accomplishments for 2017 sharp mesa vista hospital/sharp

Nursing Report

Accomplishments for 2017

Sharp Mesa Vista Hospital/Sharp McDonald Center

Welcome

Dear Colleagues:

Welcome to Sharp Mesa Vista Hospital and Sharp McDonald Center’s

annual Nursing Report. I am so proud of our nurses! I have seen their

growth and expertise blossom over the years. Our Magnet journey

provides nurses an opportunity to showcase their accomplishments in

working with our vulnerable patient population. Their caring is at the

heart of every story you will read here. I see their excellent care each

and every day — I hope you see it also.

Sincerely,

Cheryl Odell, MSN, RN, NEA-BC

Vice President and Chief Nursing Officer

Sharp Mesa Vista Hospital & Sharp McDonald Center

COVER PHOTO: Teresia Ngeno, RN, BSN, Lead RN, Senior Behavioral Unit

Since the Inaugural Nursing Report…

This annual report recognizes the extraordinary accomplishments of SMV/SMC nurses. It is

again organized by the four components of the Magnet Model: Transformational Leadership,

Structural Empowerment, Exemplary Professional Practice and New Knowledge, Innovations

& Improvements.

Our Journey to Magnet

Caring is in Our Nature is our Magnet theme and we carried it forward this past year.

We submitted our application for Magnet designation in October 2017, and the American

Nurses Credentialing Center (ANCC) Magnet Office has targeted Feb. 1, 2020, as our

document submission date.

Ongoing Hospital Modernization

Several enhancements have been made to our healing environment this past year. New

finishes were added throughout the hospital. East Wing 2 was renovated to include several

safety features and CAP 3, our Child and Adolescent Inpatient Unit, was completely

remodeled. Enhancements to the healing environment included:

• Replaced patient room flooring in ICU; painted corridors and patient rooms; replaced

patient beds; installed wall protection, handrails, and new room signage.

• Replaced flooring in Medical Records/Health Information Management; Intake and exam

rooms; and Admitting and Business Office. As a result, we added two new exam rooms

as well as new furniture in three exam rooms, Admitting, Medical Records/HIM and

Utilization Review/Case Management.

• Refreshed CAP building lobby (new flooring installed and walls painted).

• Upgraded corridor flooring throughout main building.

• Installed new hand gel dispensers and signage directing people to hand dispensers.

• Painted corridors and meeting rooms at our Mid-City outpatient location.

• Updated paint, flooring and furnishings in Adult Intensive Outpatient Program.

• Updated Physician Lounge and staff lounges: paint, flooring and furniture; installed TV

in CAP staff lounge.

• Installed new flooring (corridors and patient room) and painted East Wing 2; replaced

old furniture, signage and artwork.

• Installed two pet relief stations.

• Installed improved room-identifying signage and wayfinding signage throughout facility.

“I just wanted to let you know that I’ve been doing great lately with my

recovery, and I wanted to thank you for all your help last year. Thank

you for teaching me how to be in touch with my mental health, as I am

currently thriving in every way mentally. Thank you so much for helping

kids like me get out of the dark. Keep doing what you are doing.”

— A grateful teenage patient

2WELCOME

Vision. Leadership. Exemplary Outcomes.

Transformational Leadership

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TRANSFORMATIONAL LEADERSHIP 4

Photo: Nicole Raymundo, RN, BSN, Administrative Liaison, Nurse Residency Program Graduate

Transformational Leadership: Vision. Leadership. Exemplary Outcomes.

Transformational leadership starts with a vision and incorporates participative leadership

and management to achieve exemplary outcomes. Nursing leadership, informed by a shared

governance structure, provides an infrastructure for continuous improvement. Various

strategic initiatives build a foundation to support a culture of quality and safety, including

the Sharp HealthCare Center of Nursing Excellence (CONE), which sets the vision for the

nursing enterprise.

Six Sigma/Lean/Change Management Training

Continuously improving processes is a part of everyday life at SMV/SMC. Nursing staff are

trained in Sharp HealthCare’s continuous improvement methods: Lean Six Sigma, Change

Acceleration Process, and Work-Out. Lean Six Sigma is an important part of our ongoing

journey to make Sharp the best place to work, practice medicine and receive care.

White Belts learn Lean Six Sigma awareness, apply basic A3 problem-solving, assist in

the identification of waste, and are active participants in huddles, learning boards and

problem solving.

Yellow Belts provide local assistance for meeting facilitation, group problem solving, and

meeting effectiveness; help instill new tools and techniques across the organization; identify

and complete A3 problem-solving in the workplace; and assist in the identification and

mitigation of waste.

Green Belts oversee project analytics and are leaders in addition to their current job

responsibilities, participate in Six Sigma projects, facilitate rapid improvement events and

5S events, and coach A3 problem-solving.

Nursing staff who have achieved White, Yellow and Green Belts include:

Six Sigma Green Belt (3)

Alisha Carpenter

Naia Gomez-Andrade

Loralie Woods

Six Sigma Yellow Belt (44)

Mary Abbott

Helen Aguilar

Tricia Armfield

Stephanie Ballesta

Stephanie Bautista

Marc Brunton

Danielle Campbell

Rhodora “Odette” Campos

Cathryn Cooper

Laurie Costa

Laura Cunningham

Debra Downes

Nancy Earl

Edrienne “Drin” Fae Yap

Erica Gemgnani

Stephanie Harrington

Brooke Hartsock

James Holt

Joy Ilao

Robin Inkel

Ana Liza Javier

Bozena Kik

Linda Kueltzo

Vanessa Kurzon

Jenna Kwaitkowski

Steve Molina

Teresia Ngeno

Cheryl Odell

Luc R. Pelletier

Kirstin Poliska

Corinne Powell

Jesselyn Quiapo

Fred Quinn

Amy Recker

Kathleen Reinhardt

Gregory Robin

Tim Sanford

5TRANSFORMATIONAL LEADERSHIP

Perry Schoulten

Gretchen Smith

James Sommerville

Maria Sufan

Stephanie Velbis

Chandra Vincent

Esperanza “Maria” Zamora

Six Sigma White Belt (30)

