Holistic Nursing Research Paper
Holistic Nursing
A Way of Being, a Way of Living, a Way of Practice!
By Lucia Thornton
32
JANUARY 2008
What do holistic nurses do? Where do they work? Do I need special education and training to become a holistic nurse?
Article Copyright 2008, Lucia Thornton
NSNA IMPRINT | www.nsna.org 33
HOLISTIC NURSING
H
Figure I : Holistic Nurse Demographics from AHNA membership.
SIDEBAR I
Questions for Self-Exploration and Awareness
olistic nursing can be practiced in any setting. Demographics from the American Holistic Nurses Association (AHNA) membership show that 39 percent of holistic nurses work in hospitals, 23 percent in private practice, 15 percent in academia/education/research, 11percent hospice/palliative/long …show more content…
term care, and 9 percent are students (AHNA, 2007) (see Figure I). AHNA defines holistic nursing as “all nursing that has healing the whole person as its goal” (AHNA 2007). As a student, you can begin to incorporate holistic practices that will enrich your personal life, your educational experience and your clinical practicum. Holistic nursing is a way of being, a way of living, and a way of practicing that will transform your life and transform your work.
A Way of Being . . .
Being a Caring and Healing Presence
A primary focus of holistic nursing is to bring “caring” and “healing” back into our health care system. The first step in this process is for nurses to learn to love and care for themselves. While this may seem a selfish pursuit, learning to care deeply for ourselves by taking the time to nurture ourselves physically, emotionally, mentally and spiritually is absolutely essential. When we do so, we begin to realize our wholeness and we actually become a healing presence for our patients. As a student nurse you are concerned primarily with what nurses “do” (e.g., giving treatments, changing dressings, monitoring vital signs, etc.) Mastering clinical nursing techniques and treatments is essential in order to help your patients heal and recover from their illness or surgery. However, who you are, how you feel inside, and the attitude that you convey also have a profound effect on the patient. When you walk into a (continued on p. 36)
Take some time each day to reflect on an aspect of your life. Here are some questions to help you explore various aspects of your life: • Physical: Is my diet optimal? Does my intake consist mainly of whole and natural foods? Do I receive optimal sleep and rest daily? Do I engage in beneficial movement and exercise daily? Do my breathing patterns promote well-being? • Mental: Do I have a problem-solving orientation toward life rather than a victim mentality? Do I usually have a positive attitude and positive thoughts toward school and work? Do I have a sense of humor ? Do I possess self-awareness – am I objective about my strengths, limitations and possibilities? Am I able to perceive reality with clarity? • Emotional: Do I love and accept myself and others? Am I able to give and receive love from myself and others? Am I able to express my own truth? Am I able to have deep feelings of identification, sympathy, and affection for others? • Social/relational: Do I engage in relationships that are wholesome and loving? Do I engage in relationships that promote growth in my self and others? Am I able to set healthy boundaries with others? Do I engage in work that is meaningful? • Spiritual/Energetic: Am I able to connect with God/higher self/universe/spirit? Do I engage in meditation/prayer/introspective practices regularly? Do I know and understand love as the essence of self? Do I have a deep respect for all? Take your time in addressing each of these questions. Remember this is a life long process of deep inner inquiry and growth. As you go through these questions, note when you respond with a powerful “no.” These are the areas that you need to pay attention to. Focus on one area at a time. Create some short-term and long-term goals for each of the areas that you want to improve. Remember to treat yourself with compassion, love and kindness!
