Examining the Evolving Role of the BSN-Prepared Nurse outside Acute Care Settings: A Nursing – Shared Theory/Conceptual Model Approach

Co-Contributor: Katunzi Mutalemwa

The purpose of this blog is to describe a baccalaureate (BSN) prepared nursologist’s, Katunzi Mutalemwa personal lived pre-internship clinical learning experience in primary care at a local community-based non-governmental outpatient clinic run by The Tanzania Doctors with African CUAMM  in collaboration with a local District hospital.

Katunzi’s reflections have been interpreted within the context of nursology discipline-specific knowledge of Neuman’s Systems Model (NSM), and the Theory of Self-Care of Chronic Illness (TSCC), as well as the Expanded Chronic Care Model, a model shared with public health.

Inasmuch as the ECCM is a shared model, the starting point for the interpretation is the nursology discipline-specific conceptual model that is NSM (Villarruel et al., 2001). Whereas the NSM guided the overall understanding of the reflections, the concepts of the TSCC guided some of the specific actions described, as did the ECCM. The NSM provides a nursology conceptual foundation that takes into considerations the multiple levels of client/client system influences – the physiological, psychological, socio-cultural, developmental and spiritual interacting factors and environmental stressors. The model has the potential of advancing the future of nursology in the area of expanded nursing scope of practices and services in response to chronic disease management.

Katunzi’s reflections highlight the role of the BSN-prepared nursologists in the management and prevention of chronic diseases beyond the walls of the acute care settings (i.e., community-based primary health care settings)

The main ideas seen in this blog are consistent with the World Health Organization’s (2020) State of World Nursing publication, the nursology.net blog Primary-care-primary-nursology-and-the-attending-nursologist, the AACN White-Paper on the Vision-Academic-Nursing; the Health Resources & Services Administration (HRSA) 2018 call for Nurse Education, Practice, Quality and Retention (NEPQR) – Registered Nurses in Primary Care (RNPC) Training Program as well as several journal articles on the role of the primary care nursologist (e.g. Anderson et al., 2012; Bodenheimer, & Mason, 2016; Borgès Da Silva et al., 2018; Epping-Jordan, 2002; Lipstein, et al., 2016; Norful, et al., 2017).  The description of the roles and responsibilities discussed in this blog acknowledge the varied contextual nursing scope of practices across the globe.

Katunzi’s Nursing Context/Situation

The personal reflections demonstrate how a BSN-prepared nursologist practices within the Tanzania Nursing and Midwifery Council (TNMC) (2014) general nurse full scope of practice. The TNMC’s major role definitions of a general nurse prepared at the baccalaureate level are: 1) Accountability, Ethical and Legal Practice; 2) Care Provision, Health Promotion, Leadership and Management and, 3) Professional, Personal and Quality Development. For instance, the care provisions and leadership definition of the TNMC general scope of practice, the BSN-prepared nurse roles includes, but is not limited to developing practice guidelines, representing nursing at the management meetings, preparing and presenting nursing budgets at management team meetings, participating in nursing research and utilizing research results in provision of nursing care, providing comprehensive nursing care and carrying out nursing management independently, formulating relevant policies about patient and client care, and reviewing performance appraisal for nurses. According to the TNMC, if assigned, a BSN-prepared nurse is also allowed to prescribe medications for persons with some acute, emergency conditions and chronic illnesses and to prescribe physical therapy and other rehabilitative treatments in keeping with existing protocols.

Katunzi’s reflections

Community Resources and Policies and, Health Care System (Concepts of the ECCM)

As a BSN-prepared nurse completing a pre-internship clinical learning opportunity in a private community-based clinic (NSM community as the client system), I was mentored into the primary care role by a team of nurses and other healthcare providers. I was involved in the management of clients living with diabetes and heart diseases (adults and adolescents) (NSM developmental variable) trice a week and also participated in conducting monthly supervisions in satellite health centers. I learned to assure patients/clients maintained a maximum level of wellness by keeping stressors and stress responses at a minimum through effective, efficient care at three levels of prevention (NSM prevention as intervention). Utilizing a holistic approach (NSM physiological, psychological, socio-cultural, development, and spiritual variables), I was exposed in health counseling, medication administration, health teaching, case management and care coordination services (NSM prevention as intervention]. I worked closely with nurses in other satellite health centers within the clinic’s catchment area. The collaboration strengthened patient treatments and improved care. I regularly participated in conducting home visits and tracking down patients who were lost to follow-up careI dealt with barriers such as clients’ religious and traditional beliefs that hinder adherence to prescribed regimen (NSM socio-cultural and spiritual variables).

