JOG N N CLNICAL ISSUES

JOG N N CLNICAL ISSUES Clinical Approaches in the Assessment of Childbearing Fatigue Linda C. Pugh, RNC, PhD, Renee Milligan, RNC, PhD, Peggy L. Parks, PhD, Elizabeth R. Lenz, RN, PhD, FAAN, Harriet Kitzrnan, RN, PhD = Modifications of the Fatigue Symptoms Checklist can be used clinically to assess fatigue during the childbearing year. Data from a series of studies provide beginning norms that can be used to interpret clinical scores and point to the potential importance of assessments to pregnancy complications and maternal performance. Consistent with North American Nursing Diagnosis Association (NANDA) definition of fatigue and the theory of unpleasant symptoms, fatigue and performance are important phenomena critical to the experience of pregnancy and assumption of the maternal role. JOG, 28, 74-80; 1999. Accepted: July 1998 Nurses attempting to understand the feelings that women have during the childbearing period have long recognized the importance of fatigue. Childbearing fatigue is an unpleasant symptom with the potential to influence the well-being of mothers and their infants. Fatigue, tiredness, and exhaustion have been documented by clinicians and researchers during pregnancy (Poole, 1986; Pugh & Milligan, 1995; Reeves, Potempa, & Gallo, 1991; Tulman et al., 1991), through labor (Pugh, 1993; Pugh, Milligan, Gray, & Strickland, in press), and into the postpartum period (Affonso, Lovett, Paul, & Sheptak, 1990; Beck, 1993; Milligan, Lenz, Parks, Pugh, & Kitzman, 1996; Ruchala & Halstead, 1994; Tulman & Fawcett, 1988). However, few instruments measure fatigue in a way that is useful to clinicians. The North American Nursing Diagnosis Association (NANDA) definition of fatigue is partic- ularly useful during childbearing. Childbearing fatigue is reported to be an unpleasant feeling consistent with an overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work (NANDA, 1990, p. 73). Ruchala and Halstead (1994) reported primiparous women were overwhelmed by their constant fatigue and lack of experience. Fischman, Rankin, Soeken, and Lenz (1986) found that fatigue decreased the capacity for intimacy, even throughout the first 12 months after delivery, for most women. The decreased capacity for physical and mental work (NANDA, 1990) contributed to development of the Theory of Unpleasant Symptoms (Lenz, Pugh, Milligan, Gift, & Suppe, 1997). This theory emphasizes the importance of fatigue related to performance. Childbearing women may have difficulty performing a variety of activities, from the ability to maintain personal and social activities during pregnancy (Reeves et al., 1991), to the ability to breastfeed (Chapman, Macey, Keegan, Borum, & Bennett, 1985), return to function (Fawcett, Tulman, & Myers, 198 8; Tulman, Fawcett, Groblewski, & Silverman, 1990) and care for her family during the postpartum period. Nurse clinicians can help mothers and families better understand maternal fatigue. Frequent assessment of fatigue documents mothers feelings of well-being and can help families better recognize the need for support. In rhe era of early discharge, mothers are led to think that because they can go home from the hospital, they are completely recovered. Validation of fatigue can help mothers and families set maternal limits. There are no widely accepted clinical instruments to measure maternal 74 JOG Volume 28, Number 1

fatigue. Research instruments to assess fatigue include visual analog scales, self-report adjective checklists, and physiologic measures (Milligan, Parks, Kitzman, & Lenz, 1997; Pugh, 1993). Nurse clinicians can help mothers and families better understand maternal fatigue. An approach to fatigue measurement that has been validated in the authors research and can be applied in a clinical setting is recommended. A self-report adjective checklist, the Fatigue Symptoms Checklist (the FSC), has been useful in research studies to measure fatigue during childbearing because the checklist is multidimensional, reliable, valid, and has limited respondent burden (Kinsman & Weiser, 1976; Yoshitake, 1971). The purpose of this article is to (a) present ways of assessing fatigue during childbearing using modifications of the FSC, (b) interpret levels of fatigue during various periods of childbearing, and (c) present the potential importance of these assessments related to maternal performance at specific times during the childbearing period. The FSC (Yoshitake, 1971) is a 30-item7 self-report adjective checklist developed after extensive study of fatigue in Japanese industry. In research, two modifications of the original form were used (see Table 1). In form one (hereafter referred to as the Fatigue