Nurse. Cultural Care Concepts Getting to Know Wyoming Patients. NEW Summer Hours begin May 30th, 7:30am until 4:30pm. Check us out!

Vol. 13 Nurse Number 2 Summer 2017 R E P O R T E R Wyoming NEW Summer Hours begin May 30th, 7:30am until 4:30pm Check us out! Facebook: Wyoming State Board of Nursing Twitter: @WYNursing Cultural Care Concepts Getting to Know Wyoming Patients Official Publication Wyoming State Board of Nursing

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Wyoming Nurse Summer 2017 Vol. 13 Number 2 R Published by the Wyoming State Board of Nursing (WSBN) 130 Hobbs Ave., Suite B T a b l e o f C o n t e n t s Cheyenne, Wyoming 82002 Phone: 307-777-7601 Fax: 307-777-3519 Web Address: http://nursing.state.wy.us 4 Executive Director s Message Serving and safeguarding the people of Wyoming through the regulation of nursing education and practice E P O R T E R Mission: To serve and safeguard the people of Wyoming through the regulation of nursing education and practice. Vision Statement: Acknowledging the dynamic nature of healthcare, provides the climate, collaboration and regulatory framework for nurses to practice to the fullest extent of their scope. Values: Excellence, Ethics, Education, Safety and Competence. Board members with term dates Board President: Donna Nurss, MS, APRN, PMHNP-BC term exp: 2/28/2018 Vice President: Marjory Christiansen, MSN, RN, CEN term exp: 2/28/2018 Secretary: Charlotte Mather, MBA, RN, FACHE term exp: 2/28/2019 Member: Helen Byrd, BSN, RN term exp: 2/28/2019 Member: Susan Howard, MSN, RN-BC term exp: 02/28/2020 Member: Kathy Cromer, LPN term exp: 2/28/2020 Public Member: Stephen Delger term exp: 2/28/2019 6 What Will the Enhanced NLC (enlc) Mean for Nurses? 8 Welcome New Grads! 10 What Wyoming APRNs Need to Know about Scope of Practice 12 Getting to Know You 14 The Role of Self-Assessment in Achieving Cultural Competence 16 Education Corner 17 Call for Articles 17 Nurses Poem 18 YOU ASK WE ANSWER 20 Disciplinary Actions 20 Licensure Statistics 21 Board Talk pcipublishing.com Created by Publishing Concepts, Inc. David Brown, President dbrown@pcipublishing.com For Advertising info contact Victor Horne 1-800-561-4686 ext. 114 vhorne@pcipublishing.com ThinkNurse.com EDITION 49 22 WSBN Latest News and Current Events 23 The Care You Deserve Wyoming Nurse Reporter 3

reetings From Cynthia LaBonde, MN, RN Executive Director Compact Licensure Update CONGRATULATIONS! Graduation season is upon us! Our new nursing graduates will be taking the national nursing exam (NCLEX) and starting in new positions as graduate nurses a bit overwhelming! WSBN is here to assist with your questions on licensing, practice, discipline and education. WSBN staff and Board members wish all new nursing graduates peace, harmony and success in your future nursing careers! Update: NURSE LICENSURE COMPACTs! You may remember the enhanced Nurse Licensure Compact (enlc) and Advanced Practice Nurse Licensure Compact (APRNC) were signed into Wyoming law by Governor Mead on March 1, 2016, however, the compacts do not go into effect until certain compact stipulations are met. In Wyoming, a nurse who resides in Wyoming and desires a multi-state license will complete and submit a multi-state license application, obtain a criminal background check (CBC) and pay the associated fees. The enlc will go into effect when one of the following firsts occurs: the enlc is enacted by twenty-six (26) states or December 31, 2018 arrives. Currently, twenty (20) states have enacted the enlc and a multitude of others have introduced enlc legislation in their states. It is highly probable the enlc will be enacted by the 26 th state this summer. If that is the case, a six (6) month transition period will follow the enactment of the 26th state, which will allow the new enlc Commission to meet, elect officers and develop Articles of Organization, bylaws and rules. At the end of the six (6) month transition period, the new enlc will go live and all individuals who have met the enlc multi-state license requirements in the enacted states may practice under the privilege. In Wyoming, a nurse who resides in Wyoming and desires a multi-state license will complete and submit a multi-state license application, obtain a criminal background check (CBC) and pay the associated fees. The application and CBC will be vetted to determine eligibility. If the applicant meets all multi-state license requirements, the applicant will be able to practice under a multistate privilege when the enlc goes live! If the applicant does not meet the multi-state license requirements, the applicant will still be able to practice in Wyoming with a single-state license. *WATCH FOR INFORMATION ABOUT THE PROCESS IN FUTURE WSBN COMMUNICATIONS* The APRN compact has been enacted by three (3) states including Idaho, North Dakota and Wyoming. The APRN compact must be enacted by ten (10) states to go live. As not all states allow APRNs independent practice, required by the compact, the compact is not anticipated to go live for several years. BOARD decisions: At the most recent April Board meeting, the Board voted to eliminate detailed disciplinary information in the Wyoming Nurse Reporter, starting with this issue. Discipline documents will still be available via the WSBN website and Nursys for licensed nurses and via the WSBN website for certified nursing assistants. I wish you all a great summer filled with family and fun activities! 4 Wyoming Nurse Reporter

Work at one of America s safest hospitals! Campbell County Health is the most comprehensive healthcare provider in the state of Wyoming. We are dedicated to Excellence Every Day providing you with great benefits, patient-focused resources, professional development, a vibrant community and work/life balance. cchwyo.org/careers f t in NURSE RN JOB OPPORTUNITIES Intensive Care Unit Women s Health & Pediatrics Medical / Surgical Emergency Department EOE M/F/Disabled/Vet AAP Join our team, providing excellent care to those who choose to live, work and raise their families in northeastern Wyoming. Attractive benefits package Competitive wages Sign-on bonuses or relocation reimbursement Opportunities for professional growth Progressive organization focusing on a culture of kindness Visit us online at sheridanhospital.org 1401 West 5th St. Sheridan, WY 82801 307.673.4290 Congratulations! 2017 Class of Faith Community Nurses: Trudy C. Mary C. Linda H. Dawn G. Kris M. Sherry S. Faith Community Nurses nurture the body, mind and spirit through health education, early intervention, disease prevention and personal relationships. Wyoming Health Council 307-632-3640 ahubbard@wyhc.org www.wyhc.org Sponsored by a community benefit grant from Cheyenne Regional Medical Center. Wyoming Nurse Reporter 5