Martha Acosta

Sarah Badilla

Kimberly Bailey

Breanah Bandrowsky

Joshua Barder

Tonya Bell

Patricia Burningham

Michelle Etherington

Lynda Goldberg

Sandra Gray

Susan Hlobik

Rebecca Johnson

Lilah Joy Leon Guerrero

Lauren Levario

Richard Loving

Sharon Maidment

Peter J. Meaden

Ricardo Mera

Jennifer Moreno

Andrea Munoz

Marichu Reed

Kathleen Rhea

Carole Ross

Carmen Sagaste

Mary Kay Shibley

Shadette Soriano

Dulce Soto

Erica Tiscareno

Michael Ulrich

Keith Vargas

Improving Hand Hygiene Results in Lower Infection Rates

SMV/SMC leadership and frontline staff have utilized a multi-modal approach to foster

hand hygiene compliance for all employees for several years. Clinical processes are

standardized and hardwired to ensure best practices are being employed in an effort to

reduce health care-associated infections. Specific interventions implemented to foster hand

hygiene include:

• Utilized The Joint Commission Targeted Solutions Tool for Hand Hygiene

• Implemented hospital-wide training and monthly educational sessions

• Reviewed and clarified the definition of “wash in” and “wash out” for the inpatient

psychiatric setting

• Continued monitoring by observers; enhanced coaching provided; barriers to hand

hygiene solicited and addressed

• Created visual and verbal prompt for cross-monitoring (ID badge guards)

• Shared hand hygiene compliance data on learning boards

Yellow Belts continued:

TRANSFORMATIONAL LEADERSHIP 6

The graph below shows how increased hand hygiene compliance results in lower hospital-

acquired urinary tract infection (UTI) rates.

0.4

0.2

0.3

0.1

0.5

0.7

1

0.9

0.8

0

0.6

QUARTER

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Figure 1: SMV/SMC RN Hand Hygiene Compliance and UTI Rates

Hand Hygiene

FY2016 Q1 FY2016 Q2 FY2016 Q3 FY2016 Q4 FY2017 Q1 FY2017 Q4FY2017 Q2 FY2017 Q3

0.94

0.87

0

0.80

0.26

0.77

0.33

0.79

0.18

0.86

0

0.85

0.08 0.08

0.80

0.18

RN HH COMPLIANCE LINEARINFECTION RATES

Engagement. Lifelong learning. Community.

Structural Empowerment

STRUCTURAL EMPOWERMENT 8

Structural Empowerment: Engagement. Lifelong Learning. Community.

Structural empowerment requires nurse engagement at every level, with a commitment to

lifelong learning. We emphasize the principle of lifelong learning for all nursing staff. Nurses

have an opportunity to lead change efforts and enhance the services we provide — each and

every day.

Nurse Residency Program — A Path to Professional Nursing

Since its inception in 2011, 60 nurses have participated in the Nurse Residency Program

(NRP). The primary goal of the NRP is the recruitment and retention of nurses into the

psychiatric-mental health and addiction nursing specialties. Only 28.7 percent of California

hospitals offer an NRP. 1(p7) An NRP can serve as a recruitment and retention strategy that

lowers overall turnover rates as demonstrated in a study completed this past year. Within

the study period (2010 — 2016), there was a turnover rate of 11.7 percent in year one

(88.3 percent retention) and 2.9 percent in year two (97.1 percent retention), which are lower

than reported turnover rates in the literature (17.5 percent and 33.5 percent, respectively).

Significant correlations were revealed in the workplace domains of knowledge and skills,

social support, organizational citizenship behavior, civility, coping self-efficacy, organizational

and occupational commitment, person-organizational fit, and burnout.

Components of the program include didactic instruction, clinical immersion and competency

validation, looping, mentoring, and debriefing. Respondents to the survey have listed the

greatest source of job satisfaction as:

• “Knowing that you are helping patients get through a difficult time in their lives.”

• “Being part of a patient’s recovery. Working as part of a great team and knowing I

make an important contribution.”

• “Positive, measurable patient outcomes.”

• “Patient improvements in condition; coworkers create a pleasant environment;

teamwork.”

This past year’s graduates of the NRP were Kailyn Anderson (CAP 3), David Lindley (ICU),

and Edrienne “Drin” Fae Yap (EW1).

Over the life of the program, 13 NRP graduates have assumed nursing leadership roles

(Advanced Clinician, Lead, Administrative Liaison).

Photo: Rhodora “Odette” Campos, MSN, RN-BC, Lead RN, Senior Behavioral Unit, 2017 Nurse of the Year

Year — 1 (2017)Year — Baseline (2016)

PE

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59 63

61

40

20

30

10

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70

100

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Figure 2: SMV/SMC RNs with a Bachelor’s or Higher Degree in Nursing

GOAL: 2% ANNUAL INCREASE

Organization RNs with Nursing Degrees

9STRUCTURAL EMPOWERMENT

Raising the Bar: Baccalaureate Preparation

SMV/SMC leadership continues to foster a well-prepared nursing workforce, aligned with

The Future of Nursing: Leading Change, Advancing Health,2 which has identified a goal of

80 percent of the nursing workforce having a BSN or higher degree by 2020. Leadership

has consistently hired more nurses with a baccalaureate degree and have identified a goal

of increasing BSN or higher-prepared nurses by 2 percent annually. Additionally, there are

a significant number of clinical nurses practicing with master’s degrees. All nurse managers

have a baccalaureate degree in nursing.

Currently, 63 percent of the RN workforce at SMV/SMC has a BSN degree or higher. In

2017, only 24.8 percent of hospitals that participated in the 2017 Survey of Nurse Employers

reported having between 51 percent and 75 percent of BSN-prepared RNs on staff.3

In California, 57 percent of nurses are BSN-prepared compared to 51 percent nationally.4

Our number of BSN-prepared RNs is above the state and national rates, and we have

exceeded our goal of increasing the rate by 2 percent annually.


Several of our Mental Health Associates and LVNs are pursuing RN degrees. Currently nine

nursing staff are pursing BSNs and eight clinical RNs are in master’s programs; two are

pursuing doctorates in nursing. SMV/SMC nursing leadership is a founding member of Sharp

HealthCare’s Center of Nursing Excellence (CONE). Established in 2009, CONE provides

structures and processes to address nursing workforce challenges, along with a common

infrastructure for nursing professionals to share best practices and enhance collaboration

across the system. CONE unites Sharp’s contributions to the future of the nursing profession

through a strategic vision — shaping best practices, driving research and grant opportunities,

and influencing legislative efforts to support nursing at a national level — with the ultimate

goal of improving patient care. In 2017, CONE provided three scholarships to SMV/SMC

nursing staff totaling $12,000 to defray the costs of their nursing education.