34
JANUARY 2008
HOLISTIC NURSING
SIDEBAR II
(continued from p. 34)
The Experience of a Holistic OR Nurse
“As the nurse, caregiver - I enter a large, barren room filled with empty gurneys. Sounds echo, sharp and harsh. I plug in the music system, select a favorite classical CD as the phone rings. Days here are like clips from a silent movie run at high speed. Everything goes faster and faster. I am irritated by the pressure to prepare patients, but then I shift into my heart. Today I remember that the core of my nursing philosophy is caring, whether it is for patients, myself, colleagues, or co-workers. An operating room is a wonderful place to study the effects of parts on the whole. A disruption for one staff member is experienced by everyone because we are unitary beings. The telephone rings again… Another breath, and the patients are arriving. I smile, introduce myself, warmly greeting each of them. I gently help them onto gurneys, tucking them in with warm blankets, explaining procedures, answering questions, and teaching. My touch, tone of voice, and state of being are critical for communicating to them that they are safe and that the staff members are competent, understanding, accepting people. I listen, look and feel, accessing their needs and state of being. Having made them as comfortable as possible, I quickly become task-oriented for the moment, checking orders and documents, and assigning preps. As I do this, my intuitive self is still tuned toward each patient. I strive to be present and aware of everyone in the room. My attention is drawn to the corner. Mrs. M. lies on the gurney. Her eyes are glazed and filled with fear. She is pensive and melancholy. We talk about her illness. Her abdomen is swollen and sore. Tenderly, I guide her to happier times in her life. She is fragile and quiet spoken, depleted of energy, but not of spirit. The tumors in her stomach are going to be removed. The telephone rings, and her surgery is delayed. All the other patients have been moved to the operating room. The telephone rings again. It is Mrs. M’s daughter. I push the gurney to the phone, and they talk. Afterwards, we talk about using meditation. We sit silently, holding hands, listening to the music and meditating. Her face becomes radiant as her body relaxes. Her fear is fading. She says, “I feel so much better now. Do you connect with everyone who comes here this way?” I reply, “Each person is different, and so are their needs.” We wheel her into the OR. She is peaceful. I say goodbye as the doors close around her, a prayer in my heart.” Author’s note: This experience is shared by Pearl Root, RN, a pre-operative holistic nurse at Green Hospital of Scripps Clinic in La Jolla, CA. Used with permission, SSM™ 5 (December 1999) pp 41-44. Copyright © AORN, Inc., 2170 S. Parker Road, Suite 300, Denver, CO 80231. All rights reserved.
patient’s room feeling depleted and exhausted, you are creating an unhealthy environment by your presence. If, on the other hand, you are well rested and feel content and peaceful inside you create a healthy and wholesome environment by your very presence. Taking good care of yourself is a prerequisite to providing holistic care for your patients. Learning to listen deeply to your own heart and your own truth allows you to connect in a deeply caring way with your patients. As Jean Watson says, “We must learn to treat ourselves with love and respect before we are able to treat others that way”(Watson, 1998). Love and caring are essential in the healing process, both for ourselves and our patients!
A Way of Living . . .
Role Models for Healthy and Wholesome Living
Holistic nurses strive to be models of wholesome and healthy behavior by creating optimal health in every aspect of their lives – physically, mentally, emotionally, socially and spiritually. Achieving optimal health in all the areas of our lives is a lifelong endeavor. Resistance to change, self-doubt, and low self-esteem can block our journey to optimal nurturance. Examining these blocks is crucial for understanding and identifying sources of resistance. Many of these attitudes and beliefs are caused by social conditioning and early life experiences that simply no longer apply to adult life. Being willing to explore what lies beneath the surface is important if we are to create healthy and wholesome patterns of living (Thornton, 1998).
(continued on p. 38)
36 JANUARY 2008
HOLISTIC NURSING
(continued from p. 36)
SIDEBAR III
Centering and Intention Setting Technique
Acknowledgment of Infinite and Sacred Nature of Being
Holistic nursing acknowledges that people are infinite, sacred and spiritual beings. Florence Nightingale spoke of human beings as a “reflection of the Divine with physical, metaphysical and intellectual attributes” (McCrae, 1995). Jean Watson teaches that we are “sacred Beings” (Watson, 1998). Martha Rogers speaks of unitary human beings as “energy fields that are infinite in nature”(Thornton, 1999). From the perspective of holistic nursing theorists, people are energy fields that are infinite and sacred. This orientation makes a difference in how we approach each other. It shifts how we speak, how we listen, how we relate, and how we interact.
• Pause for a moment before entering the patient’s room • Set aside any concerns regarding the past or the future. These can be picked up when leaving the room. • Gently close your eyes. • Breathe deeply and slowly. • Repeat to yourself, “I am here for the greater good of this patient – I give my full attention to the here and now.” • Direct awareness to the area around your heart, bringing to mind something or someone that evokes your love and compassion. • When connected with that feeling of love and compassion repeat again, “I am present to the moment.” • This entire process should take only between 5 and 10 seconds.