What Will the Enhanced NLC (enlc) Mean for Nurses? What does the enlc mean for nurses in the current NLC? If your state enacts the enlc, you will be grandfathered and no further action is needed, unless you move to another state. Then you will be required to meet all the uniform licensure requirements to receive a multistate license from that state. The states that are part of the enlc are not exactly the same as the original NLC. If you have an enlc multistate license, you can only practice in those designated enlc states. You will need a single state license issued by every other state in which you plan to practice to continue to deliver care in each of those states.. What does the enlc mean for employers? Your nurses will now be able to practice (in person or by telehealth) in other enlc states with just one license obtained in their state of residence. Faculty and military spouses will just need one license to teach or practice across states in the enlc. The enlc is only for registered nurses (RNs) or licensed practical/ vocational nurses (LPNs/VNs), not for advanced practice registered nurses (APRNs). APRNs have another compact that states are considering. What are the Uniform Licensure Requirements for an enlc multistate license? An applicant for licensure in a state that is part of the enlc will need to meet the following uniform licensure requirements: 1. Has met the requirements for licensure in the home state (state of residency); 2. a. Has graduated from a board of nursing-approved education program; or b. Has graduated from a foreign education program (approved by the authorized accrediting body in the applicable country and verified by an independent credentials review agency); 3. Has passed an English proficiency examination (applies to graduates of a foreign education program not taught in English or if English is not the individual s native language); 4. Has passed the NCLEX-RN or PN Examination or predecessor exam; 5. Is eligible for or holds an active, unencumbered license (i.e., without active discipline); 6. Has submitted to state and federal fingerprint-based criminal background checks; 7. Has no state or federal felony convictions; 8. Has no misdemeanor convictions related to the practice of nursing (determined on a case-by-case basis); 9. Is not currently a participant in an alternative program; 10. Is required to self-disclose current participation in an alternative program; and 11. Has a valid United States Social Security number. 6 Wyoming Nurse Reporter

TWO COMPACTS COMPARED A Driver s License Compact vs. a Nurse License Compact Issued in your primary state of residence. When driving in other states, you must know and obey that state s laws (rules of the road). While driving in other states, if you violate the state s law, the state can remove your driving privileges in that state. When you change your primary state of residence (move) to another compact state, you need to apply for that state s driver s license. You can drive on your former license for a certain number of days (depending on the state). The former license then becomes invalid. While driving in other states, if you violate the state s laws and the state takes action (discipline), it is reported to the state that issued your license (where you reside). Most home states can take the same action as if you committed the violation in your home state. resources: nursecompact.com Driver s License NLC and APRN Compact Advocacy Issued in your primary state of residence. When practicing in other states, you must know and obey that state s laws (Nurse Practice Act). While practicing in other states, if you violate the state s laws, the state can remove your practice privileges in that state. When you change your primary state of residence (move) to another compact state, you need to apply for that state s nursing license. The former license then becomes invalid. While practicing in other states, if you violate the state s laws, and the state takes action (discipline), it is reported to the state that issued your license (where you reside). Most home states can take the same action as if you committed the violation in your home state. HIVE toolkit (NCSBN member login and password required) Reach Recruit Air & Surface Transport Nurses Association American Retain Academy of Ambulatory Care Nursing American Association of Colleges of Nursing American Association of Neuroscience Nurses American Association of Occupational Health Nurses (AAOHN) American Association of Poison Control Centers American Nephrology Nurses Association American Organization of Nurse Executives Serving over (AONE) 11,000+ American Telemedicine Wyoming nurses. Association (ATA) The Wyoming Association of Camp Nurses Association Board for Vascular of Nursing Access Case Management JOURNAL Society of America (CMSA) to reserve advertising space Center for Telehealth and E-Health contact Law Victor Horne CGFNS vhorne@pcipublishing.com International, Inc. Citizen Advocacy Center (CAC) Commission for Case Manager Certification Our nursing journals reach over Emergency 2 million Nurses nurses, Association healthcare (ENA) Health professionals IT Now and educators National Governors nationwide. Association Center Arizonafor Best Practices North Carolina Arkansas North Dakota National The District League Ohio for Nursing National of Columbia Military Oregon Family Association Georgia South Carolina National Florida Organization South for Dakota Associate Degree Indiana Nursing (OADN) StuNurse/Nationwide Kentucky Tennessee National Mississippi Patient Safety Washington Foundation Oncology Montana Nursing West Society Virginia Nebraska Wyoming Optum Nevada New Mexico Population Health Alliance Telehealth Leadership Council ThinkNurse.com U.S. Department of Commerce Some of the Organizations Supporting the NLC include: 1-800-561-4686 ext.114 Wyoming Nurse Reporter 7

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Welcome New Grads! by Stephanie Martin, Licensing Specialist Hey Grads, if you just finished nursing school, then take a bow and feel proud. Soon, however, it will be time to put that degree to work. So don t forget to apply for your license with the Wyoming State Board of Nursing. You ll want to do it soon, especially if you have job interviews lining up. Here are some things to remember when going through the application process: Start early - The required background check can take up to 45 days. This is necessary before licensure and we must have your completed fingerprint cards to even start that clock. Contact local law enforcement to acquire cards and be fingerprinted. Then send in the cards with your application. Required documents Documentation required for every application includes copies of social security card and either a driver s license, birth certificate, or passport, on which the names match. Work history Do not leave any gaps longer than three months for which your time is unaccounted. Even if you were travelling in Europe or unemployed at home, undocumented time will delay your application while we contact you to have the gap filled in. Transcripts Make sure to contact the registrar at your school to arrange transmission of that hard earned history of your degree! This can be done electronically or via snail mail, but please no faxing. This documentation will ONLY be accepted by the Board of Nursing when sent directly from your school. This is also the required step before any GN permits can be issues and before we can make you eligible to take the NCLEX. Fees Yes, more fees. Pay careful attention to the page at the end of the application on which you select what you re paying for and how you will be paying. This is another step that causes delays. We will not work any application for which the appropriate fees are not paid. History page We truly do need this information, and if you submit everything with your application you will be that much closer to getting licensed from the moment that we receive your packet. Read carefully The most common reason for delays in the process is that an applicant did not read the application and so did not supply all needed information. Questions? Please give us a call at 307-777-7616, or stop by 130 Hobbs Avenue, Suite B Cheyenne, Wyoming 82001. We are happy to answer any questions and help you apply. Wyoming Nurse Reporter 9

