syndrome. Retrieved from https://www.cdc.gov/sids/data.htm

Gradisar, M., Jackson, K., Spurrier, N. J., Gibson, J., Whitman, J., Williams, A. S., . . . Kennaway, D. J. (2016). Behavioral interventions for infant sleep problems: A randomized controlled trial. Pediatrics, 137(6), 1–10. doi:10.1542/peds.2015-1486

Hitchcock, S. C. (2017). An update on safe infant sleep. Nursing for Women’s Health, 21(4), 307–311. doi:10.1016/j.nwh.2017.06.007

Moon, R. Y., & Task Force on Sudden Infant Death Syndrome (2016). SIDS and other sleep-related infant deaths: Evidence base for 2016 updated recommendations for a safe infant sleep environment. Pediatrics, 138(5), e1–e29. doi.org:10.1542/peds.2016-2940

Storrs, C. (2016). It’s OK to let your baby cry himself to sleep, study finds. Retrieved from http://www.cnn.com/2016/05/24/health/cry-it-out-sleep-training-ok/index.html

Courtney Duggan is a digital marketing manager in the Washington, D.C. area and is a mother of 2.

My name is Jennifer Doyle.  As women’s health nurse practitioner and breast cancer survivor, I was asked to share excerpts from a 4-part blog that was published as part of my Health System’s ‘Flourish’ series in 2013.  Only 5 days ago, I passed the ‘5 year mark’ from diagnosis.  Thank you for allowing me to share my story, which I hope may help others who face breast cancer.

Diagnosis: “I am NOT a pink ribbon”

I was diagnosed with breast cancer on Sept. 24, 2012. I was not necessarily shocked, as all three of my father’s sisters had been diagnosed with breast cancer by the age of 50. I found a lump through a self-breast exam, and within a week had my diagnosis. I noticed the lump a few months prior, but it was very small and very hard.  I figured it was just my monthly cycle. However, when I re-checked my breast in the shower, it was much, much larger and hard as a rock. I could not move it. I could not find the edges of the mass on palpation. When I got out of the shower and looked in the mirror, I saw the orange peel affect, or dimpling of the skin around the area, and instantly knew that I had breast cancer.

When it came to the actual diagnostic process, it was quite memorable. I recall going in for the mammogram, already believing in some part of my brain that I had breast cancer. I thought to myself, “Hey, if I get my mammogram and get out of here, I’m good. If they keep me for an ultrasound, I’m screwed.” I had the mammogram, and wouldn’t you know it, I needed to stay for an ultrasound. As I sat waiting for the ultrasound, and again waiting for the ultrasound results, I watched women come and go from the breast center. They came in talking on their phones, making lunch plans; in and out. I was jealous. I wanted to just get up and go on with my life, too. Yet, I already knew that I could not.

Then came the inevitable. I was taken into a room with a tech and a physician, and informed that I needed a biopsy – today if possible. I was told that I had a mass in my right breast and that it was “very suspicious.” When the staff members left the room, I sat somewhat stunned. I looked around and realized I was surrounded by pink ribbons. There were quilts and pictures all hailing the pink ribbon. I instantly hated the color pink. Everything in me rebelled against the pink ribbon. I thought, “I want nothing to do with any of this. I am NOT a pink ribbon. I will not be defined by this!”

My formal diagnosis came via a phone call from my OB/GYN. Despite being a Women’s Health Nurse Practitioner, I said “I work in OB; I don’t know anything about breast cancer! What does this mean?” He informed me that it was the most common type of breast cancer, invasive ductal carcinoma, and that he was referring me to a general surgeon. My path was laid out before me, and I began my journey….

Treatment-“Wow, you look like GI Jane!”

My husband, Tim was with me for the biopsy and the diagnosis. One of the most challenging days was the day I had to tell my parents and our 13-year-old daughter, Claire, Someone wisely told me that the most difficult part of dealing with cancer is dealing with others’ reactions and emotions. It is so true. I rarely worry, but I hate being the cause for worry in the people I love. What I would say about Claire and my recovery is simple: She was ALL of my reasons.

After I broke the news to my family, my Breast Care Coordinator Heidi Eve Cahoon, MSN, CNP, of Summa’s Jean and Milton Cooper Cancer Center in Akron, met with myself, my husband, and my parents. She explained the pathology report and typical course for the breast cancer patient. We all felt more informed and educated after meeting with her. If you’re coping with the same diagnosis, it’s worth reading more about how breast cancer navigators can help you through treatment.