Caring/Healing/ Transcendent Presence
Another characteristic of holistic practice is the depth and profound quality of presence that the nurse has with his patients. Jean Watson speaks of the “full use of self” in the transpersonal caring process. When the nurse becomes heart-centered, he can connect with the person at a heart/soul level – a deep psychosocial and spiritual level.
Commitment to Self-Care, Self-Exploration and Awareness
Take some time to begin examining the various aspects of your life. The first step is gaining an awareness of your patterns and habits and bringing into consciousness that which has been unconscious (see Sidebar I). Some of the practices utilized by holistic nurses for self-exploration and awareness include meditation, creating time for reflection and introspection, dreamwork, mindfulness practice, and journaling.
A Way of Practice
Centering and Intention Setting
Centering and creating an intention for healing are processes the holistic nurse engages in prior to any patient interaction. Centering involves focusing your attention on your heart, setting aside concerns and thoughts, and connecting with feelings of love and compassion. Creating an intention is a powerful way for the nurse to create an optimal environment for a caring-healing interaction. (See Sidebar III.) With this intention the nurse is consciously setting aside her own concerns and focusing on the patient; she focuses on the idea that the interaction will be “for the greater good of this person”; and she is making a conscious decision to be fully present. The nurse creates an environment that promotes and sustains a caring-healing interaction.
Holistic Nurses in Private Practice
Many holistic nurses have their own private practices in which they use a variety of approaches and modalities in providing holistic care. Some of the common interventions that holistic nurses incorporate include: subtle energy healing (e.g., healing touch, therapeutic touch, Reiki, etc.), reflexology, guided imagery, biofeedback, aromatherapy, massage, nutritional counseling, cognitive therapy, life-style counseling, breathing and relaxation techniques, music and sound therapy and acupressure. Holistic nurses, through their knowledge and understanding of complimentary and alternative medicine
Commitment to Caring for the Environment
Holistic nurses advocate and promote healthy environments and the healing of our planet. Just as Florence Nightingale advocated and understood the importance of clean, fresh air and clean surroundings for her patients, so too holistic nurses promote practices that help ensure the sustainability of our earth. Holistic nurses understand that the health of our planet is inextricably linked to the health of every individual. 38 JANUARY 2008
(CAM) therapies can guide their clients in safely integrating them into their healing process.
references
American Holistic Nurses Association (AHNA). (2007). “Holistic Nursing: Scope and Standards of Practice.” Nursebooks.org: The Publishing Program of ANA , Silver Spring, Maryland. (1). McCrae, J. (1995). “Suggestions for thought from Florence Nightingale,” Changing Face of Healing, AHNA/AHMA conference (Phoenix: Sounds True Recording, June 22, 1995) Cassette tape. Thornton, L. (1998). “Self-Renewal and Nurturing for Holistic Nurses.” Alternative and Complimentary Therapies 4 (5), 364-366. Thornton, L. (1999). “Renewing the Spirit of Nursing: Caring for Ourselves/Caring for Others”. Keynote address, Association of California Nurse Leaders annual conference; San Francisco, CA; Feb. 1999.
Education and Board Certification
There are currently 13 undergraduate programs in the United States endorsed by the American Holistic Nurse Certification Corporation (AHNCC) that prepare undergraduate students in holistic nursing.
To be eligible for board certification by the AHNCC at the basic holistic nursing level (HN-BC), a nurse is required to have: (1) an active, unrestricted U.S. license; (2) a baccalaureate or higher degree; (3) at least one year of full-time practice or 2,000 hours of part-time practice within the last five years as a holistic nurse or graduation from an AHNCC-endorsed university; and (4) a minimum of 48 contact hours of holistic nursing continuing education within the last 2 years (AHNA, p.20) After becoming eligible for certification, the nurse must pass a qualitative assessment and a quantitative examination to obtain certification. Board certification is also offered at the advanced practice level (AHNBC) for nurses with graduate degrees. The eligibility criteria for advanced practice is similar and certification also requires passing a qualitative assessment and a quantitative exam (AHNA p.22). The American Holistic Nurses Association (AHNA) endorses and sponsors a variety of educational programs related to holistic nursing practice. For more information access the AHNA website at: www.ahna.org. Lucia Thornton, a holistic nurse educator and consultant, currently serves as President of the American Holistic Nurses Association. Her work in transforming hospitals into "healing environments" has received national, state and local recognition. Lucia can be contacted at
luciat@csufresno.edu.