What Wyoming APRNs Need to Know about Scope of Practice Background UW s Fay W. Whitney School of Nursing and the Wyoming State Board of Nursing (WSBN) frequently receive inquiries regarding the type of practice that advanced practice registered nurses (APRNs) can engage in, particularly related to primary versus acute care practice or specialty practice (e.g., dermatology, cardiology, etc.) for nurse practitioners (NPs). To answer these questions, one must understand scope of practice (SOP), a term that describes the services that a professional who is educated and deemed competent in, may perform, as well as the conditions under which these services may be provided. SOP is articulated in professional SOP statements, which also serve as boundaries for specific professions to delineate services that should not be performed and conditions when services should not be rendered. 1 The most recognized SOP model for APRN practice in the U.S. is the APRN Regulatory Model (Figure 1), contained in the APRN Consensus Document, 2 which resulted from a collaborative effort from 2004-08 by a Work Group consisting of representatives from 48 national nursing organizations, including the National Council of State Boards of Nursing, the American Nurses Association, the American Association of Colleges of Nursing, and most of the major national organizations representing APRNs, including NPs, certified registered nurse anesthetists (CRNAs), certified nurse midwives (CNMs), and clinical nurse specialists (CNSs). Of note, Wyoming s Nurse Practice Act 3 and the WSBN s Rules and Regulation 4 are also in consensus with the APRN Regulatory Model. In order to keep their practice within their recognized SOP, it is critical that all Wyoming APRNs understand the APRN Regulatory Model. Thus the purpose of this article is to describe the APRN Regulatory Model and how it applies to APRN practice. APRN Regulatory Model According to the APRN Regulatory Model, APRNs are prepared for one or more of the four APRN roles: 1) CRNA, 2) CNM, 3) CNS, and 4) CNP (Certified Nurse Practitioner), as well as in one or more of the six APRN population foci: 1) Family/ individual across the lifespan, 2) Adultgerontology, 3) Neonatal, 4) Pediatrics, 5) Women s health/gender-related, and 6) Psychiatric- mental health. According to the model, APRNs who have been educationally prepared and licensed for a recognized role and population may then specialize but are not required to specialize for licensure (See top of model). APRN Specialties Prior to the development of the APRN Regulatory Model, some APRNs were initially prepared for a specialty area (e.g., oncology, cardiology). However, with the APRN Regulatory Model, APRNs cannot specialize until they have been prepared in a specific role and population foci. For example, an NP who is interested in specializing in adult oncology would first need to be educationally prepared and licensed as an adult-gerontology NP, prior to specializing in adult oncology. The model provides examples of specialty foci; however, since the model was published, other foci have Ann Marie Hart, PhD, FNP-BC, FAANP Professor and DNP Program Director Mary E. Burman, PhD, RN, FAAN, FAANP Dean and Professor Fay W. Whitney School of Nursing University of Wyoming been developed or are currently in development (e.g., diabetes, emergency care). Primary Versus Acute Care NP Practice For CNPs, which represent the largest group of the four APRN roles, the APRN Regulatory Model also provides clarification regarding acute care versus primary care practice. Specifically, the footnote on p. 10 directly under the model states: The CNP is prepared with the acute care CNP competencies and/or the primary care CNP competencies. At this point in time the acute care and primary 10 Wyoming Nurse Reporter

care CNP delineation applies only to the pediatric and adult-gerontology CNP population foci. Scope of practice of the primary care or acute care CNP is not setting specific but is based on patient care needs. Programs may prepare individuals across both the primary care and acute care CNP competencies. If programs prepare graduates across both sets of roles, the graduate must be prepared with the consensus-based competencies for both roles and must successfully obtain certification in both the acute and the primary care CNP roles. CNP certification in the acute care or primary care roles must match the educational preparation for CNPs in these roles. Thus according to the APRN Regulatory Model, CNPs prepared for the family/across the lifespan role (i.e., FNPs) are prepared for primary care. There is no acute care role for FNPs, and FNPs who desire to engage in acute care must be prepared at either the adult-gerontology or pediatric population level as an adult-gerontology acute care nurse practitioner (AGACNP) and/or a pediatric acute care nurse practitioner (PACNP). It is also important to note that model does not distinguish primary care from acute care by practice setting and allows for primary care occurring in traditional acute care settings (e.g., urgent care clinic in a hospital) and acute care occurring in ambulatory settings. The distinction between primary and acute care CNP practice is further discussed in a multi-organization APRN document published in 2013, Primary care and acute care certified nurse practitioners. 5 This document reiterates that setting does not distinguish acute from primary care, stating, The patient s condition and acuity level are the primary factors in determining the most appropriate CNP to manage the patient s health care needs, not the setting of care (p. 2). Additionally, this document clarifies that APRN educational preparation and national certification are critical to APRN licensure in a specific population foci, adding, Previous work experience as an RN does not substitute for the population foci of the CNP s education and certification if there is a mismatch when CNP employment is sought. Conclusion SOP provides a framework for APRN practice. The 2008 APRN Regulatory Model contained in the APRN Consensus Document 2 provided much needed clarification to APRN SOP. Wyoming s Nurse Practice Act 3 and the WSBON s Rules and Regulations 4 are in consensus with the APRN Regulatory Model, thus all Wyoming APRNs, APRN educators, and APRN regulators should be familiar with the APRN Consensus Document and its Regulatory Model. 4 The APRN Consensus Document and the document, Primary Care and Acute Care Certified Nurse Practitioners, are available on-line at no cost. In addition, the NCSBN also has an APRN Consensus Model Toolkit. 6 See References for URLs. References 1. American Nurses Association (2016, September 30). Scope of practice. Retrieved from http://www.nursingworld.org/especiallyforyou/ AdvancedPracticeNurses/Scope-of-Practice-2 2. APRN Consensus Work Group & the National Council of the State Boards of Nursing APRN Advisory Committee (2008, July 7). Consensus model for APRN regulation: Licensure, accreditation, certification, and education. Retrieved from https://www.ncsbn. org/736.htm 3. Wyoming Statute (n.d.). Chapter 21 Nurse Practice Act. In Title 33 Professions and Occupations. Retrieved from https://nursingonline.state.wy.us/resources/chapter 21 - NURSES.pdf 4. Wyoming State Board of Nursing (n.d.). Rules and regulations. Retrieved from https:// nursing-online.state.wy.us/default.aspx?page=24 5. Primary Care and Acute Care Certified Nurse Practitioners 2013. Retrieved from https://www.aanpcert.org/resource/documents/ ACPCNPStatementFinal2013.pdf. 6. National Council of State Boards of Nursing (2017). APRN Consensus Model Toolkit. Retrieved from https://www.ncsbn. org/739.htm Wyoming Nurse Reporter 11