I opted for chemotherapy prior to any surgery. This was due in part to medical recommendations, but it appealed to me because it bought me time to assess my options for surgery and/or radiation. My four rounds of chemotherapy included “AC,”which stands for Adriamycin and Cytotoxin (sounds so lovely). The very first round of chemo came with a side of the vomits. I began vomiting within four hours of leaving treatment, and this continued for a couple of days. Thankfully Dr. R. Douglas Trochelman (my oncologist) and the nurses changed up my antiemetic medications, and I did not experience any vomiting during the last three rounds.

Chemotherapy is quite interesting. The ‘chemical menopause’ ceased periods and brought on hot flashes. The nausea, the vomiting, mouth sores, and the utter exhaustion were novel and unwanted companions. Hair loss seemed to be the most focused-on side effect by nearly everyone. I followed the advice given to me: Buy a wig. Buy two wigs. Be prepared. I spent $400 on wigs. When the time came and the hair began to fall, my husband and I went into the bathroom. Clippers in hand, my remaining blonde locks fell all around. A tear or two did escape. But then my husband looked at me with wide eyes and said, “Wow, you look like GI Jane!” I regarded myself in the mirror for some time and decided I didn’t mind the bald chick look. I briefly tried wigs but found them intolerable. I decided to rock the new look and traded up the wigs for bandanas, ball caps, and very often, nothing at all!

I underwent a double mastectomy at Summa Health Akron in early February 2013. I chose to have this, despite being a “good candidate” for a lumpectomy. I did not have either of the BRCA genes. However, I wonder how many genes are there out there that we do not know about yet? Part of my reasoning was a desire to avoid radiation. The other was family history. My general surgeon performed the double mastectomy and my plastic surgeon placed tissue expanders. I took the Scarlett O’Hara approach to the double mastectomy. I did not think about it. I thought, “I will think about it when it is over.” I woke up after surgery and a funny thing happened. I actually was OK. I did not mourn my breasts. The pain was tolerable. I thought I was over halfway through my journey, when the road took an unexpected turn. My lymph nodes removed during surgery tested positive for cancer.

Somewhere in the back of my mind I heard a game show announcer: “Jennifer Doyle, guess what YOU’VE won?! Four more rounds of chemotherapy!” I endured four more rounds of chemotherapy with the drug Taxol. No nausea, vomiting, or mouth sores, but the exhaustion persisted, and I experienced exquisite bone pain.

Breast reconstruction following mastectomy is quite novel and interesting. There are many options, from flaps to implants to prosthetics. Would you like a nipple created? Did you keep your own? Or would you like a nipple tattooed on? I chose to go with implants. What I would choose for nipples; Stars? Flowers? This was one of amusing things I thought about while going through the process.

It wasn’t easy as it seemed. In order to get implants, one must first endure the tissue expanders. The tissue expanders are like balloons made of tire tread. They are placed during mastectomy. A series of injections expands the balloon. The skin expands and stretches, giving the plastic surgeon a pocket, or space to place the implant, and adequate skin to cover the new implant. I began going to my plastic surgeon’s office for weekly expansion. I referred to them as my “pump me up” sessions.

The first time the nurse came in with the two large 60 cc syringes and extra-long needles, my husband swore and exclaimed, “Are you going to hit her heart with that?!” This was the expansion process. For me, it was one of the most painful processes of breast cancer. My husband went with me to nearly every expansion. When he could not go, my parents went. I always had Tim or my mom there to hold my hand during the expansion. I know it sounds wimpy. But, hey, it helped!

As I waited for my final surgery, a combination of breast reconstruction and oophorectomy (ovary removal), life went on. I went back to work at Summa Health’s Women’s Health Services Department once chemo was over.

A Successful Journey: “There is a lesson in every joy and every sorrow.”

I believe three factors have made my journey a success, even though the ending yet eludes me, and the outcome is not set in stone. First, is the seemingly endless support I have received from my family and friends. The care and outpouring has been humbling and heartwarming, to say the least. I am glad it was me who has breast cancer, and not my mom or sisters, though I know they would trade places with me. You see, as a baby, I was born with multiple birth defects and spent a large part of my childhood sick, undergoing surgery, or admitted to the hospital. So for me, medical issues are nothing new. I’m not Superwoman. It’s just that I take such things in stride; that is the second factor. The third factor is faith. From the diagnosis until now, my faith has held fast. I have always believed that everything has purpose. If it were not for my childhood challenges, I probably would not have become a nurse. There is a lesson in every joy and every sorrow. It may sound hard to believe, but I have never asked God “Why?”I have also never asked God to cure me. I have simply prayed for two things:

One, that God grants me the strength to endure this with dignity and grace, no matter what, and two, “Thy will be done.”