Recognition of Nursing Excellence

SMV/SMC recognizes the contribution of its exceptional nursing staff through various award

programs. These include Employee of the Month and Year, Nurse and LVN/LPT of the Year,

Great Catch Awards, Nursing Support Staff of the Year, and the Sharp HealthCare Center of

Recognized Excellence (C.O.R.E.) and Pillar Awards.

Employee of the Month

The Employee of the Month program honors employees for service excellence. Nursing staff

who received this award in 2017:

Marichu Reed (CAP 31), Roland Guy (CAP 3), Ryan Harina (ICU), Robert Bayaca (EW1) ,

Helen Rees (EW2)

Employee of the Year

The Employee of the Year is chosen from the Employee of the Month pool. The recipient of

Employee of the Year for 2017 was Roland Guy, MHA (CAP 3).

Exemplary Professional Practice — Clinical Nurse of the Year/LVN-LPT of the Year

Frontline nurses are central to The Sharp Experience and contribute to SMV/SMC’s

innovations and accomplishments. Each year, SMV/SMC honors nurses who demonstrate

outstanding qualities in their chosen area of practice and who show a commitment to the

nursing profession. While all the nurses at Sharp are truly exceptional, a select few exemplify

an above-and-beyond standard of excellence that deserves special recognition. The Nursing

Excellence Awards provide the opportunity to recognize and reward registered nurses for

the special contribution they make to SMV/SMC. Rhodora “Odette” Campos, MSN, RN-BC

(EW1), was recognized as Clinical Nurse of the Year in 2017.

1 CAP3 = Child & Adolescent Program; ICU = Intensive Care Unit; EW1 = East Wing 1; EW2 = East Wing 2; SMC = Sharp McDonald Center; NR = North Rotunda; AL = Administrative Liaison; SBU = Senior Behavioral Unit; SR = South Rotunda; NA = Nursing Administration

The Licensed Vocational Nurse (LVN)-Licensed Psychiatric Technician (LPT) Award provides

the opportunity to recognize and reward an outstanding LVN or LPT in a clinical setting

for the special contribution they make to SMV/SMC. The goal is to honor individuals who

demonstrate outstanding qualities in their area of practice and contributions to patient care.

The recipient of the 2017 LVN-LPT award was Megan Pehl, LVN (ICU).

Great Catch Awards

The Great Catch Award recognizes staff who have intervened to prevent a potentially

harmful event from reaching a patient. Why is this program important? Increased reporting

of Great Catches will help us learn of risks and issues and make improvements to provide

safer care. For example, while preparing to administer medications, an RN questioned why

a patient who had never taken opiates had Suboxone ordered for pain. He continued with a

questioning attitude, reviewed the patient’s history and physical, and called the physician to

clarify the order. The physician confirmed that the order was not intended for this patient.

The lesson learned is to have a questioning attitude when conducting medication rights of

administration, and closed-loop communication for order clarification in order to help catch

errors before they happen. Recipients of Great Catch Awards include:

• Marina Buhle, RN (SR; 2013)

• Brooke Hartsock, BSN, RN (SR; 2013)

• Gretchen Smith, RN-BC (EW2; 2015)

• Christopher Marrazzo, BSN, RN (EW1; 2017)

Nursing Support Staff of the Year

The Nursing Support Staff of the Year Award seeks to recognize nursing support staff who

reflect a positive, professional image by his/her commitment to leadership, collaborative

practice, support of professional growth and excellence in patient care. SMV/SMC award

recipients for 2017 include:

Patient Care — Direct

SMV/EW1 Veronica Silver, MHA

Patient Care — Indirect

SMV/Quality Jennifer Thomas, Data Quality Analyst

Sharp HealthCare C.O.R.E. and Pillar Awards

C.O.R.E. and Pillars of Excellence Awards recognize team members and partners who

exemplify the spirit of The Sharp Experience and produce extraordinary results under one

of Sharp’s seven Pillars of Excellence. Each year, SMV/SMC presents C.O.R.E. Awards to

recognize exemplary team members. All C.O.R.E. Award winners are then considered for

Sharp’s system-wide Pillars of Excellence Awards, which are honored at the annual All-Staff

Assembly. The following is a list of SMV/SMC C.O.R.E. and Pillar Award recipients (RN and

other nursing staff names are italicized). Awards with an asterisk also won the Pillar award.



2017 C.O.R.E. and Pillar Awards

Adolescent Partial Hospitalization Program (Safety — Team)

Jennifer Wojciechowski, Alison Wilbanks, Alisha Carpenter, Roland Guy, Jennifer McWaters,

Kimberly Thornton, Stephanie Lord, William Wright, Garrett Work, Dianna Fischer

Amanda Gastelum Munoz* (People — Individual)

Denials and Appeals Team (Finance — Team)

Kari Cornicelli, Christiana Paul, Scott Carruthers, Jennifer Ward, Angela McKinney, Stacie

Elamparo, Penny Peterson, Jodi Carlton, Martha Acosta, Aileen Carr, Mildred York, Suzanne

Sorrells, Chanon Chenowth, Julia Monell, Allen Lee, Elaine Coney

COG/DBT Intensive Outpatient Programs (Community — Team)

Christina Huang, Rafael Reyes, Joseph Gannon, Jacqueline Noonan, Safa Rashid, Kristin

Whitaker, Abby Griesbach, Alexandra Mazzulo, Amber Salvador, Romi Mouhibian, Angelica

Waring, Colleen Auth, Suhair Erikat, Anna Morgan, Laura Thackray, Julie Braatz, Jonna

Ferma, Suzanne Whittemore, Terra Schmookler, Karl Pongyingpis, Raymond Fideleo

San Diego Evidence-Based Practice Institute (EBPI)

Sharp HealthCare participates in the San Diego Evidence-Based Practice Institute (EBPI),

which prepares teams of staff fellows (interprofessional staff) and mentors to change and

improve clinical practice and patient care. This evolution in practice and care occurs through

identifying a care problem, developing a plan to solve it and then incorporating this new

knowledge into practice. EBPI is part of the Consortium for Nursing Excellence, San Diego,

which promotes evidence-based practice in the nursing community. The consortium is a

partnership between Sharp HealthCare; Scripps Health; Palomar Health; Rady Children’s

Hospital-San Diego; University of California, San Diego Health System; U.S. Department of

Veterans Affairs (VA) San Diego Healthcare System; Elizabeth Hospice; Point Loma Nazarene

University; San Diego State University; Azusa Pacific University; and the University of San

Diego Hahn School of Nursing and Health Science.