Getting to Know You Jennifer L. Burns, MJ, BSN, RN-BC Florence Nightingale, in discussing communication techniques wrote, (the) most important practical lesson that can be given to nurses is to teach them what to observe. (Nightingale, 1860, p. 105) It is this statement that defines my interest and my eagerness to pursue additional research in the area of culturally sensitive communication practices; I want to know exactly, what to observe when I care for my patients of low health literacy. What effect, if any, does the practitioner s own presentation have on the client s ability to learn? I am a well-established and experienced nurse, with years of assessment skills and a multitude of patient communication techniques among them. A recent practicum experience, however, has begun opening my eyes to the struggles such individuals and aggregates encounter, when trying to obtain quality health information. How can we as a nursing society begin to understand our patients as individuals, if we, as individuals, cannot communicate effectively with them? I ponder this idea as I explain a situation that I noticed during the first of my nutrition presentations in a Faith-based organization. English is my primary language, and I am a well-spoken, educated individual with an aristocratic grammar style. I pride myself on proper speech. During an early presentation about the health benefits of oatmeal, I noticed that two young women seated at the head of the group, would summarize my instructions in Spanish to the rest of the members. In addition, they translated the questions back to me in English. These two young women were about eighteen years old and had completed a public high school education in America. The questions they presented were mainly to clarify health information usually garnished from television marketing ads. It was at this point that I had two shocking realizations; 1) although my speech pattern was clear and precise, this group could not understand the concepts due to my language choice, and 2) the group members seemed eager to be presented with evidenced-based information about their health. The barrier was mine, (the expresser), and I needed to find a way to communicate effectively with them, (the recipients). As the professional, this was my responsibility. This early revelation was significant because I still had time to adjust my presentation to improve the aggregate s outcomes. This is how I changed my plan of care in order to provide safe and effective nursing care of this aggregate. Obviously, my lack of Spanish language speaking skills was a detriment to the presentation outcome. I consider my own experiences and feelings when I travel abroad. Although I speak polite Italian and French, I rely much on non-verbal body language for communication. Many times during my travels, I have felt frightened and alone as a result of not being able to understand the quickly spoken foreign word. Although broken verbs may suffice for shopping and directions, they would sorely fail in providing me vital health information had an emergency occurred during my visitations. I imagine that my patients with low health literacy must feel similarly so; confused and frightened, even less validated as a person with capacity for learning. HRSA defines health literacy as the degree to which individuals have the capacity to obtain, process and understand basic health information needed to make appropriate health decisions and services needed to prevent or treat illness. (HRSA, 2016, health literacy) The capacity to obtain information should not only be reflected from the individual s perspective, but from the provider s as well. Why shouldn t providers be responsible for learning the culture and language of our patients? Not a day passed in twenty-five years that I could not have utilized Spanish language as a tool to better communicate and understand my Hispanic patients. I insisted both my children took extensive Spanish courses through middle and high school, on the slight chance they would pursue health careers. Research by Heisler et al (2002) shows that provider styles enhance selfmanagement. If I were able to adjust my How can we as a nursing society begin to understand our patients as individuals, if we, as individuals, cannot communicate effectively with them? 12 Wyoming Nurse Reporter

style to connect more appropriately with my group members, perhaps, the outcome of my intervention might improve. Since I could not possibly improve my Spanish language skills immediately, I chose to adjust my wording during the next presentation. I focused on decreasing the vocabulary to two and three syllabus words, minimize formal style of grammar, and incorporate more body language. I utilized free nutrition posters in Spanish that I downloaded from the AHRQ website. In the past, I would not have pursued such lengths and would have expected my patients to adjust to my style. I understand now, that should not be the case. This is one method I used to integrate clinical standards and expertise to adjust to patient preferences. I also regard these acts as demonstrating ethical reasoning, advocacy and effective use of communication. Provision seven of the Code of Ethics, identified by the American Nurse Association states the nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development. (ANA, 2015, code of ethics) It is the knowledge development and my own pursuit of education that vexes me, however. At which point in my pursuit of formal knowledge shall I have obtained all the necessary tools to provide optimum patient care? Are my three board certifications sufficient? I feel as though the more I learn, the more I realize I have so much more to learn about what Florence meant to nurse. I will apply cultural learning to my future nursing practice. Singleton and Krause (2009) express that integrating cultural and linguistic consideration with health literacy necessitates an expanded paradigm among the future of quality improvement efforts in nursing. (Singleton & Krause, 2009, abstract) Providing safe and effective patient centered care requires my own pursuit of what, exactly, I need to know. The direction I take clearly needs to mirror the diversity of my future patient population. This is my commitment to lifelong learning. By integrating evidence, clinical expertise and patient preference, I can improve the outcomes of care. By learning and understanding such concepts as cultural effects on health literacy and effective communication techniques, I can motivate lifestyle changes in my patients. By collaborating with other disciplines and nurse peers, I can essentially expand my knowledge of practice interventions vicariously, through their experiences, as well. By collaborating with other IDT members and forming a team, I have shown transitioning efforts toward professional nursing. As I reflect on my career in nursing I summarize my first step in my quest to improve outcomes must begin with observing my patients. The second; involves realizing that there is much I do not know, even after all these years. The third, humbling myself to begin to learn all over. This is what Florence would do. References American Nurse Association. (Ed.). (2015). Code of ethics for nurses with interpretive statements. Silver Springs, MD: Publication of nursing world. Retrieved from http://www.nursingworld.org/ MainMenuCategories/EthicsStandards/ CodeofEthicsforNurses/Code-of-Ethics-For- Nurses.html. Heisler, M., Bouknight, R., Hayward, R., Smith, D. and Kerr, E. (2002). The relative importance of physician communication, participatory decision-making, and patient understanding in diabetes self-management. Journal of General Internal Medicine. April: 17(4): 243-52. Nightingale, F. (1860). Notes on nursing: What it is, and what it is not. Philadelphia. US Department of Health and Human Services. Health Resources and Services Administration. (2016). Health Literacy. Washington DC. Retreived from http:// www.hrsa.gov/publichealth/healthliteracy/. Singleton, K., and Krause, E., (2009) Understanding cultural and linguistic barriers to health literacy OJIN: The Online Journal of Issues in Nursing. Vol. 14, No. 3, Manuscript 4. The University of Northern Colorado Nursing Programs: Nursing BS Degree: RN-BS Nursing MSN Degree: Adult-Gerontology Acute Care Nurse Practitioner (AGACNP)* or Family Nurse Practitioner (FNP)** Emphasis Nursing DNP Degree: Post-Bachelor s with AGACNP* or FNP** Emphasis Post-Master s Certificate in AGACNP* or FNP** Nursing DNP Degree: Post-Master s* Nursing Education PhD Degree* The *AGACNP and Post-Master s doctoral programs are online with summer intensives in Greeley, CO; and the **FNP Programs are delivered on-campus one day a week + online. EXTENDED.UNCO.EDU/NURSING Wyoming Nurse Reporter 13