As a part of the learning process, I practiced advocacy and I was able to participate in regular district administrative meetings to negotiate consultation fees and cost of drugs with district authorities (NSM socio-cultural variable). I improved my nursing skills in individual/family and community assessment while fulfilling this role. For instance, I was able to share with the authorities how financial challenges forced clients to take half doses of their prescribed medication and intentionally caused missed follow-up visits. Likewise, I noted that other clients opted to traditional herbal treatments as they were perceived to be cheaper than hospital medications. I was able to see how self-medication practices (Concepts of the TSCC) can harden caring of chronic patients. Some patients opt to buy drugs in stores rather than visit the clinic or hospital. Some of the challenges were attributed to lack of transportation and health illiteracy on disease processes (NSM socio-cultural variable). I called attention to the impact of laxed drug dispensing policies on clients’ lives.  For example, I shared how clients with contraindicated medication can easily procure the drugs from a local drug store, making them at risk of readmissions and possibly death. In addition, as a community health educator, I advised patients and their families to participate in community development projects such as livestock keeping, small scale agricultural that helped them to earn extra money for buying drugs and supporting individual and family their well-being (NSM socio-cultural and spiritual variables ).

Delivery System Design and Self-Management Support(Concepts of the ECCM)

The community clinic was centered at a District Hospital and operated synergically with ten other health centers within our catchment area (NSM community as the client system). I learned to assure the provision of self-care maintenance, self-care monitoring, and self-care management services (Concepts of the TSCC). For instance, I was involved in caring for chronic disease patients especially type 1 diabetic patient by empowering and preparing clients to manage their health through effective and safe self-injection practice. I provided health education on regular testing to control glucose levels as well as insulin-self administration.  Assessing clients’ health literacy levels in the treatment process was a crucial piece of my practice role. I developed peer guided groups with an interpofessional team comprising of a nutritionist and physician. In addition, I conducted monthly supervision at each of the ten assigned health centers. During the supervisory visits, I was involved on assessing the overall patient’s adherence practice to nursing care and follow up (Concepts of the TSCC). I also participated in conducting professional development seminars to nurses on management of patients living with chronic diseases, how to conduct referrals and improve protocols to manage patients with diabetic ketoacidosis and heart failure (NSM variances from wellness). I completed frequent home visits with nurses and other providers to assess the client’s progress, adherence practices and storage of medications (concepts of the TSCC), as well as delivered promotional health messages to patients and families (NSM primary prevention as intervention).

Decision Support and Clinical Information System (Concepts of the ECCM)

I learned how to make clinical decisions in chronic disease management consistent with scientific data and patient preferences. For example, when I saw patients with medical adherence issues, I made sure I educated the clients on possible consequences and let the clients make informed decisions (NSM primary prevention as intervention). I always acknowledged the challenging presence of scientifically unproved treatment plans attributed to the growing number of traditional doctors involved in client’s health care decisions (NSM individual as the client system). I always paid attention to gender-based influences (NSM socio-cultural and spiritual stressors) in medication adherence NMS-. For instance, I was able to determine that men attended treatments when they had severe signs and symptoms of an illness and/or at advanced stage of disease. To address this social determinant among some of the men, I participated in initiating the use of mobile phones to trace patients on monthly basis. This initiative had a positive impact on “no show” clients who had access to mobile phones.

Implications for nursologist scholars

Katunzi’s reflections have implications for advancement of nursology discipline-specific knowledge and future professional transformations. The evolving role of the nursologist  in primary care (Wojnar & Whelan, 2017) calls for a well-rounded RN (Swan, et al, 2006) and, most importantly, a BSN-prepared global nursology  workforce (Wojnar & Whelan, 2017). Use of the ECCM requires ongoing research — or review of existing research – to determine the validity of the model as a shared theory/model (Villarruel et al., 2001) that is useful in new nursing education curricula (Humphrey, 2019),  reimbursement (Funk & Davis, 2015) and regulatory models (Start, 2020) situations that fit BSN-prepared nurses’ full scope of nursologists’ practice and meet clients’ health and social needs in places where people live, learn and play.  

We would like to learn from our nursology.net readers on their perceptions of these questions:

  1. What does the future of nursology hold for the role of the BSN-prepared nursologist in primary care, especially in the United States where primary care is regarded as a major role of advanced practice nursologists holding master’s and/or Doctor of Nursing Practice degrees?
  2. How can nursologists overcome the barriers and maximize contextual opportunities to fulfill their roles? 
  3. What barriers may influence effective adoption of applicable borrowed and shared theories/models in nursology-led chronic disease management interventions?

We welcome nursologists at different levels of practice (i.e., LPN, ADN, BSN, DNP, PhD-prepared) to share their stories of how they provide primary care services (or ambulatory care or community-based care), in private or public health care systems.  Please share your thoughts in comments section below

References

Anderson, D., St. Hilaire, D., Flinter, M., (May, 2012). Primary Care Nursing Role and Care Coordination: An Observational Study of Nursing Work in a Community Health Center OJIN: The Online Journal of Issues in Nursing, 17, 2, http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-17-2012/No2-May-2012/Primary-Care-Nursing-Role-and-Care-Coordination.html

Barr, V, Robinson, S, Marin-Link, B, Underhill, L, Dotts, A, Ravensdale, D, & Salivaras, S. (2003). The expanded chronic care model: an integration of concepts and strategies from population health promotion and the chronic care model, Hospital Quarterly, 7(1), 73-82.