On July 8, I underwent my final two surgeries. The surgeries included reconstruction and an oophorectomy (ovary removal). You may recall that my reconstruction choice was tissue expansion followed by silicone breast implants. Both surgeries went very well. I actually woke up feeling a bit more comfortable than I did going into surgery. The implants are much better than tissue expanders! I consider myself lucky to have had such a fabulous care team of Summa Akron City Hospital nurses and surgeons!

Survivorship

Fast forward five years.  It is hard to believe all that has happened since Sept., 2012.  Now it is Sept, 2017 and I am President-Elect of AWHONN!  Claire is now a senior in high school and will leave for college next summer.  I am grateful every day for the opportunity to contribute in a meaningful way both in my personal and professional life.  For now, I have defeated cancer.  However, cancer and I have each left our mark on the other. I still experience some discomfort most every day in my right chest and axillary region.  Not exactly sure why that is, but it is most likely related to scarring and adhesions.  I still cannot lift my right hand very far above my head unless manually assisted.  Opening a can or bottle comes with significant difficulty that offers a regular reminder. I continue to experience aphasia from time to time; this peaked during chemotherapy and has not completely left.  Finally, the neuropathy in my feet remains profound.  I have very little feeling in my feet and most of the time; they just feel ‘asleep’.  That can be really annoying, to say the least.  Despite some of these physical effects, I am overall quite healthy and physically active.

Once cancer has personally impacted your life, there may always be some small measure of worry in the deep (or not so deep) recesses of your brain.  Cancer can become a lifelong resident in your mind:  What if it comes back?  Is that a lump or just scar tissue?  I cannot believe that anyone is immune to these doubts that come to call on occasion. What I think is important is to own your thoughts and where you allow those thoughts to go.  Of course I have fears, but I remind myself to center and to refocus my thoughts and efforts in another direction.  Sometimes this takes specific intention. In every story, there is meaning.  While I still have not fully come to understand the meaning of my breast cancer, perhaps it will be made clear to me one day.  Lessons learned via a renewed appreciation for life’s small moments are perhaps what I take from this part of my journey.  Every person has a unique story and must come to their own point of resolution and peace.  I thank you for allowing me this opportunity to share some of my experiences.

My life was certainly entangled in the pink ribbon for some time.  Now, that has come full circle.  Today I embrace that ribbon and am proud to wear it as a banner symbolizing survival.

Jennifer Doyle is a WHNP with nearly 25 years of experience in obstetrics. She is the APN of the Women’s Service Line at Summa Health in Akron, Ohio as well as Faculty and Coordinator of the WHNP program at Kent State University in Kent, OH. She is AWHONN’s President elect in 2017 and is happy to share her personal story from the perspective of a breast cancer patient.

Prenatal exposure to alcohol can lead to a range of physical, mental, behavioral, learning, and developmental disabilities, with possible lifelong effects for the child exposed in utero. This range is commonly known as fetal alcohol spectrum disorder or FASD. FASDs are 100% preventable when a baby is not  exposed to alcohol during pregnancy.

Healthcare professionals may tell women that it’s OK to drink alcohol on occasion or even in moderation, when they are pregnant. However, evidence shows that there is no known safe type, safe amount, or safe time to consume alcohol while pregnant.

Additionally, it’s important for healthcare professionals to broach the subject of alcohol consumption, not only with their pregnant patients, but with all women of reproductive age. Women who are sexually active and not using effective contraception may be at an increased risk for alcohol exposed pregnancies, as nearly half of all pregnancies within the United States are unplanned.

It is critical that healthcare professionals educate all women of reproductive age about alcohol use and pregnancy. Alcohol screening and brief intervention (alcohol SBI) is one evidence-based approach to assessing patients for at-risk alcohol use. Screening includes use of a validated tool, such as the Alcohol Use Disorders Identification Test (AUDIT). The AUDIT is a clinically reliable and valid instrument (Bohn, Babor & Kranzler, 1995). The AUDIT has been consistently found to screen and detect alcohol use across a spectrum of low, moderate, and high risk consumption (Reinert & Allen, 2007).  The AUDIT has been found to be valid and reliable with diverse populations and in a variety of settings.