Identification Form) the lead-in phrase requires a dichotomous (yesho) response (Milligan et al., 1997). In form two (hereafter referred to as the Fatigue Continuum Form), an ordinal (not at all/sometimes/moderately sohery much so) response is requested in response to a sentence description of a feeling (Pugh, 1993). In the Fatigue Identification Form, the mother chooses from a number of symptom-related adjectives. Sample items include my head feels heavy ; my legs feel tired, my movements are rigid or clumsy ; and I can t concentrate. Scores range from a low of 0 to a high of 30. Sample items in the Fatigue Continuum Form include: I feel that my head is heavy ; I feel tired in my legs ; I feel clumsy when moving ; and I feel unable to concentrate. Scores range from a low of 30 to a high of 120 (see Table 1). Reliability and validity statistics for the FSC in the studies using modifications of the FSC have been reported (Milligan et al., 1997; Pugh, 1993). The measure is reliable; during the intrapartum period, items on the Fatigue Continuum Scale consistently represented fatigue (a =.91 to.94; Pugh, 1993). During the postpar- tum period, items on the fatigue identification form also were consistent (a = -82 to.85; Milligan et al., 1997). There is support for both forms measuring the construct of fatigue. Specific construct validity indices include significant correlations with relevant variables that should be related to fatigue (such as sleep, length of labor, type of delivery, and infant difficulty) (Milligan et al., 1997; Pugh, 1993). For example, fatigue scores were higher when women had longer labors and less sleep. History of Instrument Use in Research After considerable experience measuring fatigue with a variety of instruments, the authors found two forms of the modified FSC to be useful in their research. The eight studies using these instruments had a total of 770 subjects (71 pregnant subjects, 113 who were in the intrapartum period, and 586 who were in the postpartum period), and within these studies, fatigue was measured 2,640 times. These studies were conducted through all phases of childbearing. The Pregnancy Studies Milligan and Kitzman (1992) studied 60 low-income, predominantly minority pregnant women longitudinally at 28 weeks and 36 weeks of gestation. Pugh and Milligan (1995) studied 24 low-income women longitudinally, including all trimesters of pregnancy. The Intrapartum Studies Pugh (1990) conducted a pilot study of 13 women in which fatigue was measured when they were admitted for labor, and measurements were continued after delivery and through the immediate postpartum period. Pugh (1990) also conducted a second study of 100 women in which fatigue was measured on admission to the labor unit. Data were collected three other times during labor, and the final data point was within 24 hours of delivery. The Postpartum Studies Parks and Lenz (1991) measured fatigue in 399 women at five data points from the immediate postpartum period through the first 18 months of the infant s life. Pugh (1990) measured fatigue in 108 women in the first 24 hours after delivery. Milligan, Flenniken, and Pugh (1996), in a study of 20 breastfeeding women, measured fatigue twice in the hospital after delivery. In another sample, Pugh and Milligan (1998) examined fatigue in 59 breastfeeding women at four data points from the immediate postpartum period through 6 weeks after delivery. Postpartum measures also were included in longitudinal studies already mentioned (Milligan & Kitzman, 1992; Pugh, 1993). JanuarylFebruary 1999 JOGNN 75

TABLE 1 Specific Foms Fatigue identification Form Directions: I m going to read a list of things you may have generally experienced since delivery. For each one, please say yes if you have experienced it. (If asked to clarify generally say most of the time. ) O=No 1 =Yes 1. My head feels heavy. 2. My body feels tired. 3. My legs feel tired. 4. I yawn a lot. 5. My brain feels hot and muddled. 6. I am drowsy. 7. My eyes feel strained. (tired) 8. My movements are rigid or clumsy. 9.1 am unsteady when standing 10. I want to lie down. 1 1. It s difficult to think. 12. I get weary talking. 13. I am nervous. 14.1 can t concentrate. 15. I am unable to get interested in things. 16. I am apt to forget things. 17. I lack self confidence. 18. I m anxious about things. 19. I can t straighten my posture. 20. I lack patience. 2 1. I have a headache. 22. My shoulders feel stiff. 23. My back hurts. 24. It s hard to breathe. 25, I m thirsty. 26. My voice is husky. 27. I feel dizzy. 28. My eyelids twitch. 29. My legs or arms tremble. 