NSNA IMPRINT | www.nsna.org 39
A Way of Being, a Way of Living, a Way of Practice!
By Lucia Thornton
32
JANUARY 2008
What do holistic nurses do? Where do they work? Do I need special education and training to become a holistic nurse?
Article Copyright 2008, Lucia Thornton
NSNA IMPRINT | www.nsna.org 33
HOLISTIC NURSING
H
Figure I : Holistic Nurse Demographics from AHNA membership.
SIDEBAR I
Questions for Self-Exploration and Awareness
olistic nursing can be practiced in any setting. Demographics from the American Holistic Nurses Association (AHNA) membership show that 39 percent of holistic nurses work in hospitals, 23 percent in private practice, 15 percent in academia/education/research, 11percent hospice/palliative/long …show more content…
term care, and 9 percent are students (AHNA, 2007) (see Figure I). AHNA defines holistic nursing as “all nursing that has healing the whole person as its goal” (AHNA 2007). As a student, you can begin to incorporate holistic practices that will enrich your personal life, your educational experience and your clinical practicum. Holistic nursing is a way of being, a way of living, and a way of practicing that will transform your life and transform your work.
A Way of Being . . .
Being a Caring and Healing Presence
A primary focus of holistic nursing is to bring “caring” and “healing” back into our health care system. The first step in this process is for nurses to learn to love and care for themselves. While this may seem a selfish pursuit, learning to care deeply for ourselves by taking the time to nurture ourselves physically, emotionally, mentally and spiritually is absolutely essential. When we do so, we begin to realize our wholeness and we actually become a healing presence for our patients. As a student nurse you are concerned primarily with what nurses “do” (e.g., giving treatments, changing dressings, monitoring vital signs, etc.) Mastering clinical nursing techniques and treatments is essential in order to help your patients heal and recover from their illness or surgery. However, who you are, how you feel inside, and the attitude that you convey also have a profound effect on the patient. When you walk into a (continued on p. 36)
Take some time each day to reflect on an aspect of your life. Here are some questions to help you explore various aspects of your life: • Physical: Is my diet optimal? Does my intake consist mainly of whole and natural foods? Do I receive optimal sleep and rest daily? Do I engage in beneficial movement and exercise daily? Do my breathing patterns promote well-being? • Mental: Do I have a problem-solving orientation toward life rather than a victim mentality? Do I usually have a positive attitude and positive thoughts toward school and work? Do I have a sense of humor ? Do I possess self-awareness – am I objective about my strengths, limitations and possibilities? Am I able to perceive reality with clarity? • Emotional: Do I love and accept myself and others? Am I able to give and receive love from myself and others? Am I able to express my own truth? Am I able to have deep feelings of identification, sympathy, and affection for others? • Social/relational: Do I engage in relationships that are wholesome and loving? Do I engage in relationships that promote growth in my self and others? Am I able to set healthy boundaries with others? Do I engage in work that is meaningful? • Spiritual/Energetic: Am I able to connect with God/higher self/universe/spirit? Do I engage in meditation/prayer/introspective practices regularly? Do I know and understand love as the essence of self? Do I have a deep respect for all? Take your time in addressing each of these questions. Remember this is a life long process of deep inner inquiry and growth. As you go through these questions, note when you respond with a powerful “no.” These are the areas that you need to pay attention to. Focus on one area at a time. Create some short-term and long-term goals for each of the areas that you want to improve. Remember to treat yourself with compassion, love and kindness!