When a patient screens positive for at-risk use, a non-judgmental discussion, called a “brief intervention” occurs with the use of motivational interviewing techniques. For example, the patient is provided with the score on the AUDIT during the health care visit. If a patient scores between an 8 and 15, this score is discussed in relation to their current health condition and presented objectively to the patient as moderate alcohol consumption. If the AUDIT score is between 16 and 19, then brief counseling and continued monitoring are suggested. With a score of 20+ a referral for further assessment is indicated (Babor & Higgins-Biddle, 2001). The main goals of the brief intervention are to increase a patient’s awareness of their alcohol consumption patterns, understand the associated risks and options for reducing or eliminating those risks, and to increase their motivation to make healthy choices.

As nurses, it is our obligation to ensure that women are provided with the knowledge needed to make informed choices regarding their health. For example, giving the patient objective feedback about their score on the AUIDT and then asking them “What are your thoughts about this score?” is a way to elicit their thoughts and feelings about their alcohol consumption in relation to their health and wellness. Further, exploring the pros and cons of the patients current level of alcohol consumption is an excellent technique to elicit the patients thoughts and provides an opportunity for the health professional to provide feedback and health education.  Patients have high trust in confiding to their healthcare provider and in particular nurses.

Additional Resources

• AWHONN’s FASD Resources
• AUDIT Website

Dr. Ann M. Mitchell is professor of nursing and psychiatry at the University of Pittsburgh School of Nursing. She is principal investigator on a CDC-funded project for the implementation of alcohol screening and brief intervention with the ultimate goal of preventing FASDs.

Dr. Holly Hagle is Director of Education for the Institute for Research, Education and Training in Addiction (IRETA) and a partner in the CDC-funded FASD project.

Brayden Kameg is a graduate student in the psychiatric-mental health nurse practitioner DNP program at the University Of Pittsburgh School Of Nursing. She is actively participating in grant-related activities on Dr. Mitchell’s projects.

When a mother is unable to provide enough milk for her own infant’s needs, then donor milk is the next best option. There are basically two business models for human donor milk bank operations; not-for-profit and for-profit. Both models provide safe, processed donor milk for infant consumption. One of the differences lies in the human species-specific properties retained post-processing procedures. The Human Milk Banking Association of North America (HMBANA) is a professional association that supports non profit milk banks by  providing its members with standardized guidelines to screen donors, and process and distribute human milk.⁶ The for-profit milk banks utilize different, but safe, milk processing procedures, yet the end milk product produced by each contains significantly different human bioactive milk immune and metabolic components. HMBANA milk banks utilize holder pasteurization (milk is heated to 62.5°C for 30 minutes then rapidly cooled to 4°C) whereas for-profit milk banks utilize high vat pasteurization (milk is heated to 63°C ≥ 30 minutes), and  sterilization (milk is heated to 121°C for 5 minutes at 15 pounds per square inch). This sterilization process renders significantly less human species concentrations of protein, fat, immune components, and oligosaccharides.⁷ Donor mothers will benefit from knowing  this information to make informed decisions about where to donate their milk.

Another social and commercial pressure is the monetary compensation for donating milk . Donor mothers should know the differences in processing fees between non-profit and for-profit milk banks. A mission of HMBANA milk banks is to contain processing costs so that donor milk can be equitably distributed. One mechanism to contain costs is to not offer monetary compensation for milk donations.  For-profit milk banks offer monetary compensation which is then passed on to the consumer resulting in higher prices for donor milk. Guiding principles to determine whether or not a donor of a biological product can be offered compensation is outlined in an international statement developed by the convention of the Council of Europe   ; only those products created using patents can be distributed for commercial profit.⁸ This guidance protects for-profit milk banking companies. Donor mothers have the right to know how their milk will be processed and sold.

Lastly, for-profit milk banking companies have abundant resources to promote their product using sophisticated, provocative ad campaigns. Donor mothers have the right to receive informed healthcare data regarding the value of donor milk that retains 50-90% of human milk properties post-processing-the milk provided by non-profit human milk banks- which benefits  optimal infant growth and development.