Sharp HealthCare actively supports the EBPI by providing instructors and mentors as well as

administrative coordination. The San Diego EBPI includes six full-day class sessions featuring

group activities, self-directed learning programs outside of the classroom and structured

mentorship throughout the program. The EBPI fellows partner with their mentors and

participate in a variety of learning strategies. Mentors facilitate the process of conducting an

evidence-based practice change and navigating the hospital system to support the fellows

through the process of evidence-based practice. Mentors also assist the fellows in working

collaboratively with other key hospital leadership personnel.

*Awardee also won Pillar Award

The nine-month program culminates with a community conference and graduation

ceremony in November, during which the project results of all EBPI fellows are shared.

In 2017, the following nursing staff participated in the program:

MENTEE MENTOR PROJECT

Marta Michalowska, RN, ICU Mary Kay Shibley, MSN, RNWall Art in Psychiatric Intensive

Care Unit

Kathleen Reinhardt, RN, EW1 Loralie Woods, MSN, RN-BCImproving Throughput by

Implementing a Discharge RN

Providing a Learning Space and Service in the Community — Adjunct Faculty

In FY2017, nearly 400 nursing students worked clinical rotations of six- to eight-hour

shifts in all inpatient units and several of the outpatient programs at SMV and SMC. SMV

offers two clinical rotations in one day, including morning and evening shifts, and nursing

students are on campus seven days a week. Including time spent with groups and individual

preceptors, nursing students served nearly 30,000 hours at SMV in FY2017. Academic

institution partners included, but were not limited to, Azusa Pacific University, California

State University San Marcos, National University, Point Loma Nazarene University, San Diego

City College, San Diego State University, Southwestern College, and University of San Diego

Hahn School of Nursing and Health Science.5

Our professional nurses serve in the community as adjunct faculty at various health

professions schools. Their impact on future health care professionals is critical to ensuring a

vibrant workforce. A recent quote from a nursing student exemplifies these nurses’ influence

on the next generation of professional nurses:

Regardless of their status, the nurses demonstrated an unparalleled respect for

the patients; their rights, wishes and feelings; and all nurses were a credit to the

profession. Rarely have I seen these characteristics demonstrated to such a degree.

— Student Nurse, University of San Diego, May 2017

Adjunct Faculty: 13 nursing staff serve

as adjunct faculty at 10 colleges,

universities and professional schools


STRUCTURAL EMPOWERMENT

Adjunct Faculty Appointments

Azusa Pacific University

Nancy Earl, Lead RN

Living Works

Kris Lambert, Senior Specialist, Nursing

Loma Linda University

Janet Donnelly, Clinical RN

Point Loma Nazarene University

Kris Lambert, Senior Specialist, Nursing

Kathleen Rhea, Clinical RN

SDSU

Sharon B. De Peralta, Clinical RN

Jay Villaflores, Clinical RN

Suastha Yoga Academy

Chris Marrazzo, Clinical RN

University of San Diego Hahn School of

Nursing and Health Science

Nancy Earl, Lead RN

Luc R. Pelletier, Senior Specialist, Nursing

University of California, San Diego

Sharon B. De Peralta, Clinical RN

U.S. Navy Independent Duty Corps School

Joe Lacanienta, Administrative Liaison

Vinyasa Krama School of Yoga

Chris Marrazzo, Clinical RN

Crisis Prevention Institute (CPI) Training and Crisis Management

SMV/SMC staff employ nonviolent crisis-intervention principles and practices that prioritize

care, welfare, safety and security. Staff are training initially upon employment and annually

by certified instructors. This training builds confidence and competence, and staff

demonstrate improved capabilities in preventing or reducing risks.6 Several nursing staff are

trainers for CPI, the crisis management program used at SMV/SMC. They include:

Jonathan Cartford, MHA (EW2)

Brian Donald, BSN, RN, CEN (ICU)

Naia Gomez-Andrade, MSN, RN (Outpatient, SMC)

Rene Gonzales, MHA (CAP3)

Kris Lambert, Ph.D., RN (NA)

Amanda Gastelum Munoz, MSN, RN-BC, CNL (NA)

Jacob Pfister, RN (Intake)

Chandra Vincent, MSN, RN (NA)

SMV/SMC Honors its Certified Nurses

SMV/SMC values professional board certification of nurses in specialty areas. The Sharp

HealthCare Center of Nursing Excellence partners with the ANCC to implement an efficient

pathway to certification, which reduces test-taking anxiety and eliminates financial barriers

through the Success Pays Program™. Each year, the Sharp Metropolitan Medical Campus

holds a celebration of our certified nurses. Nurses are recognized and receive a certification

coat to wear proudly.

14

This past year, clinical nursing staff offered a board certification preparation course.

This program included evidence-based components and was taught by SMV/SMC nurses.

Several staff attended the course, covering the following topics: neuroanatomy/physiology,

high-risk behaviors, milieu therapy, crisis concepts and interventions, pharmacology and

integrative therapies, communication, and test-taking and practice questions. In 2017,

48 nurses held board certification in 14 nursing and health care specialties (several nurses

had more than one certification).

We congratulate our nurses for achieving and maintaining board certification. The following

list includes SMV/SMC nursing staff certified in various nursing, education and other health

care specialties.

Adult Clinical Nurse Specialist

(ANCC; ACNS-BC)

Janet Donnelly

Adult Psychiatric-Mental Health Clinical

Nurse Specialist (ANCC; PMHCNS-BC)

Keynan Hobbs

Luc R. Pelletier

Patricia Rodgers

Certified Addictions Registered Nurse

(IntNSA; CARN)

Sandra Gray

Linda Kueltzo

Lilah Joy Leon Guerrero

Matt Lockart

Certified Critical Care Nurse

(AACN; CCRN)

Mary Abbott

Certified Emergency Nurse

(BCEN; CEN)

Brian Donald

Certified Medical-Surgical Registered

Nurse (AMSN; CMRN)

Bozena Kik

Certified Professional in Healthcare

Quality (HQCC)

Sharon De Peralta

Luc R. Pelletier

Clinical Nurse Leader (AACN)

Amanda Gastelum Munoz

Certified Case Manager (CCMC)

Penny Peterson

Family Nurse Practitioner (AANP)

Kelly Mullins

Nurse Executive (ANCC; NE-BC)

Bozena Kik

Nurse Executive — Advanced

(ANCC: NEA-BC)

Cheryl Odell

Nursing Professional Development

(ANCC; RN-BC)