34
JANUARY 2008
HOLISTIC NURSING
SIDEBAR II
(continued from p. 34)
The Experience of a Holistic OR Nurse
“As the nurse, caregiver - I enter a large, barren room filled with empty gurneys. Sounds echo, sharp and harsh. I plug in the music system, select a favorite classical CD as the phone rings. Days here are like clips from a silent movie run at high speed. Everything goes faster and faster. I am irritated by the pressure to prepare patients, but then I shift into my heart. Today I remember that the core of my nursing philosophy is caring, whether it is for patients, myself, colleagues, or co-workers. An operating room is a wonderful place to study the effects of parts on the whole. A disruption for one staff member is experienced by everyone because we are unitary beings. The telephone rings again… Another breath, and the patients are arriving. I smile, introduce myself, warmly greeting each of them. I gently help them onto gurneys, tucking them in with warm blankets, explaining procedures, answering questions, and teaching. My touch, tone of voice, and state of being are critical for communicating to them that they are safe and that the staff members are competent, understanding, accepting people. I listen, look and feel, accessing their needs and state of being. Having made them as comfortable as possible, I quickly become task-oriented for the moment, checking orders and documents, and assigning preps. As I do this, my intuitive self is still tuned toward each patient. I strive to be present and aware of everyone in the room. My attention is drawn to the corner. Mrs. M. lies on the gurney. Her eyes are glazed and filled with fear. She is pensive and melancholy. We talk about her illness. Her abdomen is swollen and sore. Tenderly, I guide her to happier times in her life. She is fragile and quiet spoken, depleted of energy, but not of spirit. The tumors in her stomach are going to be removed. The telephone rings, and her surgery is delayed. All the other patients have been moved to the operating room. The telephone rings again. It is Mrs. M’s daughter. I push the gurney to the phone, and they talk. Afterwards, we talk about using meditation. We sit silently, holding hands, listening to the music and meditating. Her face becomes radiant as her body relaxes. Her fear is fading. She says, “I feel so much better now. Do you connect with everyone who comes here this way?” I reply, “Each person is different, and so are their needs.” We wheel her into the OR. She is peaceful. I say goodbye as the doors close around her, a prayer in my heart.” Author’s note: This experience is shared by Pearl Root, RN, a pre-operative holistic nurse at Green Hospital of Scripps Clinic in La Jolla, CA. Used with permission, SSM™ 5 (December 1999) pp 41-44. Copyright © AORN, Inc., 2170 S. Parker Road, Suite 300, Denver, CO 80231. All rights reserved.
patient’s room feeling depleted and exhausted, you are creating an unhealthy environment by your presence. If, on the other hand, you are well rested and feel content and peaceful inside you create a healthy and wholesome environment by your very presence. Taking good care of yourself is a prerequisite to providing holistic care for your patients. Learning to listen deeply to your own heart and your own truth allows you to connect in a deeply caring way with your patients. As Jean Watson says, “We must learn to treat ourselves with love and respect before we are able to treat others that way”(Watson, 1998). Love and caring are essential in the healing process, both for ourselves and our patients!
A Way of Living . . .
Role Models for Healthy and Wholesome Living
Holistic nurses strive to be models of wholesome and healthy behavior by creating optimal health in every aspect of their lives – physically, mentally, emotionally, socially and spiritually. Achieving optimal health in all the areas of our lives is a lifelong endeavor. Resistance to change, self-doubt, and low self-esteem can block our journey to optimal nurturance. Examining these blocks is crucial for understanding and identifying sources of resistance. Many of these attitudes and beliefs are caused by social conditioning and early life experiences that simply no longer apply to adult life. Being willing to explore what lies beneath the surface is important if we are to create healthy and wholesome patterns of living (Thornton, 1998).
(continued on p. 38)
36 JANUARY 2008
HOLISTIC NURSING
(continued from p. 36)
SIDEBAR III
Centering and Intention Setting Technique
Acknowledgment of Infinite and Sacred Nature of Being
Holistic nursing acknowledges that people are infinite, sacred and spiritual beings. Florence Nightingale spoke of human beings as a “reflection of the Divine with physical, metaphysical and intellectual attributes” (McCrae, 1995). Jean Watson teaches that we are “sacred Beings” (Watson, 1998). Martha Rogers speaks of unitary human beings as “energy fields that are infinite in nature”(Thornton, 1999). From the perspective of holistic nursing theorists, people are energy fields that are infinite and sacred. This orientation makes a difference in how we approach each other. It shifts how we speak, how we listen, how we relate, and how we interact.
• Pause for a moment before entering the patient’s room • Set aside any concerns regarding the past or the future. These can be picked up when leaving the room. • Gently close your eyes. • Breathe deeply and slowly. • Repeat to yourself, “I am here for the greater good of this patient – I give my full attention to the here and now.” • Direct awareness to the area around your heart, bringing to mind something or someone that evokes your love and compassion. • When connected with that feeling of love and compassion repeat again, “I am present to the moment.” • This entire process should take only between 5 and 10 seconds.
Caring/Healing/ Transcendent Presence
Another characteristic of holistic practice is the depth and profound quality of presence that the nurse has with his patients. Jean Watson speaks of the “full use of self” in the transpersonal caring process. When the nurse becomes heart-centered, he can connect with the person at a heart/soul level – a deep psychosocial and spiritual level.