HMBANA mentors those who are developing milk banks in areas where improvement in breastfeeding support is needed. To learn more about how to become a HMBANA- developing milk bank  visit www.hmbana.org . The Mothers’ Milk Bank of Louisiana, a developing milk bank member of HMBANA, would like to express sincere gratitude for the guidance of our mentor bank, the Mothers’ Milk Bank at Austin under the leadership of Kim Updegrove, Executive Director, as well as HMBANA guidance documents. August is National Breastfeeding Month. Let’s join together to honor all donor mothers for their lifesaving donation of miracle milk and pledge to inform and enlighten them of the invaluable impact of their milk donation decisions.

References

1.            American Academy of Pediatrics Committee on Nutrition SoB, Committee on Fetus and Newborn. Donor Human Milk for the High-Risk Infant: Preparation, Safety, and Usage Options in the United States. Pediatrics. 2017;139(1):e20163440.

2.            Medicine AoB. ABM Position on Breastfeeding – Revised 2015. Breastfeeding Medicine. 2015;10(9):407-411.

3.            Agarwal S, Karmaus, W., Davis, S., & Gangur, V. Immune markers in breast milk and fetal and maternal body fluids: A systematic review of perinatal concentrations. Journal of Human Lactation. 2011;27(2):171-186.

4.            UNICEF. #breatfeeding- Breastfeeding A Smart Investment. 2017; https://www.unicef.org/breastfeeding/. Accessed August 5, 2017, 2017.

5.            Labbock ML, Clark, D. & Goldman, A. Breastfeeding: maintaning and irreplaceable immunological resource. Nature Reviews Immunology. 2004;4(7):565-572.

6.            Human Milk Banking Association of North America. Guidelines for the establishment and operation of a donor milk bank. Forth Worth, Texas: Human Milk Banking Association of North America; 2016.

7.            Meredith-Dennis L, Xu, G., Goonatilleke, E., Lebrilla, C., Underwood, M. . Composition and variation of macronutrients, immune proteins, and human milk oligosaccharides in human milk from nonprofit and commercial milk banks. Journal of Human Lactation. 2017.

8.            Council of Europe. Convention for the Protection of Human Rights and Dignity of the Human Being with Regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine. Treaty No.164. 1997; http://conventions.coe.int/Treaty/en/Treaties/html/164.htm. Accessed July 27th, 2017.

Shelley Thibeau, PhD, RNC, is the Director of the developing Mothers’ Milk Bank of Louisiana. As a NICU nurse for 38 years, her interest in breastmilk has expanded to exploring breastmilk immunology associated with preterm infant health.

According to the U.S. Department of Health, one in four girls and one in five boys will be sexually abused before they turn 18. One in five women and one in 71 men will be raped at some point in their lives. This is in many ways a silent epidemic. Sometimes victims don’t disclose their abuse to their care providers. The reasons vary, and can range from  ongoing suffering of the traumatic effects of the abuse and  avoiding  reliving it, to a continuing sense of shame that victims  may have never come to grips with.

What are some possible signs of sexual abuse?

According to When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse on Childbearing Women, having a constellation of these symptoms can indicate a history of abuse. Having one or more of the following should trigger a red flag and considerations for a woman’s  care during childbirth:

• Not able to feel fetal movement. Some women have “numbed” that part of the body
• Hyperemesis gravidarum
• Chronic pelvic pain
• Missed prenatal appointments
• Panic with vaginal exams
• Extreme anxiety with IV starts
• Disassociation that manifests as if she’s going into a trance

Many of these symptoms can understandably occur in women who don’t have a history of sexual abuse, but when a woman has two or more, it’s reasonable to suspect that such a history is possible. These symptoms can stem from PTSD, which is triggered by a woman’s perception of loss-of-control, as well as the physical sensations that occur during pelvic exams, labor, and birth. By rushing through procedures, and not allowing the woman time to process (if possible), understand, and consent to what is happening to her body, we can inadvertently trigger a posttraumatic reaction.

Admittedly, the discussion of sexual abuse is a tough topic for those on either end of the conversation. We often just touch on the subject while reviewing women’s admission histories, and then move on. Fortunately, we don’t need the admission of abuse to employ strategies developed for survivors. It’s actually much more common for caregivers to pick up on non-verbal cues and then tailor their care. A real tragedy is the guilt and shame survivors can feel after giving birth. So, like we would do for any woman,  it’s best to acknowledge the struggle of labor and birth, the strength a woman demonstrated, and the effort and precious reward she  achieved.

What are interventions that nurses and other caregivers can provide?