Janet Donnelly

Amanda Gastelum Munoz

Loralie Woods

Psychiatric-Mental Health Nursing

(ANCC: RN-BC)

Helen Aguilar

Sarah Badilla

Donis Baquirquir

Marc Brunton

Rhodora “Odette” Campos

Carlos Cisneros

Debra Downes

Nancy Earl

Nicole Entenza

Kenneth Fernandez

Rebecca Suzanne Johnson

Olivia Kearnes


STRUCTURAL EMPOWERMENT

Psychiatric-Mental Health Nursing

(ANCC: RN-BC) Continued

Dawn Kochel

Joe Lacanienta

Matt Lockart

Maria Dulce Mariano

Ricardo Mera

Steven Molina

Cristin Peacock-Coleman

Corinne Powell

Fred Quinn

Judy Reagan

Amy Recker

Justin Sabol

Gretchen Smith

Shadette Soriano

Carmen Sugaste

Tom Warmuth

Susan K. Williams

Peggy Wilson

Rachel Suh Yang

Marie Zamora

16

Professional Certification: 48 nursing

staff are certified in 14 nursing and health

care specialties

Engagement in Professional AssociationsEngagement in professional nursing organizations advances the profession. Many of our

nurses are active in their specialty nursing organizations and contribute to making health

care better for all Americans by influencing policy and practice standards. Some have even

held elected office in these prestigious groups. Belonging to a professional association is a

venue for professional practice and excellence, health care and public policy, knowledge and

research, unification, and workforce and workplace advocacy.7 Below is a list of SMV/SMC

nurses and their professional organization affiliations.

Alpha Tau Delta

Stephanie V. Ballesta

Academy of Integrative Health & Medicine

Jennifer Francis

American Academy of Nursing

Luc R. Pelletier

American Association of Critical Care

Nurses

Janet Donnelly

American Association of Nurse

Practitioners

Kelly Mullins

American Holistic Nurses Association

Kris Lambert

American Nurses Association

Sarah H. Badilla

Odette Campos

Naia Gomez-Andrade

Erin Hansen

Olivia Kearnes

Petra Klee

Vanessa Kurzon

Kris Lambert

Jacqueline Linehan

Abby Nauman

Luc R. Pelletier

Jesselyn Quiapo

Kathleen Reinhardt

Leila Riches

Shadette Soriano

Joyce Wei

Loralie Woods

American Psychiatric Nurses Association

Marc Brunton

Patricia L. Burningham

Odette Campos

Daniel M. Casale

Laurie Costa

Sharon B. De Peralta

Debi Downes

Nancy Earl

Erica Gemgnani

Naia Gomez-Andrade

Bozena Kik

Vanessa Kurzon

Kris Lambert

Richard Loving

Luc R. Pelletier

Cheryl Odell

Cristin Peacock-Coleman

Kathleen Reinhardt

Leila Riches

Madeleine Thompson

Loralie Woods


Association of California Nurse Leaders

Debi Downes

Bozena Kik

Cheryl Odell

Naia Gomez-Andrade

Kathleen Reinhardt

Mary Kay Shibley

Loralie Woods

International Association of Forensic Nurses

Steve Molina

International Nurses Association

Hannah Biernacki

Kripalu School of Ayurveda

Chris Marrazzo

National Alliance on Mental Illness

Justin Sabol

National Association of Clinical Nurse

Specialists

Janet Donnelly

National Association for Healthcare Quality


Luc R. Pelletier

National Black Nurses Association

Donny Brown

National Coalition Against Domestic

Violence

Kris Lambert

Philippine Nurses Association

Theresa Dacuycuy

Sigma Theta Tau International

Laurie Costa


Cristina Diocson

Nancy Earl

Bozena Kik

Joe Lacanienta

Kris Lambert

Jacqueline Linehan

Cheryl Odell

Shadette Soriano

Loralie Woods

Rachel Yang

University of Santo Tomas Nurses

Association International

Evelyn B. Cuevas

Western Institute of Nursing Research

Kris Lambert

Yoga Alliance

Chris Marrazzo



Community Volunteer Service

Community service is an important part of the professional nursing role. In FY2017,

SMV/SMC contributed more than $18 million in programs and services to improve the health

and well-being of the San Diego community. This included $16.8 million in unreimbursed

medical care services through the dedication of SMV and SMC team members to community

service activities, examples of which are listed below.

USO 4th Tuesday Dinner

Kris Lambert

Penny Peterson

Alzheimer’s San Diego Memory Screenings

Tonya Bell

American Foundation for Suicide

Prevention

Kris Lambert

California State University, San Marcos

Free Clinic

Cynthia Chesy

Check Your Mood Depression Screening


Date with a Cure

Tonya Bell

Linda Vista Cultural Fair

Kris Lambert

Miracle Babies Gala

Mary Kay Shibley

National Alliance on Mental Illness (NAMI)

Debi Downes

Kris Lambert

Operation Amped

Keynan Hobbs

Roll for Puerto Rico

Naia Gomez-Andrade

Sharp Lends a Hand (Coastal Habitat

Restoration, Doors of Change, Feeding San

Diego, Habitat for Humanity, I Love a Clean

San Diego, Life Rolls On, San Diego Food

Bank, Special Olympics, Ssubi Foundation

Greening for Good, Stand Down, Veterans

Village of San Diego, and Wreaths Across

America, etc.)

Martha Acosta

Maria A-Spears

Tonya Bell

Marc Brunton

Cynthia Chesy

Carlos Cisneros

Sandy Gray

Naia Gomez-Andrade

Carole Hayworth

Petra Klee

Jenna Kwaitkowski

Penny Peterson


Survivors of Suicide Loss

Kris Lambert

Engagement in Professional Associations:

73 nursing staff are involved with

22 professional associations

Philanthropy — Giving at Sharp HealthCare

Thousands of Sharp employees support foundations and initiatives at Sharp HealthCare

through charitable gifts, and together, employees system-wide donate more than $1 million

a year. Employees choose from over 30 funds to help build facilities, fund innovative

programs and equip expert caregivers with technology that saves lives. We are grateful to

the following staff members for their generous financial support in 2017 on our journey to

transform the health care experience:

Sara A. Ackerman

Helen Aguilar

Naia Andrade-Gomez

Francisco Calinisan

Debra Columb

JohnPaul Conly

Benjamin Contreras

Susana S. Corpuz

Shirley Felicien

Bernita Florentino

Gerald Heath

Keynan Hobbs

Rebecca S. Johnson

Vanessa Kurzon

Richard Loving

Cheryl Odell

Luc R. Pelletier

Jessalyn N. Quiapo

Irais S. Stricklin

Catherine Trager-Dobbs

Loralie Woods


Collaboration. Accountability. Autonomy.