Commitment to Self-Care, Self-Exploration and Awareness
Take some time to begin examining the various aspects of your life. The first step is gaining an awareness of your patterns and habits and bringing into consciousness that which has been unconscious (see Sidebar I). Some of the practices utilized by holistic nurses for self-exploration and awareness include meditation, creating time for reflection and introspection, dreamwork, mindfulness practice, and journaling.
A Way of Practice
Centering and Intention Setting
Centering and creating an intention for healing are processes the holistic nurse engages in prior to any patient interaction. Centering involves focusing your attention on your heart, setting aside concerns and thoughts, and connecting with feelings of love and compassion. Creating an intention is a powerful way for the nurse to create an optimal environment for a caring-healing interaction. (See Sidebar III.) With this intention the nurse is consciously setting aside her own concerns and focusing on the patient; she focuses on the idea that the interaction will be “for the greater good of this person”; and she is making a conscious decision to be fully present. The nurse creates an environment that promotes and sustains a caring-healing interaction.
Holistic Nurses in Private Practice
Many holistic nurses have their own private practices in which they use a variety of approaches and modalities in providing holistic care. Some of the common interventions that holistic nurses incorporate include: subtle energy healing (e.g., healing touch, therapeutic touch, Reiki, etc.), reflexology, guided imagery, biofeedback, aromatherapy, massage, nutritional counseling, cognitive therapy, life-style counseling, breathing and relaxation techniques, music and sound therapy and acupressure. Holistic nurses, through their knowledge and understanding of complimentary and alternative medicine
Commitment to Caring for the Environment
Holistic nurses advocate and promote healthy environments and the healing of our planet. Just as Florence Nightingale advocated and understood the importance of clean, fresh air and clean surroundings for her patients, so too holistic nurses promote practices that help ensure the sustainability of our earth. Holistic nurses understand that the health of our planet is inextricably linked to the health of every individual. 38 JANUARY 2008
(CAM) therapies can guide their clients in safely integrating them into their healing process.
references
American Holistic Nurses Association (AHNA). (2007). “Holistic Nursing: Scope and Standards of Practice.” Nursebooks.org: The Publishing Program of ANA , Silver Spring, Maryland. (1). McCrae, J. (1995). “Suggestions for thought from Florence Nightingale,” Changing Face of Healing, AHNA/AHMA conference (Phoenix: Sounds True Recording, June 22, 1995) Cassette tape. Thornton, L. (1998). “Self-Renewal and Nurturing for Holistic Nurses.” Alternative and Complimentary Therapies 4 (5), 364-366. Thornton, L. (1999). “Renewing the Spirit of Nursing: Caring for Ourselves/Caring for Others”. Keynote address, Association of California Nurse Leaders annual conference; San Francisco, CA; Feb. 1999.
Education and Board Certification
There are currently 13 undergraduate programs in the United States endorsed by the American Holistic Nurse Certification Corporation (AHNCC) that prepare undergraduate students in holistic nursing.
To be eligible for board certification by the AHNCC at the basic holistic nursing level (HN-BC), a nurse is required to have: (1) an active, unrestricted U.S. license; (2) a baccalaureate or higher degree; (3) at least one year of full-time practice or 2,000 hours of part-time practice within the last five years as a holistic nurse or graduation from an AHNCC-endorsed university; and (4) a minimum of 48 contact hours of holistic nursing continuing education within the last 2 years (AHNA, p.20) After becoming eligible for certification, the nurse must pass a qualitative assessment and a quantitative examination to obtain certification. Board certification is also offered at the advanced practice level (AHNBC) for nurses with graduate degrees. The eligibility criteria for advanced practice is similar and certification also requires passing a qualitative assessment and a quantitative exam (AHNA p.22). The American Holistic Nurses Association (AHNA) endorses and sponsors a variety of educational programs related to holistic nursing practice. For more information access the AHNA website at: www.ahna.org. Lucia Thornton, a holistic nurse educator and consultant, currently serves as President of the American Holistic Nurses Association. Her work in transforming hospitals into "healing environments" has received national, state and local recognition. Lucia can be contacted at
luciat@csufresno.edu.
NSNA IMPRINT | www.nsna.org 39