• Explain as much as you can in advance, for example “If we run into an emergent situation there might be unfamiliar nurses coming in to help. I know this can cause anxiety, but I want to prepare you ahead of time in case it happens.”
• Always start with asking permission. From starting an IV to turning on the overhead lights, make sure to obtain permission before doing any procedures or making changes to the environment
• Go slowly with everything you do–this can be helpful in relation to a woman’s  fear of losing control. Fast movements can be triggers. This is especially important when uncovering a woman or assisting her with positioning.
• Limit vaginal exams. These are especially traumatic and should be minimized. If a woman is having difficulty in relaxing enough to complete an exam, try making an agreement about when and why you can perform one. If a woman understands that the exams are being performed only when necessary, and with her consent, her anxiety is often more controllable during exams.
• Minimize people in her room. She might have issues with nursing students or residents, especially if they are male. Obtain her permission before any new staff come into the room, unless there’s an emergent situation.

What are things not to say?

• Intrusive interest-prying for details or descriptions of the abuse
• Minimizing the abuse: “Well, that’s over now.”
• Exaggerated concern
• Shock or disgust
• Pity

What are good things to say?

• “I can imagine that was very hard to share that with me. It takes a lot of courage to talk about and I respect you for doing that.”
• “Sometimes talking about these episodes can trigger strong feelings. How are you feeling right now?”
• And, it’s always essential to assess the woman’s current well-being “Do you feel unsafe in any aspect of your life?”

Not all survivors of sexual abuse have difficulty with pregnancy or childbirth, for some it can be empowering. For those who do struggle, recognize that we have a powerful opportunity to help them. We can communicate therapeutically to help  change the woman’s focus from feeling out-of-control.  We can employ care practices to avoid the woman feeling re-traumatizatized.  And we can set the stage to promote healing and bonding with the newborn. In many instances it’s our tacit recognition and respectful and supportive care that facilitates healing, more than any words we could utter or medicines we could administer.

Where can I learn more?

• When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse on Childbearing Women
• Simkin, Penny and Phyllis H. Klaus. Seattle: Classic Day, 2011. Print.

What are resources for my patients?

• National Sexual Abuse Hotline: 1800-656-HOPE
• RAINN: Rape, Abuse, Incest National Network, www.rainn.org

Tasha Poslaniec has been a registered nurse for 17 years. She has been working in obstetrics for over a decade and is currently a Perinatal Quality Review Nurse and Childbirth Educator.

She also writes about nursing and childbirth and has been published in the Huffington Post and the American Journal of Nursing. Pain control in childbirth has long been a topic of study and research for her.

There are many great reasons why hospitals choose to work toward and achieve Baby-Friendly hospital status. There are also plenty of ways to encourage breastfeeding in line with the World Health Organization’s (WHO) guidelines without having that official Baby-Friendly Hospital designation. In fact, research has shown that implementing Baby Friendly practices such as early breastfeeding after birth, skin-to-skin care , and rooming-in,  in hospitals that do not have this designation, resulted in higher rates of breastfeeding initiation and duration.

Whether or not you’re pursuing Baby-Friendly status, your hospital can effectively support and promote breastfeeding among staff, mothers, and their families. Here are just 5 of many ways to go about it:

1. Start educating women about breastfeeding early.

Setting expectations and goals early in the care process that a mother will achieve desired health objectives. This is true of breastfeeding, as well.

• Educating mothers about the benefits of breastfeeding is most successful when it starts during pregnancy. Indeed, Step 3 of WHO’s 10 Steps to Successful Breastfeeding—the key criteria for formal Baby-Friendly hospital status—requires that hospitals “inform all pregnant women about the benefits and management of breastfeeding.”
• Educating parents proactively, rather than waiting for them to request information, ensures they have the education they need when they need it.
• Educating parents electronically means the information can be shared in small, consistent pieces that don’t feel overwhelming. It’s also a time savings for staff and providers who would otherwise need to use medical appointments for breastfeeding education.

2. Incorporate breastfeeding education into your ongoing staff training.

Keeping your staff updated on supportive breastfeeding practices doesn’t have to be time-consuming or require organized training classes. Consider providing electronic breastfeeding education for staff to access anywhere and at their own convenience. Choose a solution that lets you track their progress, so you know when they’ve read the required information.

3. Stay in touch with women and their families about breastfeeding support opportunities, even after they’ve returned home.

In the U.S., 74% of babies have breastfed at least once, but only 23% are still breastfeeding by 1 year of age, according to the CDC’s Breastfeeding Report Card. Once new mothers are discharged, a strong connection with your hospital can encourage them to take advantage of available support, overcome challenges and stick with breastfeeding.