Exemplary Professional Practice

EXEMPLARY PROFESSIONAL PRACTICE 21

Exemplary Professional Practice: Collaboration. Accountability. Autonomy.

Our Professional Practice Model (PPM), developed by frontline nurses, is the framework

used to envision and provide nursing care. The SMV/SMC PPM serves as a framework for all

nursing activities and forms the basis of our pursuits of innovation in nursing science. Sharp

HealthCare’s nursing vision is “Transforming lives through caring, innovation and leadership.”

We are guided by the Sharp HealthCare seven Pillars of Excellence: Quality, Safety, Service,

People, Finance, Growth and Community. SMV/SMC’s PPM includes five components:

Professional Nursing Values, Professional Relationships, Leadership Approach, Care Delivery

System, and Reward and Recognition. Our care delivery system (circle in graphic below)

envisions patient- and family-centered care that is relationship-based, trauma-informed and

recovery-focused.

The foundation of our nursing practice at SMV/SMC includes the Magnet Recognition

Program components of Transformational Leadership, Structural Empowerment, Exemplary

Professional Practice, and New Knowledge, Innovations & Improvement; a shared

governance structure; core values of The Sharp Experience: Integrity, Caring, Innovation,

Safety and Excellence; and our professional nursing scope of standards and practice. The

PPM is depicted below.

Professional Practice Model — Sharp Mesa Vista Hospital — Sharp McDonald Center

Vision

Transforming Lives ThroughCaring, Innovation and Leadership

Quality Safety Service People CommunityGrowthFinance

Magnet Recognition Program:

Transformational Leadership, Structural Empowerment, Exemplary Professional Practice, New Knowledge, Innovations & Improvement

Shared Governance

The Sharp Experience: Integrity, Caring, Innovation, Safety, Excellence

Professional Nursing Scope and Standards of Practice

Relationship-Based Care

Trauma-Informed

Recovery-Focused

Nurses

Community

He

alt

hcare

Team

Pat

ient-

and Family-Centered Care

Patient& Family

Photo: Laura Thill, BSN, RN, Advanced Clinician, ICU

RN Engagement Survey

In 2017, RN engagement was measured through the annual employee engagement survey

administered by Press Ganey. SMV/SMC nursing leadership believes that engaged nurses

are central to effective, efficient, caregiving teams. By capturing the voice of nurses, our

organization can better understand the unique concerns of nurses, build a patient-centered

culture that reduces stress for caregivers, and support strategies to attract and retain valued

nurses.8 The survey is a multi-dimensional view of nurse engagement and provides nursing

leadership with data on strengths and opportunities for improvement. Six out of seven scores

were above the national mean compared to other comparable hospitals (national benchmark;

see below).

SURVEY DOMAINS

RN Engagement

Figure 3: SMV/SMC 2017 RN Engagement Survey Results

Fundamenta

ls

of Qualit

y

Nursin

g Care

Inte

r-

profe

ssio

nal

Relatio

nship

s

Leadership

Access

and

Responsi

veness

Profe

ssio

nal

Developm

ent

Adequacy

of Reso

urces

Autonom

y

RN-t

o-RN

Teamw

ork a

nd

Collabora

tion

ME

AN

4.02

3.41

4.09

3.86

4.21

3.96

4.37

4.07

3.69

3.754.08

3.85

4.37

4.08

NATIONAL BENCHMARK MEANSMV/SMC MEAN

2

1

6

5

4

0

3

22EXEMPLARY PROFESSIONAL PRACTICE


External Recognition for Exemplary Professional Practice

SMV/SMC has received recognition from external organizations acknowledging various

aspects of our care and services

2017 Association of California Nurse Leaders — San Diego Chapter Poster Award

SMV’s poster entry,“Increasing Board Certification Using Frontline Nurse-Driven Review

Courses,” won the 2017 ACNL Innovations Conference: Professional Advancement of the

Frontline Caregiver Poster Award. Congratulations to Odette Campos, MSN, RN-BC; Amanda

Gastelum Munoz, MSN, RN-BC, CNL; Gretchen Mansch, BSN, MEd, RN; Kathleen Reinhardt,

RN; and Peggy Wilson, BSN, MEA, RN-BC.

American Psychiatric Nurses Association 31st Annual Conference Poster Award

SMV won first prize in the Education category for “Increasing Board Certification Using

Frontline Nurse-Driven Review Courses.” Congratulations to Odette Campos, MSN, RN-BC;

Amanda Gastelum Munoz, MSN, RN-BC, CNL; Gretchen Mansch, BSN, MEd, RN; Kathleen

Reinhardt, RN; and Peggy Wilson, BSN, MEA, RN-BC.

2017 Sharp HealthCare Interprofessional Research & Innovations Conference Poster Award

SMV received a Professional Advancement of the Frontline Caregiver Poster Award

for “Increasing Board Certification Using Frontline Nurse-Driven Review Courses.”

Congratulations again to Odette Campos, MSN, RN-BC; Amanda Gastelum Munoz, MSN,

RN-BC, CNL; Gretchen Mansch, BSN, MEd, RN; Kathleen Reinhardt, RN; and Peggy Wilson,

BSN, MEA, RN-BC.

Seclusion and Restraint Reduction

SMV/SMC continues to implement strategic interventions to reduce the use of physical and

mechanical restraint and seclusion. These interventions include:

• Ongoing training in crisis prevention and management

• Monitoring and trending of restraint and seclusion data

• Implementation of an assault risk assessment (Brøset Violence Checklist) into the clinical

nursing workflow

• Patient and staff debriefing

• Sharing seclusion and restraint rates on learning boards

• Updated CPI instruction to include a new decision-making matrix to assist staff in

selecting the type of intervention to be used

Figure 4: SMV Restraint Rates Compared to CA and National Rates

CY 2013 CY 2014 CY 2015

RA

TE

PE

R 1

,00

0 P

AT

IEN

TS

CALENDAR YEAR

0.03

0.66

0.58

0.68

0.44

0.55

0.03

0.38

0.03

0.09

0.42

0.3

0.2

0.1

0.8

0.7

0.6

0

0.5

0.4

CA NATIONALSMV

SMV Restraint Rates

CY 2016

The following graph shows comparisons between SMV and California and national rates for

available reporting years.