30. I feel ill. Fatigue Corrtirruum Form Directions: A number of statements are given below that people have used when they feel tired. Listen to each statement and tell the nurse reading if this statement indicates how you have generally felt since delivery. There are no right or wrong statements. Do not spend too much time thinking about each item but give the best answer for how you have generally felt since delivery. 1 = Not at all; 2 = Somewhat; 3 = Moderately So; 4 = Very Much So 1. I feel that my head is heavy. 2. I feel tired over my whole body. 3. I feel tired in my legs. 4. I feel like yawning. 5. I feel like my brain is hot and muddled. 6. I feel drowsy. 7. I feel like my eyes are strained. 8. I feel clumsy when moving. 9. I feel unsteady when standing. 10. I feel I want to lie down. 11, I feel I can not think. 12. I feel I am weary of talking. 13. I feel nervous. 14. I feel unable to concentrate. 15. I feel am unable to take an interest in things. 16. I feel I am apt to forget things. 17. I feel that I lack self confidence. 18. I feel anxious. 19. I feel I am unable to straighten my posture. 20. I feel that I have no patience. 21. I feel like 1 have a headache. 22. I feel stiff in the shoulders. 23. I feel a pain in my back. 24. I feel oppressed in my breathing. 25. I feel thirsty. 26. I feel like my voice is husky. 27. I feel dizzy. 28. I feel like I have spasms of the eyelids. 29. I feel like I have tremors in my limbs. 30. I feel ill. Evaluation Process The researchers used a combination of research findings and clinical experience to develop recommenda- pared across samples within each of the childbearing periods. Both forms of the scale were compared. TWO clinicians, a certified labor and delivery nurse, and an 76 JOG Volume 28, Number 1

sight. The goal was to help nurse clinicians evaluate levels of maternal fatigue to effectively intervene with patients and families before the symptoms became disabling. Levels of Fatigue Fatigue scores are presented at representative times during child bearing: pregnancy, the intrapartum period, and the postpartum period. Although it is not possible to present absolute cut scores for low, moderate, and high levels of fatigue, relative scores are presented using descriptive statistics (means and standard deviations). These relative scores were used to estimate criteria. Moderate fatigue is estimated as scores that were between one standard deviation above and one standard deviation below the mean (inclusive). Low fatigue is estimated as scores less than one standard deviation below the mean, and high fatigue is estimated as scores more than one standard deviation above the mean. At some periods in childbearing, the authors had more than one sample, or more than one measure during the representative time period. In this case, the largest sample was used for the estimate. Pregnancy Fatigue. One study of 60 low-income pregnant women at 28 weeks of pregnancy (Milligan & Kitzman, 1992) used the Fatigue Identification Form. On this form, the average number of symptoms was 9.6 (range, 0-30). Based on these data, moderate pregnancy fatigue ranged from a score of 3.9 to 15.3, with low fatigue estimated as a score of 3.8 or less, and high fatigue as a score of 15.4 or more. In another study of 11 low-income women during pregnancy (Pugh & Milligan, 1995), in which the Fatigue Continuum Form was used (score range, 30-120), during the third trimester the average score was 51.5. Moderate fatigue ranged from a score of 34.6 to 68.4, with low fatigue being a score of 34.5 and below, and high fatigue being a score of 68.5 and above. These scores suggests that practitioners must recognize the wide range of fatigue scores during pregnancy because standard deviations were large. Nursing assessment of fatigue during pregnancy is appropriate during prenatal care or during antepartum testing or hospital stays. Fatigue scores during pregnancy may help the nurse to verify patients stress, nutritional status, or general well being. Although high scores during pregnancy may indicate that a patient is at high risk for preterm labor (Pitzer, 1990), nurses need to balance actual scores with their clinical judgment because the reference samples are quite small. The literature indirectly suggests some interventions that may ameliorate fatigue. During pregnancy, women who reported high anxiety and high depressive symptoms also had high fatigue (Pugh & Milligan, 1995). Tracking fatigue and intervening may help to decrease fatigue symptoms, thus potentially contributing to the relief of anxiety and depression. Performance indices that emphasize the importance of nursing assessment of fatigue during pregnancy include the ability to maintain usual activities, the ability to carry the pregnancy to term, and