When following up with women who’ve recently had babies invite them to schedule a session with a lactation consultant or attend a  breastfeeding support group at your hospital. These opportunities not only provide additional revenue sources,  but also nurture relationships with women and their families, who will be more likely to return to your hospital in the future—whether for obstetric or other medical care.

4. Ask new moms for feedback about your hospital’s breastfeeding support practices.

Breastfeeding is an emotional topic for new mothers. With patient experience and satisfaction so important to a hospital’s bottom line these days, you want to know where you stand in patients’ minds.

Surveys are a great way to measure patient satisfaction with your breastfeeding education practice and policy. Send a quick survey by email or text message, asking new moms specifically about how your breastfeeding support has helped them and where you can improve.

5. Collect data on how many women who had their babies at your hospital continue breastfeeding.

Healthy People 2020, the population health measures created by the federal Office of Disease Prevention and Health Promotion, set goals for how many infants are breastfed by the year 2020, including 34% of infants breastfeed at 1 year and 26% breastfed exclusively through 6 months.

If you want to work toward or even surpass this goal, you need to measure how your patients are doing after they leave the hospital. Providing patients education in a digital format, i.e. on their mobile device, combined with data collection technology can help you gain insight.

Baby-Friendly status remains the gold standard for many hospitals encouraging breastfeeding. But if your facility has limited resources, these 5 strategies can help your hospital successfully support and encourage breastfeeding.

For additional information on becoming a Baby-Friendly hospital, visit www.babyfriendlyusa.org

AWHONN Resources

• Breastfeeding Support
• Perinatal Nursing
• Breastfeeding Rates Improve with Support and Education for Mothers
• Increasing Initiation and Exclusivity of Breastfeeding in the Hospitalized, Postpartum Dyad (JOGNN)

Deirdre Wilson, Senior Editor for UbiCare, is an award-winning writer and editor with 30 years’ experience researching and writing on a wide range of health, wellness and education topics for newspapers, magazines and a news wire service.

Nancy Nurse walks into the hospital for her twelve hour shift like she has hundreds of times before in her eight year career as an obstetrical nurse.  Tonight, like so many other nights, she contemplates if she will have an enough nurses to care for the ladies presenting in labor tonight.  She dreads the thought of having another discussion with Dr. Kantwaite about delivering a baby before the 39^th week and the evidence that has been presented to him multiple times by the nurses and chief of the department.  The chief is so frustrated and tired of dealing with Dr. Kantwaite that he has stopped answering the calls from the nurses pushing this physician’s blatant noncompliance with safety and best practice through their chain of command.  Nancy documents and reports these occurrences to her nurse manager who throws up her hands, asking what can she do to resolve these problems.  She knows through several candid conversations with her manager that there is approval to hire only a limited number of staff in the budget and she is always pressured regarding the productivity of the unit.  The moment-to-moment operations of the labor and delivery unit is challenging at best.  The needs of one patient turn into needs for two patients or more with the mother through recovery and the baby as they transition into life on their own.

Nancy Nurse has been assigned to care for a woman delivering an anencephalic baby.  The family has requested that all resuscitation measures be used to save their baby despite discussions with the parents on the mortality of anencephalic babies from the neonatologist and obstetrician.  Nancy realizes that Dr. Kantwaite is on call tonight and is already calling to induce a 37.3 week gestation primagravida patient.  Her cervix is closed but he wants the nurse to insert cervadil to ripen her cervix and start Pitocin in the morning.  Nancy has reviewed the prenatal record and finds no medical reason to induce this woman.  Nancy is also in charge tonight and has had one of the nurses for her shift call in ill.  This leaves them one nurse down tonight, giving her patient assignments as well as taking charge nurse responsibilities assisting the other nurses with their deliveries, transitioning babies and checking that the unit is stocked, paperwork is completed, staffing is evaluated for the next shift and all of the charge nurse assigned duties.  Nancy has planned to attend the clinical excellence meeting in the morning to discuss a new medication reconciliation process the hospital wants to implement through the computer system.     Moral distress, ethical dilemmas and ethical distress are all difficulties that nurses face on a daily basis in virtually every healthcare environment.  These quandaries can influence nurse engagement, job satisfaction, turnover, nurse attrition, patient safety and quality of care.^9,23  The personal impact of moral distress can result in feelings of frustration, anger, anxiety, guilt, and loss of self-worth, depression, nightmares, resentment, sorrow, helplessness and powerlessness.²³ Rather than experience these negative feelings, they may choose to transfer to another position or even leave the nursing profession in order to escape this distress.^13(p258),23

Morals and ethics, although frequently used interchangeably, are different in definition.  The simple difference to distinguish morals and ethics is that “morality is about making the correct choices while ethics is about proper reasoning”.¹⁶  Healthcare systems across the nation, in some form or fashion, have an ethics committee, yet  morals committees or boards are absent.