EXEMPLARY PROFESSIONAL PRACTICE 25

Satisfaction with Nursing Services Remains High

Patients rate their satisfaction with nursing services as measured regularly through the Press

Ganey survey. These surveys are reviewed by managers and frontline staff, and the results

inform the enhancement and continuous improvement of our programs. When compared to

other freestanding psychiatric hospitals, SMV rates higher in all nursing-sensitive items.

SATISFACTION SURVEY ITEM

Patient Satisfaction

Figure 5: FY2017 SMV Patient Satisfaction Compared to National Benchmark

Friendlin

ess/

court

esyNurs

es’

intr

oduction

to u

nit Nurses’

prom

pt

resp

onse Nurses’

info

re: t

x

progra

mOvera

ll

nursin

gNurs

es’

info

re:

medic

ation

Helpfu

lness

of the n

urses

ME

AN

91

87

93

90 90

86

90

85

89

84

91

86

93

89

88

80

82

84

86

96

94

92

78

90

PSYCHIATRIC FREESTANDING HOSPITAL MEAN SMV MEAN

High Rankings in Hospital-Based Behavioral Inpatient Psychiatric Services Core Measures

SMV/SMC continues to report Hospital-Based Behavioral Inpatient Psychiatric Services

(HBIPS) core measures. HBIPS is a major leadership effort to improve quality, safety and

performance. Management staff have worked collaboratively with frontline staff to ensure

that systems and infrastructure support compliance with these evidence-based core quality

measures. Nurse-sensitive core measures include seclusion and restraint (HBIPS-2 and

HBIPS-3) and tobacco cessation. Our restraint reduction performance was described above.

Figure 6: HBIPS Tobacco Cessation Measures Compared to State and Benchmark — CY2017

TOB-1 TOB-2

PE

RC

EN

T

HBIPS TOBACCO MEASURES

99.799.3 98.1

86.3

88.9

70

50

40

20

10

30

100

90

80

0

70

60

CA NATIONALSMV

TOB-2a

41

82.2

27.1

HBIPS Tobacco Cessation Measures


In regards to the tobacco cessation measures, although smoking in general has decreased

in the past few years, smoking rates among patients with mental health issues continues to

be high. For those with phobias and fears, 34.3 percent smoke; 88 percent of patients with

schizophrenia smoke. This is compared to 18.3 percent of people without a mental illness

who smoke. At SMV, the percent of patients admitted who smoke remained about the

same from 2016 to 2017 (18.0 percent and 17.9 percent, respectively). At SMC, there was a

significant decrease in smoking rate; 16.8 percent in 2016 compared to 9.1 percent in 2017.

CY 2016 CY 2017

SMV SMC SMV SMC

Total Admits 9,912 333 9,015 330

Current Everyday or

Same-Day Smoker1,780 56 1,618 30

Current Everyday or

Same-Day Smoker Rate

18.0

percent

16.8

percent

17.9

percent

9.1

percent

Table 2: SMV/SMC total admits, current everyday or same-day smoker numbers and rates

Tobacco cessation measures include TOB-1: Tobacco Use Screening, and TOB-2: Tobacco

Use Treatment Provided and Offered, and TOB-2a: Tobacco Use Treatment. SMV is above

the state and benchmark targets on these measures. Frontline staff and managers continue

to ensure that structures and processes are in place to provide evidence-based care to

persons who smoke.

Innovation. Evidence. Teamwork.

New Knowledge, Innovations& Improvements

NEW KNOWLEDGE, INNOVATIONS & IMPROVEMENTS 28

New Knowledge, Innovations and Improvements: Innovation. Evidence. Teamwork.

To date, SMV/SMC has completed two Institutional Review Board-approved research

studies and initiated a new study to advance nursing science in psychiatric-mental health

and addictions nursing. In addition, clinical and administrative nurses have managed and

participated in various evidence-based and performance-improvement projects.

The Effectiveness of a Psychiatric-Mental Health Nurse Residency Program on

Retention (Completed)

This study asked the question: What is the effectiveness of a Nurse Residency Program

(NRP) in retaining new graduate nurses in a psychiatric-mental health setting? The Nurse

Residency Program provides new graduate nurses with social support and experiential

activities as a formal transition to clinical practice.

The researchers conducted a quantitative time-sequenced comparative study of multiple

cohorts of nurses hired into an NRP. The study yielded a turnover rate of 11.7 percent in

year one (88.3 percent retention) and 2.9 percent in year two (97.1 percent retention rate),

which are lower than turnover rates reported in the literature (17.5 percent and 33.5 percent,

respectively). Significant correlations were described in the workplace domains of knowledge

and skills, social support, organizational citizenship behavior, civility, coping self-efficacy,

organizational and occupational commitment, person-organizational fit, and burnout.

The researchers concluded that NRPs are effective in attracting and retaining competent,

confident new graduate nurses in psychiatric-mental health nursing. All of the respondents

were satisfied with their job and believed that the NRP offered a welcoming environment. A

research article based on this study has been accepted for publication in a future issue of the

Journal of the American Psychiatric Nurses Association.

Psychometric Testing of a Survey to Measure Patient Engagement in Hospitalized

Patients (Ongoing)

This study, initiated in 2017, is a collaboration between SMV and Sharp Memorial Hospital

nurse researchers. The study is being conducted to determine the psychometric properties

of a patient engagement survey for hospitalized patients. There are a limited number

of surveys in the public domain for measuring patient empowerment, engagement and

activation. In 2017, a survey was developed and tested at all seven Sharp HealthCare system

hospitals. Data from these surveys were analyzed and an updated survey will be tested in

early 2018.

Photo: Amanda Gastelum Munoz, MSN, RN-BC, CNL, Senior Specialist, Nursing

29NEW KNOWLEDGE, INNOVATIONS & IMPROVEMENTS

An Exploratory, Descriptive Study of Nurse Leaders’ Personal and Work Experiences During

Union Negotiations and Strike Events (Completed)

This study was a collaboration between SMV and Sharp Memorial Hospital nurse

researchers. There is little in nursing literature about nursing unions and their impact on

patient outcomes, nursing leadership, Magnet designation, overall job satisfaction and

retention, or other such variables. In a review of the literature, fewer than five articles were

published in peer-reviewed nursing or health care journals.

Other than anecdotal stories shared during union negotiations and strike preparations, we

know very little about how such events affect the personal and professional experiences

of nurse leaders. This research was significant because of the dearth of evidence-based

information in the nursing literature. The findings indicated that nurse leaders experience

a range of emotional states in response to union activities, with perceptions of increased

workload, job stress and constrained and deliberate communications with their staff. This

study adds to the body of knowledge about nurse leader experiences and feelings during

union activities.