The Role of Self-Assessment in Achieving Cultural Competence An overview by Tawara Goode, MA Director of the Georgetown University National Center for Cultural Competence Essential elements in achieving cultural competence. The Georgetown University National Center for Cultural Competence (NCCC) embraces a RN-BSN Online Program Accepts students Fall, Spring, and Summer semesters Enrollment is open up to 4 weeks prior to the beginning of each semester Registration by last name: (A-J) 435.879.4813 (K-Z) 435.879.4803 For more information: health.dixie.edu/nursing/rn-to-bsn-program/ conceptual framework and model for achieving cultural competence adapted from the work of Cross et al., 1989. Cultural competence requires that Your Future is in Your Hands Nursing is an emotionally ful lling and rewarding career. At Regional West, our RN clinical ladder recognizes professional growth and development and contributions beyond expected performance, providing recognition, personal satisfaction, and economic reward! As one of our team members, you will not only enjoy great bene ts and competitive pay, but you will also become a part of our health services community... a bene t that is truly priceless. OUR BENEFITS INCLUDE: Paid Vacation l Tuition Reimbursement l Flexible Schedules l Matching HSA 401k Health, Vision and Dental Insurance We update our career opportunities frequently, so check us out at www.rwhs.org/careers or call 308.630.1586 to learn more! 4021 Avenue B l Scottsbluff, NE 69361 308.630.1586 l www.rwhs.org organizations and their personnel have the capacity to: (1) value diversity, (2) conduct selfassessment, (3) manage the dynamics of difference, (4) acquire and institutionalize cultural knowledge, and (5) adapt to diversity and the cultural contexts of individuals and communities served. The importance of self-assessment. The NCCC supports the concept that cultural competence is a developmental process and evolves over an extended period. Both individuals and organizations are at various levels of awareness, knowledge and skills along the cultural competence continuum. The capacity to engage in self-assessment helps individuals and organizations to: gauge the degree to which they are effectively addressing the needs of culturally and linguistically diverse groups; determine their strengths and areas for growth; and strategically plan for the systematic incorporation of culturally and linguistically competent policy, structures and practices. The NCCC views self-assessment as an ongoing process, not a one-time occurrence. Self-assessment can lead to the development of a plan with clearly defined short- and long-term goals, measurable objectives and identified resources. It can also provide a vehicle to measure outcomes for personnel, organizations and the community at large. The NCCC is a component of the Georgetown University Child Development Center, Georgetown University Medical Center. For additional information contact:202-687-5387 or cultural@ georgetown.edu Adapted with Permission from the NCCC from The Cultural Competence Exchange, Issue 4, Fall/Winter 2001 14 Wyoming Nurse Reporter

Now Recruiting! Welcome to Wyoming Behavioral Institute, an 85-bed acute care psychiatric hospital in Casper, Wyoming, specializing in the treatment of children, adolescents and adults. Our philosophy is to provide a range of specialized and individualized treatment options with a focus on service and excellence to support care healing for our patients and families. If you have a commitment to service excellence, we invite you to join our team today! RNs LPNs New Grads Welcome We offer an excellent compensation and benefits package. The state of Wyoming has no state income tax! Visit our website to review openings and apply online. HunGER keeps up On current EVEnTs, TOO. Wyoming Behavioral Institute has been accredited by The Joint Commission (TJC) and is licensed by the State of Wyoming s Department of Health. Wyoming Behavioral Institute is owned managed and operated by UHS of Wyoming; a subsidiary of Universal Health Services, Inc., one of the largest providers of care in the nation. high-quality healthcare in the nation. APPLY ONLINE TODAY! www.wbihelp.com Join Our Team! 1 in 6 americans struggles WiTH HunGER. Are you ready to make a change? At Ivinson Memorial Hospital we know our employees are our best asset. Consider the exciting opportunities and benefits waiting for you. TOGETHER WE RE Sign-on bonuses available! Hunger is closer than you think. Reach out to your local food bank for ways to do your part. For more information or to apply, please visit our website or contact Human Resources at kparry@ivinsonhospital.org Visit Feedingamerica.org today. 255 N. 30th Street Laramie, WY 82072 307.742.2141 www.ivinsonhospital.org Wyoming Nurse Reporter 15