Moral distress and how it effects the overall nursing engagement has been understudied and is frequently the “elephant” no one wishes to discuss in the organizational structure of healthcare.  Many factors and situations influence moral distress including staffing, physician practice, nursing practice, ethical climate, violence in the workplace and organizational policies but since moral distress in based on individual values and perceived obligations this varies from nurse to nurse.⁸   Nursing turnover, job satisfaction, quality of care, nurse attrition, caring attitudes, moral sensitivity and overall nurse engagement can be affected by moral distress.  Moral distress and ethical distress are continuing to be utilized interchangeably in research and education.  Ethics training focuses on ethical dilemmas and principles and may not include the tools needed to minimize the effects of the moral residue.  The American Association of Critical Care Nurses has developed the “4 A’s”.  Ask if you are feeling moral distress, Affirm your feelings, Assess and put the facts together and Act or create a plan and implement it.⁸  Other strategies that have been utilized include speaking up, be deliberate and accountable, build support systems and focus on changes in your environment at work.  Get educated on moral distress and get everyone involved.  Get down to the roots and develop polices, plan an inservice to train others.⁸

As we move toward improving our professional satisfaction with our work, improving quality of patient care and expanding our roles in healthcare; we must address the needs to diminish moral distress through effective tools that are easily accessed, supported by our institutions and professional organizations.  We know that how we engage in our work can be crucial to our outcomes.  Breaking down barriers in achieving our greatest work satisfaction, placing our mission first for our patients, developing a professional practice model and implementing tools to assist us with dealing with our moral distress will bring us closer to our purpose of caring.

Dr. Cheryl Bonecutter has been a registered nurse for over thirty years, and a Nurse Practitioner for over twenty years, specializing in Women’s Health, NICU, and Pediatrics.  She received her ADN degree from North Central Technical College (nka North Central State College) in Mansfield, Ohio, and thereafter, achieved her certification as a Women’s Health Nurse Practitioner from the University of Wisconsin-Milwaukee.  After completion of her BSN, Cheryl attained her MSN from Drexel University in Philadelphia, and followed that with a Doctor of Nursing Practice (also from Drexel University), graduating Summa Cum Laude as to both advanced degrees.

Cheryl has been active with numerous agencies and organizations, including the March of Dimes, AWHONN, and Sigma Theta Tau.  In support of women’s and children’s health policy, she has provided testimony to various committees of the Ohio, South Carolina and Texas legislatures, and has served on several local and state advisory boards.

Through her career, Cheryl has worked the entire vertical spectrum of Women’s Health, from bedside to provider to administration, and is currently working as a Nursing Administration consultant with Healthtrust in the Houston, Texas area.

References

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2. Bakibinga, P., Vinje, H., & Mittelmark, M. (2012, February 20) Factors contributing to job engagement in Ugandan nurses and midwives. 2012 March 29. International Scholarly Research Network Volume 2012.

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19. Rivera, R., Fitzpatrick, J., & Boyle, S. (2011, June). Closing the RN engagement gap. The Journal of Nursing Administration. 2011; 41(6):265-272

20. Schaufeli, W. B., Salanova, M., Gonzales-Roma, V., & Bakker, A.B. (2002). The measurement of engagement and burnout: A two sample confirmatory factor analytic approach. Journal of Happiness Studies, 3, 71-92.

21. Simpson, M. (2008 July 8). Predictors of work engagement among medical-surgical registered nurses. The Journal of Nursing Research. 2009 February; 31(1):44-65

22. Wilkinson, J.W. (1987/1988). Moral distress in nursing practice: Experience and effect. Nursing Forum, 23(1), 16-29.

23. Zuzelo, P. (2007). Exploring the moral distress of registered nurses. Nursing Ethic. 2007; 14 (3) retrieved from: http://www.lasalle.edu/schools/snhs/content/pdf/moraldistresss.pdf