Findings will help executive leaders in anticipating nurse leaders’ professional and personal

responses to union activities and in planning organizational strategies for future union

negations and strike preparations to neutralize the effect on providers, patients and families,

and the organization as a whole. The study has been accepted for publication in a 2019 issue

of the Journal of Nursing Administration.

New Knowledge and Innovation Council

To support research and evidence-based practice through research projects and activities

at SMV/SMC, a New Knowledge and Innovation Council was initiated in 2017. Participants

learn how to translate research, improve clinical research, facilitate podium and poster

presentations, develop evidence-based procedures and provide feedback on proposed

projects. The group meets monthly and is led by Richard Loving, DNS.

Leading New Knowledge — Presentations and Publications

SMV/SMC nurses disseminated new knowledge and innovations through presentations and

publications to internal and external audiences. Author names in bolded type are nurses at

SMV/SMC.

Internal presentations — Poster

Campos, O., Mansch, G., Gastelum Munoz, A., Reinhardt, K., & Wilson, P. Increasing board

certification using frontline nurse-driven review courses. 3rd Annual Sharp HealthCare

Interprofessional Research & Innovations Conference, June 2017.

Donnelly, J. and Geany, K. Greening for good: A collaborative community-based project.

Sharp HealthCare Research and Innovation Conference, June 2017.

Internal presentations — Podium

Donnelly, J. and Geany, K. Greening for good: A collaborative community-based project.

Sharp HealthCare Research and Innovation Conference, June 2017.

External presentations — Poster


certification using frontline nurse-driven review courses. Association of California Nurse

Leaders-San Diego Chapter, 2017 Innovations Conference, March 2017.


certification using frontline nurse-driven courses. American Psychiatric Nurses Association

31st Annual Conference, Phoenix, AZ, October 2017.

Reinhardt, K. Improving throughput by implementing a discharge RN. San Diego EBPI Annual

Conference, Point Loma Nazarene University, Nov. 7, 2017.

Zamora, E. Health literacy: Development of inpatient education packet utilizing readability

statistics and materials-assessment tools to increase usability. APNA 31st Annual National

Conference, Phoenix, AZ, Oct. 20, 2017.

External presentations — Podium

Lambert, K. Coming alongside: Crisis prevention in the acute care setting. Professional

Development Workshop for Sharp Mary Birch Hospital for Women & Newborns,

September 2017.

Woods, L. and Kurzon, V. What is the secret? Open the medical record. American Psychiatric

Nurses Association 31st Annual Conference, Phoenix, AZ, October 2017.

Publications

Pelletier, L.R. (2017). Quality and safety. In D. Huber, Leadership and nursing care

management. Atlanta, GA: Elsevier.

Pelletier, L.R., and Beaudin, C.L. (Eds). (2017). HQ Solutions: Resource for the healthcare

quality professional. Alphen aan den Rijn, The Netherlands: Wolters-Kluwer.


2017 Knowledge Sharing: 7 Poster

Presentations, 3 Podium Presentations,

2 Publications

NEW KNOWLEDGE, INNOVATIONS & IMPROVEMENTS31

Innovations in Health Information Technology and their Benefits

Health information technology (IT) has an important role in helping nurses work more

efficiently and safer. Over the past few years, SMV/SMC has implemented various hospital-

wide initiatives that serve to enhance the quality of care and safety through the use of IT.

These included:

• Barcoding and VitalsLink: These technologies were implemented at Sharp McDonald

Center in 2017. In an effort to minimize medication errors, barcoding was implemented.

In January 2018, 99 percent of medications were scanned at SMC. VitalsLink was

implemented to reduce the process steps in taking and recording vital signs.

• SurgiNet: This Cerner application was implemented in the SMV Electroconvulsive

Therapy (ECT) Department. The application ensures increased patient safety by allowing

allergies, infection prevention information and medical history to be easily accessible

throughout the ECT procedure. It also provides automated methods of capturing vital

signs and touch screens that allow for easier data capture and conformation.

Photo (from left): Christina Devoe, RN (Intake), Jonathan Brininger, RN (EW 1), and Jennifer Jones, RN (EW 2)


Acknowledgements

Our sincere thanks to all who contributed to this report.

Angela Behnke

Jennifer Chapman

Jessica Crawford

Connie Duquette

Karen Flowers

Steven George

Rachel Gold

Ameen Koucheki

Richard Loving

Emilia Macias

Luc R. Pelletier

Tiana Powell

Beth Redman

Stacey Robinson

Mary Kay Shibley

Thomas Snyder

Tyrone Thomas

Chris Tomac

Chandra Vincent

Marisol Vizcarra

Kristine White

1Chu, L., Spetz, J., & Bates, T. (2018). Survey of nurse employers in California, Fall 2017. San Francisco: Philip R. Lee Institute for Health Policy Studies & Healthforce Center at UCSF. Online at https://rnworkforce.ucsf.edu/sites/rnworkforce.ucsf.edu/files/2017_Moore_Report_Final.pdf

2Institute of Medicine (IOM). (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press.

3Chu, L., Spetz, J., & Bates, T. (2018). Survey of nurse employers in California, Fall 2017. San Francisco: Philip R. Lee Institute for Health Policy Studies & Healthforce Center at UCSF. Online at https://rnworkforce.ucsf.edu/sites/rnworkforce.ucsf.edu/files/2017_Moore_Report_Final.pdf

4Berg, J. (2018). Personal communication (HealthImpact). April 9, 2018.

5Sharp HealthCare. (2018). Sharp HealthCare community benefit plan and report, fiscal year 2017. Retrieved from https://www.sharp.com/about/community/community-benefits/upload/Community-Benefits-Report-2017.pdf

6CPI. (2015). Instructor guide: Nonviolent crisis intervention foundation course. Milwaukee, WI: Author.

7American Nurses Association. (n.d.). The importance of belonging to your professional nursing associations. Retrieved from http://www.nursingworld.org/EspeciallyForYou/Educators/Educator-Tools/TheImportanceofBelonging.ppt

8Press Ganey. (2016). Nurse engagement. Retrieved from http://www.pressganey.com/solutions/engagement/nursing

9Indiana Prevention Resource Center. (n.d.). Tobacco dependence and treatment for smokers with co-occurring mental illness. Retrieved from http://desalledesigns.com/cdesalle/Tobacco1/development/index.html

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