Practice and Education Corner New Advisory Opinions related to practice and education in Wyoming New Advisory Opinions Know before you go! See official Advisory Opinions on practice related matters, located on the WSBN website. ADVISORY OPINION AMNIOTOMY Within the Scope of Practice/Role of _X APRN RN LPN CNA In accordance with W.S. 33-21-122 (c) (iii) of the Wyoming Nursing Practice Act (NPA), the Wyoming State Board of Nursing (WSBN) has approved the following Advisory Opinion on the practice of amniotomy. The purpose of this opinion is to guide safe practice. Introduction: For the purposes of this advisory opinion, amniotomy, aka artificial rupture of membranes (AROM) is defined as either the intentional rupture of the amniotic membranes using an amnihook or the placement of an internal fetal spiral electrode through intact membranes. The Association of Women s Health Obstetric and Neonatal Nurses (AWHONN) retired the 2009 position statement that recommended amniotomy as being outside of the RN scope of practice. 1 AWHONN currently affirms amniotomy should be considered individually by boards of nursing and facility risk management resources (C. Brown, personal communication, May 10, 2016). WSBN acknowledges that amniotomy is within the scope of practice for the APRN with additional education, skills, and demonstrated competency when facility and patient criteria are met. An amniotomy procedure is NOT within the scope of practice of a registered nurse. ADVISORY OPINION AURICULAR ACUPUNCTURE Within the Scope of Practice/Role of _X_APRN _X RN LPN CNA In accordance with W.S. 33-21-122 (c) (iii) of the Wyoming Nursing Practice Act (NPA), the Wyoming State Board of Nursing (WSBN) has approved the following Advisory Opinion on auricular acupuncture. The purpose of this opinion is to guide safe practice. Introduction: For the purposes of this advisory opinion, auricular acupuncture (also known as battlefield acupuncture), is defined as a minimally invasive technique whereupon metal studs are placed only on the surface of the ear for pain control.[i] It is not medical or oriental acupuncture which requires extensive medical training. WSBN acknowledges that auricular acupuncture is within the scope of practice for the RN with additional education, skills, and demonstrated competency when facility and patient criteria are met. ADVISORY OPINION PERICARDIAL FLUSH Within the Scope of Practice/Role of _X APRN _X RN LPN CNA In accordance with W.S. 33-21-122 (c) (iii) of the Wyoming Nursing Practice Act (NPA), the Wyoming State Board of Nursing (WSBN) has approved the following Advisory Opinion on flushing a pericardial drain. The purpose of this opinion is to guide safe practice. Introduction: For the purposes of this advisory opinion, flushing a pericardial drain is a nursing intervention directed by an APRN or physician/physician assistant s order. The practitioner may leave a pericardial catheter in place to drain excess pericardial fluid post surgery. While the pericardial catheter remains in place, a specialty trained nurse may maintain patency by flushing the drain. ADVISORY OPINION Suprapubic Catheter Insertion Within the Scope of Practice/Role of _X APRN RN LPN CNA In accordance with W.S. 33-21-122 (c) (iii) of the Wyoming Nursing Practice Act (NPA), the Wyoming State Board of Nursing (WSBN) has approved the following Advisory Opinion on suprapubic catheter insertion. The purpose of this opinion is to guide safe practice. Introduction: For the purposes of this advisory opinion, insertion of a suprapubic catheter is a bedside surgical procedure, whereupon a large gauge needle is inserted through an abdominal wall into the bladder. In some cases, a catheter is placed over the needle and left in place for repeated access. The WSBN acknowledges that suprapubic catheter insertion requires extensive clinical skills and training and therefore, is within the scope of practice for the APRN; providing he/she has the additional education and skills, and has demonstrated competency. Facilities must also have a policy and procedure guide in place. WSBN also acknowledges that an RN may re-insert a catheter in a patient that has an established stoma. Ref: [i] Military Medicine. http://military medicine.amsus.org/doi/ pdf/10.7205/milmed-d-13-00075. MILITARY MEDICINE, Vol. 178, August 2013 Auricular Acupuncture Downloaded from publications.amsus.org: AMSUS - Association of Military Surgeons of the U.S. IP: 159.238.054.008 on Jan 13, 2017. 16 Wyoming Nurse Reporter

Call for Articles The Wyoming Nurse Reporter invites you to consider submitting an article for publication. The WNR is full of practical information and keeps Wyoming nurses up to date on evidenced-based practices, maximizing outcomes, and valuable career pathway information. We welcome personal stories from Wyoming nurses that reflect the frontier culture and specific interests to our residents. Please send an email inquiry to wsbn-pe-info@wyo. gov to confirm your topic meets our publication needs and focus. This publication is not an official peerreviewed journal. Nurses Poem A poem from the famous English satirical magazine Punch published during the time of the Crimean War, 1854-1856, when Miss Florence Nightingale and her nurses were nursing English soldiers for the first time in English history. The Nightingale s Song to the Sick Soldier Listen, soldier, to the tale of the tender nightingale, Tis a charm that soon will ease your wounds so cruel, Singing medicine for your pain, in a sympathetic strain, With a jug, jug, jug of lemonade or gruel. Singing bandages and lint; salve and cerate without stint, Singing plenty both of liniment and lotion, And your mixtures pushed about, and the pills for you served out, With alacrity and promptitude of motion. Singing light and gentle hands, and a nurse who understands How to manage every sort of application, From a poultice to a leech; whom you haven t got to teach The way to make a poppy fomentation. Singing pillow for you, smoothed; smart and ache and anguish smoothed, By the readiness of feminine invention; Singing fever s thirst allayed, and the bed you ve tumbled made, With a cheerful and considerate attention. Singing succour to the brave, and a rescue from the grave, Hear the nightingale that s come to the Crimea, Tis a nightingale as strong in her heart as in her song, To carry out so gallant an idea. FAY W. WHITNEY SCHOOL OF NURSING University of Wyoming uwyo.edu/nursing Come take a seat in the new online MS Program Application deadline 6/30 for fall 2017 start date Nurse educator and nurse leader concentrations Online program (307) 766-6565 or (307) 766-6576 gradnurse@uwyo.edu www.uwyo.edu/nursing/programs/ms-program GO FOR GOLD RNs SIGN ON BONUS! Med/Surg RNs (2 FT) Emergency Room RN Advanced Practice Provider Cabinet Peaks Medical Center is a new state-of-the-art 25-bed, top 100 critical access hospital located in one of the most beautiful forests in North America. We offer excellent compensation & benefits To view all available positions & apply online visit our website or contact Paula Marcinkowski, HR at (406) 283-7169 or pmarc@cabinetpeaks.org www.cabinetpeaks.org EOE Wyoming Nurse Reporter 17