the woman s general condition for labor (Pugh & Milligan, 1993). Intraparturn Fatigue. During the intrapartum period, only the Fatigue Continuum Form has been used. In a study of 100 healthy primigravida women on admission to the labor unit (Pugh, 1990), the average fatigue score was 57.5. Thus, moderate intrapartum fatigue was a score of 41.6 to 73.4, low fatigue was a score of 41.5 or less, and high fatigue was a score of 73.5 or more. Discussion with subjects and clinical observation supported the notion that the intrapartum period is a time of high fatigue. Fatigue assessment would be valuable on admission to the unit, and could help clinicians evaluate general patient status throughout labor, particularly at critical times, such as when decisions are made regarding anesthesia and before pushing. During the intrapartum period, fatigue was found to be lower in persons who exercised during pregnancy (Pugh, 1990). Fatigued women who were admitted to the hospital for labor progressively became more tired and were exhausted when it was time to begin the role of parent (Pugh, 1990). Recognizing this, nurses may choose to intervene during prenatal care to encourage exercise and other ways to conserve energy. Performance indices that might relate to intrapartum fatigue are the mother s condition for bonding after delivery and her ability to push (Pugh & Milligan, 1993). Postpartum Fatigue. During the postpartum period, both forms of the FSC were used. In a study of 399 healthy women during postpartum hospital stays (Parks & Lenz, 1991), the Fatigue Identification Form was used; the average fatigue score was 7.2. Moderate fatigue was a score of 2.7 to 11.7, low fatigue was a score of 2.6 or less, and high fatigue was a score of 18.8 or more. Using the Fatigue Continuum Form, in a study of 108 patients during the first 24 hours after delivery, the average fatigue score was 51.5. Moderate fatigue was a score of 38.6 to 64.4, low fatigue was a score of 38.5 or less, and high fatigue was a score of 64.5 or more. The nurse interacting with patients during the postpartum period (whether in the hospital, clinic, or community) will find fatigue assessment useful. During the postpartum period, it has been reported that women who breastfeed report greater fatigue than do women who bottle feed (Milligan, 1989). Finding ways to save a breastfeeding woman s energy levels may help to prevent premature weaning. The American Academy of Pediatrics (AAP) recommends that women breastfeed for 1 year (AAP, 1997). Helping women to continue breastfeeding by helping them understand their JanuarylFebruary 1999 JOGNN 77

fatigue may aid in lengthening the duration of breastfeeding. Using a positioning intervention was found helpful (Milligan et al., 1996) and may be one easy way to intervene with these women. Fatigue gives insight into postpartum performance related to mothers return to function, level of self-care, mothering behaviors, infant care, relationships with others, coping behaviors, and physical recovery from childbirth (Pugh & Milligan, 1993). In one postpartum study. both the identification and the continuum forms of fatigue assessment tools were used (Pugh & Milligan, in press). In this sample, the correlation between scores on the two instrument types and with other theoretically relevant variables were computed and were similar. Within 24 hours of delivery, the mean and standard deviation were computed for the fatigue identification form (M = 12.7, SD = 5.3) and for the fatigue continuum form (M = 53.6, SD = 13.1). As expected, the scores from the Fatigue Continuum Form had higher variability (note standard deviations), which is useful in research; however, the form was more complex to administer and for patients to comprehend. The Fatigue Identification Form scores had less variability, but the form was easy for patients to comprehend. Either form had little respondent burden in terms of time of administration; both could be completed in less than 10 minutes. Conclusions and Recommendations Fatigue is a common problem for childbearing women during all phases of pregnancy. Ways to assess this unpleasant symptom are available to nurses. Two different forms of the FSC have been presented that can easily be incorporated into clinical practice. Specific scoring has been suggested that will indicate levels of fatigue. These methods can be part of prenatal assessment and can be an early warning of changes in a woman s well-being. Assessment (measurement) and intervention are both necessary parts of the process of clinical care. Measurement precedes and follows intervention. Measurement is used to determine whether intervention is needed and is used to