YOU ASK WE ANSWER Jennifer L. Burns, MJ, BSN, RN-BC Practice & Education Consultant Tasha Selfridge Office Support Specialist Q : What are the Wyoming state board of nursing s regulations and mandatory guidelines for a CNA who engages in marketing her services to a community as an independent free lancing CNA? I have had several calls regarding this and I desire you to forward to me literature covering this topic. A : In Chapter 3, Section 6 (a) of the Administrative Rules and Regulations, a CNA must work under the direction of a licensed nurse. An individual who is certified as a CNA may work for a private party providing personal care. However, in this situation, the individual shall not market herself as a CNA to obtain to position, describe the work being done as CNA work, work under the title of CNA nor use the hours to recertify. Q : I am a licensed APRN in WY and I am certified in pediatrics. If I wanted to work in an area other than pediatrics as a nurse practitioner would I need to obtain additional master s education to do so? [submitted April 2013, section numbers adjusted for clarity] A : The Administrative Rules and Regulations Chapter 3, Section 2 addresses your question. As you are licensed and certified in pediatrics, your practice would be limited to the population for which you received your postgraduate education. It states: Chapter 3, Section 2 Standards of Advanced Practice Registered Nursing. (i) The APRN is subject at all times to the standards and scope of practice established by national professional organizations and/or accrediting agencies representing the various core, role and population focus areas for APRNs, and the NPA. Scope and Standards for APRN: (ii) The Board recognizes APRN core, role and population focus areas described in the scope of practice statements for APRNs issued by national professional organizations and/or accrediting agencies. (iii) Role and population focus of the APRN shall be declared, and the role and population focus to be utilized shall be the title(s) granted by nationally recognized professional organization(s) and/or accrediting agency(ies) or the title(s) of the role and population focus of nursing practice in which the APRN has received postgraduate education preparation. (iv) In order to practice in one of the four roles and in a defined population, the APRN shall be recognized by the Board in that particular role with a population focus of advanced practice nursing. Q : I am an L.P.N at a family practice and urgent care clinic. We have on staff an MD, two physicians assistants, an APRN, a RN, and myself. The RN is thinking about leaving her position. If she does leave am I still ok to practice since in the rules and regulations it states an LPN may practice under the direction and/or supervision of a physician, dentist, APRN, and RN. I was confused and just wanted to make sure. Also I had an iv certification in 2015. It has since lapsed. What do I need to do to get recertified for iv therapy? A : Regarding your LPN IV Therapy question: you will need to take a basic IV therapy class again. You would have needed to have a refresher class again. You would have needed to have a refresher class for the 2015 renewal period in order to keep it current. Now you will need to take a basic LPN IV Therapy class again and send the certificate to the WSBN. Regarding your supervision question, you are correct, the APRN and MD may supervise your practice. In the Nurse 18 Wyoming Nurse Reporter

Practice Act, Administrative Rules and Regulations: Chapter 3, Section 4 (iii)(a) an LPN shall participate in the plan of care by providing care for clients in basic patient care situations under the direction of a licensed physician, dentist, APRN or RN. Q :I am in need of some clarification. I saw in the nurse magazine that just came out a question regarding pronouncing when someone dies. Are there certain situations that nurses can do it or is it never at all? I work for an organization and we have a participant that has returned to us for comfort care/end of life care. Do I need to call the coroner in this case, when she passes? The doctor thought that it was ok for nurses to pronounce. A : A registered nurse may not pronounce a death. However, they may assess for absence of vital signs and neurological reflexs, or lack of papillary reaction that may indicate absence of life in which case, he/she would notify the medical doctor. A registered nurse may not sign a death certificate. If a patient passes at home under home health services, a policy should be created whereby the doctor is notified and post-mortum care can be initiated. County coroners are usually notified. We suggest you contact a local hospice director for some procedural suggestions as the WSBN does not regulate internal processes. There has been a new state bill passed into law [SF0021 and enrolled act No. SEA No.0066] which allows for Advanced Practice Registered Nurses to complete medical certifications of death. Contact the Wyoming Department of Health for further information on how to register. Wyoming Nurse Reporter 19

DISCIPLINARY ACTIONS Quarter 1, 2017 January 1-March 31, 2017 The full statutory citation for disciplinary actions can be found on the WSBN website at https://nursing-online.state.wy.us. Each individual nurse is responsible for reporting any actual or suspected violations of the Nurse Practice Act. To submit a report, use the online complaint form or to receive additional information, contact Compliance & Discipline at 307-777-5281, Wyoming State Board of Nursing, 130 Hobbs Ave, Suite B, Cheyenne, Wyoming, 82002. Letter of Reprimands 6 Summary Suspensions 7 Revocation 2 Denial 2 Voluntary Surrender 7 Conditional License 10 LICENSURE STATISTICS Quarter 1, 2017 January 1-March 31, 2017 The full statutory citation for licensing requirements can be found on the WSBN website at https://nursing-online.state.wy.us. To submit an application, use the online forms appropriate to your discipline. For additional information, contact Licensing at 307-777-7616, Wyoming State Board of Nursing, 130 Hobbs Ave, Suite B, Cheyenne, Wyoming, 82002. The following are numbers of applications processed in each discipline for the quarter: CNA by Exam 130 CNA by Endorsement 37 CNA by Recertification 53 LPN by Exam 36 LPN by Endorsement 18 LPN by Relicensure 8 RN by Exam 50 RN by Endorsement 515 RN by Relicensure 87 APRN by Exam 0 APRN by Endorsement 13 APRN by Relicensure 5 TOTAL 952 20 Wyoming Nurse Reporter

BOARD TALK BOARD MEETINGS A seven (7) member Board appointed by the Governor, the Wyoming State Board of Nursing (WSBN) consists of five (5) registered nurses, one (1) licensed practical nurse and one (1) consumer member. Meetings are open to the public. Agendas are posted on the Board s website. BOARD MEETING DATES June 8, 2017/12:00 p.m. Teleconference July 10-12, 2017 Board Meeting Cheyenne Aug.10, 2017/12:00 p.m. Teleconference Sept. 14, 2017/12:00 p.m. Teleconference October 9-11, 2017 Board Meeting, at Eastern Wyoming College, Torrington, WY STATE HOLIDAYS - WSBN S OFFICE IS CLOSED: Tuesday July 4, Independence Day Monday September 4 Labor Day Thursday November 23 Thanksgiving Day EXECUTIVE DIRECTOR Cynthia LaBonde, MN, RN PRACTICE & EDUCATION CONSULTANT Jennifer L. Burns, MJ, BSN, RN-BC LICENSING SUPERVISOR Lisa Hastings LICENSING SPECIALIST Raymie Bingman & Stephanie Martin FISCAL & HUMAN RESOURCES (HR) COORDINATOR Cindy Stillahn COMPLIANCE AND DISCIPLINE (C&D) MANAGER Victoria Pike, J.D., RN LEGAL ASSISTANT Kara Aguirre INVESTIGATIVE ASSISTANT Joey Clure OFFICE SUPPORT SPECIALIST II (vacant) COME TALK TO THE BOARD During each regularly scheduled meeting at WSBN, Board members hold a Public Forum for people to talk to them on nursing-related issues. If you want to speak during the Public Forum, check the meeting agenda for the date and time it will be held. If multiple individuals wish to address the Board, time is divided equally among those who wish to speak. For more detailed information regarding the Public Forum, please contact the Office Support Specialist at the Board office. The contact number is (307) 777-3425. WE LL COME TALK TO YOU Board staff will come speak to your organization on a range of nursingrelated topics, including nursing education, continuing education, licensure and discipline processes as well as the Nurse Practice Act (NPA). YOU RE IN GOOD COMPANY! Active Wyoming Licenses/certificates as of May 15, 2017: CNA: 4,447 APRN: 660 LPN: 989 RN: 11,302 BOARD COMMITTEES WSBN is advised by and appoints members to four standing committees. These are the Application Review Committee (ARC), Discipline Committee (DC), Legislative Committee (LC) and the Practice & Education (P&E) Committee. Further information on the committee s charge as well as meeting dates may be found on WSBNs website at: https://nursing-online.state.wy.us/ Default.aspx?page=68 MOVING? The law requires you to inform the Board when you have a change in your contact information. The easiest and fastest way for you to update your information is to email our office at wsbn-info-licensing@wyo.gov. You may also call the office at 307-777-7601, or mail a letter to the Wyoming State Board of Nursing, 130 Hobbs Ave, Ste B, Cheyenne, WY 82002. Please remember to provide your name, license/certificate number, former and current addresses. WSBN ACCOMPLISHMENTS Congratulations to Marjory Christiansen, MSN, RN, CNE who was promoted to Nursing Program Director, Casper College. Congratulations to Cynthia LaBonde MN, RN who was accepted as an esteemed running candidate for the Director of Area 1 within the National Council of State Boards of Nursing. Elections will be held in August at the Annual Meeting for NCSBN! Wyoming needs a strong voice to address rural concerns in regulation. CNA SKILLS/WRITTEN EXAM TESTING AND SCHEDULING INFORMATION: Please contact Christine.Nelson1@pearson.com or Sue at Scorleto@getcredentia.com Wyoming Nurse Reporter 21