determine whether intervention was effective. Measurement before and after treatment can be done with either the identification form or the continuum form. A specific cut point cannot be determined on the forms at this time. A cut point is used to determine whether the measured fatigue is high enough to warrant treatment. An explicit cut point is not available for two reasons. First, there has been little research on the relationship between levels of fatigue and performance. We do not know how high the level of fatigue must be to significantly affect performance. Second, there is not a gold standard diagnostic tool for fatigue against which Fatigue is a common problem for childbearing women during all phases of pregnancy. Ways to assess this unpleasant symptom are available to nurses. to gauge the level of fatigue measured on the two forms of the FSC. However, means and standard deviations are available for each of the forms, and it can be inferred that one standard deviation above the mean is on the high end of an expected distribution. Women whose scores are this high should be candidates for intervention. Women with higher scores should be considered at high risk for more accident proneness, decreased sex drive, decreased performance, less interest in their surroundings, increased irritability, and increased listlessness (Sparks & Taylor, 1995). Conversely, these risks could be considered indices for fatigue intervention. Either form of the FSC can be used before and after intervention. Lower levels of fatigue after treatment can be interpreted as movement in a healthy direction; however, the improvement may not be attributable to intervention. Interventions to prevent fatigue may be warranted for high risk groups (such as breastfeeding mothers). Interventions can include conservation of energy, planning and controlling life situations, nutritional enhancement, exercise, and cognitive strategies for better understanding the effects of fatigue on life (Sparks & Taylor, 1995). Continuous measurement of fatigue during and after effective intervention should reveal a below average level on the measures. In nursing practice, the Fatigue Identification Form may provide an easy way for clinicians to quantify fatigue at various periods during chi Id bea ri ng. The authors measured childbearing fatigue in research settings during the past 10 years and found two ways of using the FSC useful in research settings. This article presents insights regarding why scores are important and how to interpret them. In nursing practice, the Fatigue Identification Form may provide an 78 JOGNN Volume 28, Number 1

easy way for clinicians to quantify fatigue at various periods during childbearing. The Fatigue Continuum Scale is useful but may be more appropriate to research than in clinical practice. It is important to note that in the studies reported, significant results have been found using both forms, which supports the use of either instrument. Acknowledgements Partial funding from The National Center for Nursing Research, now the National Institute of Nursing Research, the Robert Wood Johnson Foundation, and Mead Johnson Nutritionals through Sigma Theta Tau International made this analysis possible, REFERENCES Affonso, D. D., Lovett, S., Paul, S., & Sheptak, S. (1990). A standardized interview that differentiates pregnancy and postpartum symptoms from perinatal clinical depression. Birth, 17(3), 121-130. American Academy of Pediatrics, Work Group on Breastfeeding. (1997). Breastfeeding and the use of milk. Pediatrics, 100(6), 1035-1039. Beck, C. T. (1993). Teetering on the edge: A substantive theory of postpartum depression. Nursing Research, 42, 42-48. Chapman, J. J., Macey, M. J., Keegan, M., Borum P., & Bennett, S. (1985). Concerns of breast feeding mothers from birth to 4 months. Nursing Research, 34(6), 374-377. Fawcett, J., Tulman, L., & Myers, S. T. (1988). Development of the inventory of functional status after childbirth. Journal of Nurse-Midwifery, 33(6), 252-260. Fischman, S. H., Rankin, E. A., Soeken, K. L., & Lenz, E. R. (1986). Changes in sexual relationships in postpartum couples. JOGNN, 15, 58-63. Kinsman, R. A., & Weiser, P. C. (1976). Subjective symptomatology during work and fatigue. In E. Simonson & P. C. Weiser (Eds.), Psychological aspects and physiological correlates of work and fatigue (pp. 336-405). Springfield, Illinois: Charles C. Thomas. Lenz, E. R., Pugh, L. C., Milligan, R. A., Gift, A., & Suppe, F. (1997). The middle-range theory of unpleasant symptoms: An update. Advances in Nursing Science, 19(3), 14-27. Milligan, R. (1989). Maternal fatigue during the first three months of the postpartum period. Dissertation Abstracts