The Wyoming State Board of Nursing is inviting all Wyoming APRNs, to be their guest at a special focus group discussion on scope of practice issues concerning advanced nursing practice in Wyoming. The Wyoming State Board of Nursing would like your input and ideas relating to three areas; the APRN Consensus Model of 2008, the Wyoming Nurse Practice Act and population focused practice. Date: Wednesday, June 14th, 2017 Time: 5:30pm to 8:00pm Location: Cheyenne Regional Medical Center Room: A/B Please RSVP via email to Jennifer Burns at Jennifer.Burns1@wyo.gov or phone at 307-777-6127 We are working on schedule for Gillette, Evanson, Cody, Riverton as well, please see website for updates under educational offerings. The Wyoming State Board of Nursing would like to express their gratitude to Eastern Wyoming College for hosting our October 2017 Board Meeting. Photo of the first class of Nursing students at the EWC Douglas Campus. They have completed year one and are ready for a break before they begin year two. EWC is excited to host the Wyoming State Board of Nursing on our campus for the October 2017 Board Meeting and will look forward to showing the new Career and Technical Education Center (CTEC) on the Torrington Campus. CTEC includes new health technology classrooms for the colleges CNA courses. WSBN Latest News and Current Events NOTICE of Intent, Proposed Rules: The Wyoming State Board of Nursing is proposing Chapter 3: Scope and Standards of Nursing Practice and CNA Role, and repeal Rules in Chapter 9: Delegation and Assignment. The amendments update language in Chapter 3 to reflect the suggested language provided by the National Council of State Boards of Nursing s model rules and add relevant language from Chapter 9. See more information on the website, https://nursing-online.state.wy.us/default. aspx?page=24 under tab NPA/Rules-Rules and Regulations. 22 Wyoming Nurse Reporter

The Care You Deserve By John Jacobs, FNP I have worked in and toured hospitals and medical clinics throughout the world from big teaching hospitals to international mobile clinics. Even though nursing takes many forms and takes place in many environments, the central concept of nursing never changes. It is always providing the best care no matter how difficult the conditions or the environment. I started working in a medium-sized hospital in a wealthy ski town with well trained doctors and nurses, the most advanced equipment, multiple operating rooms, and a wide variety of specialists on call. It was an easy learning environment with plenty of patients from all over the region providing care not only to the tourists and locals but also to the smaller ranching communities often an hour s drive in any direction. This was a stimulating environment with occasional winter storms cutting off our access from the outside world and limiting our abilities to send patients to larger, more advanced facilities in major cities. My passion was to learn more about medical and hospital care, and I moved to teaching hospitals on the east coast. Working as a travel nurse showed me the diversity in care. Big city hospitals were understaffed, and I spent long hours in poor neighborhoods in major cities with overworked nurses and auxiliary staff. Medical needs of larger inner city hospitals, while moving at an exhausting pace, provided an ideal learning environment for an ambitious nurse. The variety of aliments and pure patient numbers seen in any week were far more diverse than in my previous small town experience, but the experience confirmed that nursing does not change; patients have the same needs. Working as a travel nurse throughout my schooling and training as a family nurse practitioner provided me with the time and flexibility to follow my love of travel and bring the skills I have learned to the international environment. I made more than ten trips to the Caribbean to work on the islands of Haiti, the Dominican Republic, and St. Croix. Working with little access to advanced care and often nothing more than I could carry through customs in a backpack, this was a return to the bare bone roots of nursing. The needs of the patients are still the same and the role of the nurse is to fill these needs. In the Caribbean, medical problems, such as diabetes and hypertension, are similar to those in other communities, but in these environments sometimes the needs go down to a more basic level. I learned this lesson the first time I worked in Haiti. I was treating a younger girl in her twenties with a very infected wound in her leg. I supplied her with oral antibiotics and asked her to recheck with me the day before I was leaving. On recheck I looked at the wound and it clearly did not appear any better. Through the translator I was told that she knows that she should take the medicine with food and she has not had any this week. Here I was, an international nurse providing advanced care in difficult environments, and I had missed the most basic of human needs. As I reached a point in my life and my nursing career where I wanted to find one town to call home, I returned to the Rocky Mountain west. I like the smaller towns, the tough rancher folk and recreational opportunities that mountains provide, and I moved to Laramie, Wyoming, to open Grand Ave Urgent Care. I developed the best team of nurse practitioners, business, and ancillary staff that truly cares for patients. Diversity in nursing is a driving force and a reality in everyday business, but it is fundamental to nursing that the true values of nursing are consistent. We care about a patient not just as a client or customer, but as a person, helping them meet their needs from those as basic as food and water to understanding their medical condition or why they need a particular advanced test. Grand Ave Urgent Care s slogan is The Care You Deserve. Patients all have the same needs and we are here in Laramie to provide the community with the care they need and deserve. Wyoming Nurse Reporter 23

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