International, 50, 07-B. Milligan, R. A., Flenniken, P. M., & Pugh, L. C. (1996). Positioning intervention to minimize fatigue in breastfeeding women. Applied Nursing Research, 9(2), 67-70. Milligan, R., & Kitzman, H. (1992, March). Fatigue during pregnancy. Paper presented at Nursing Research Across the Life Span: Methods, Issues and Interventions, sponsored by the Johns Hopkins University and University of Maryland at Baltimore, Baltimore, Maryland. Milligan, R., Lenz, E. R., Parks, P. L., Pugh, L. C., & Kitzman, H. (1996). Postpartum fatigue: Clarifying a concept. Scholarly Inquiry for Nursing Practice, 10(3), 279-291. Milligan, R. A., Parks, P., Kitzman, H., & Lenz, E. (1997). Measuring women's fatigue during the postpartum period. ]ournal of Nursing Measurement, 5( l), 3-16. North American Nursing Diagnosis Association. (1990). Taxonomy I revisited- 1990 with official nursing diagnoses. St. Louis: Author. Parks, P., & Lenz, E. (1991). Final report to NIH: Predictors of Maternal Behavior and Infant Development. Unpublished. Pitzer, M. (1990). The consequences of preterm labor for the previously employed woman. Paper presented at NAA- COG'S Third Biennial Research Conference, Denver, Colorado, July. Poole, C. J. (1986). Fatigue during the first trimester of pregnancy. JOGNN, 15,375-379. Pugh, L. (1990). Psychophysiological correlates of fatigue during childbirth. Dissertation Abstracts International, 51, 01-B. Pugh, L. C. (1993). Childbirth and the measurement of fatigue. Journal of Nursing Measurement, 1 (l), 57-66. Pugh, L. C., & Milligan, R. (1993). A framework for the study of childbearing fatigue. Advances in Nursing Science, 15(4), 60-70. Pugh, L. C., & Milligan, R. A. (1995). Patterns of fatigue during childbearing. Applied Nursing Research, 8( 3), 140-143. Pugh, L. C., & Milligan, R. A. (1998). A home nursing program to increase duration of breastfeeding. Applied Nursing Research, 11, Pugh, L. C., Milligan, R. A., Gray, S., & Strickland, 0. (in press). First stage labor management: An examination of patterned breathing and fatigue. Birth. Reeves, N., Potempa, K., & Gallo, A. (1991). Fatigue in early pregnancy. Journal of Nurse-Midwifery, 36, 303-309. Ruchala, P. L., & Halstead, L. (1994). The postpartum experience of low-risk women: A time of adjustment and change. Maternal-Child Nursing Journal, 22(3), 83-89. Sparks, S., & Taylor, C. (1995). Nursing diagnosis reference manual. Springhouse, Pennsylvania: Springhouse Corporation. Tulman, L., & Fawcett, J. (1988). Return of functional ability after childbirth. Nursing Research, 37, 77-81. Tulman, L., & Fawcett, J., Groblewski, L., & Silverman, L. (1990). Changes in functional status after childbirth. Nursing Research, 39, 70-75. Tulman, L., Higgins, K., Fawcett, J., Nunno, C., Vansickel, C., Haas, M. B., & Speca, M. M. (1991). The inventory of functional status-antepartum period. Journal of Nurse- Midwifery, 36, 117-123. JanuarylFebruary 1999 JOG" 79

Yoshitake, H. (1971). Relations between the symptoms and the feeling of fatigue. Ergonomics, 24, 175-186. Linda C. Pugh is an AssociateProfessorand the DirectorofProfessional Education Programs at the The Johns Hopkins University School ofnursing in Baltimore, MD. Renee Milligan is an Associate Professor in the School ofnursing at Georgetown University in Washington, DC. Pew L. Parks is a DevelopmentalPsychologistin Baltimore, MD. Elizabeth R. Lenz is an Associate Dean for Nursing Research and Director of the Doctoral Program at Columbia University in New York, NY. Ham-etKitzman is an Associate Professor in the Schoolo fnursing and an Associate ProfessorofPediatrics at the University of Rochester in Rochester, NY. Address for correspondence: Linda C. Pugh, RNC, PhD, 525 North Wolfe Street, Baltimore, MD 21205. Earn Continuing Education Credit for Clinical Issues This and other Clinical Issues (CI) series can be used to earn continuing education credit to meet your career, licensure, and/or certification needs. The independent study modules (purpose/goal, objectives, and multiple-choice posttest) can be obtained from AWHONN by phone, fax on demand, or on its website. The number of contact hours awarded varies between 1.5 and 4.0 (depending on the number of articles contained in the CI series); the processing fee for members is $10 and for nonmembers, $15. Credit may be earned up to 1 year after the date of publication. For more information, contact AWHONN at 800-673-8499, ext. 2417, or http:\\www.awhonn.org. AWHONN is accredited as a provider of continuing education in nursing by the ANCC Commission on Accreditation. California CE Provider #BRN 00580; Alabama Board of Nursing Provider #ABNPOO58. 80 JOGNN Volume 28, Number 1