Bodenheimer, T., & Mason, D. (June, 2016). Registered nurses: Partners in transforming primary care. In Proceedings of a conference sponsored by the Josiah Macy Jr. Foundation in June. http://64.62.135.154/docs/macy_pubs/Macy_Monograph_Nurses_2016_webPDF.pdf

Borgès Da Silva, R., Brault, I., Pineault, R., Chouinard, M.-C., Prud’homme, A., & D’Amour, D. (2018). Nursing Practice in Primary Care and Patients’ Experience of Care. Journal of Primary Care & Community Health, 9, 1-7 https://doi.org/10.1177/2150131917747186

Epping-Jordan, J., (Ed.) (2002). Innovative care for chronic conditions: building blocks for action: global report (document no. WHO/NMC/CCH/0201). World Health Organization Global Report. https://www.who.int/diabetes/publications/icccreport/en/

Funk, K. A., & Davis, M. (2015). Enhancing the role of the nurse in primary care: the RN “co-visit” model. Journal of general internal medicine30(12), 1871-1873.

Health resources & Services Administration (2018).  Nurse Education, Practice, Quality and Retention (NEPQR) – Registered Nurses in Primary Care (RNPC) Training Program. Retrieved from https://www.hrsa.gov/grants/find-funding/hrsa-18-012

Humphrey, B., L., Mixer, S. J., Thompson, K., Davis, S., Elliott, L., Lakin, B., … & Niederhauser, V. (2019). Transforming RN roles in community-based integrated primary care (TRIP): Background and content. Issues in mental health nursing40(4), 347-353.

Lipstein, S. H, Kellermann, A. L., Berkowitz, B., Phillips, R., Sklar, D., Steele, G. D., & Thibault, G. E. (September, 2016). Workforce for 21st century health and health care: A vital direction for health and health care. National Academies of Medicine. https://nam.edu/wp-content/uploads/2016/09/Workforce-for-21st-Century-Health-andHealth-Care.pdf.

Norful, A., Martsolf, G., de Jacq, K., & Poghosyan, L. (2017). Utilization of registered nurses in primary care teams: A systematic review. International journal of nursing studies74, 15-23.

Start, R., Brown, D. S., May, N., Quinlan, S., Blankson, M., Rodriguez, S. R., & Matlock, A. M. (2020). Strategies for creating a business case that leverages the RN role in care coordination and transition management. Nursing Economics38(4), 203-217.

Swan, B. A., Conway-Phillips, R., & Griffin, K. F. (2006). Demonstrating the value of the RN in ambulatory care. Retrieved from https://jdc.jefferson.edu/cgi/viewcontent.cgi? article=1012&context=nursfp

The Tanzania Nursing and Midwifery Council (2014). Scope of Practice for Nursing and Midwives in Tanzania. United Republic of Tanzania.

Wojnar, D. M., & Whelan, E. M. (2017). Preparing nursing students for enhanced roles in primary care: The current state of pre-licensure and RN-to-BSN education. Nursing Outlook65(2), 222-232.

Villarruel, A.M., Bishop, T.L., Simpson, E.M., Jemmott, L.S., & Fawcett, J. (2001). Borrowed theories, shared theories, and the advancement of nursing knowledge. Nursing Science Quarterly, 14, 158-163. 

Guest Post: I Thought all Nurses used Mirrors!

Contributor: Wyona M. Freysteinson, PhD, MN
Theory: Neurocognitive Model of Mirror-Viewing

Wyona Freysteinson

At the age of two, I decided I was going to be a nurse. My great grandmother, my first patient, taught me my colors while testing urine for ketones, how to give insulin, and that when I combed her hair, she looked in a mirror.

I thought all nurses used mirrors.

The quest to understand the mirror-viewing experience began in the 1970s-1980s when I practiced bedside nursing, with a small mirror my uniform pocket. I wondered why the mirror was soothing to so many of my patients (e.g., seeing how I had re-taped a nasogastric tube)? In some patients, I witnessed a look of terror (e.g., viewing a scalp incision)?

When I suggested a mirror-viewing study in my master’s program in 1990, the dean called me into her office. The dean said I could not study mirrors as sick people do not want to look in mirrors. Upon deep reflection, I realized that I had not caused severe psychological harm to thousands of patients with my pocket mirror. I turned to the philosophy department where a professor who had been a student of Paul Ricoeur joined me in my quest. The mirror research journey had begun.

This research trajectory continued with studies of the mirror-viewing experience after a terminal illness diagnosis, amputation, mastectomy, and military sexual trauma. This mirror knowledge base helped me understand the experience of mirroring.

This knowledge base, however, did not explain the mirror phenomenon. Why did some participants tell stories of severe mirror distress (e.g., I wanted to run out on the road screaming)? Why did other participants say they felt no emotions when seeing their bodies for the first time after disfigurement? Why did so many participants remember a terrifying mirror image that occurred several years earlier, and I struggled to remember my mirror image from this morning?

A deep dive into the literature unearthed MRI studies demonstrating self-recognition occurs in the pre-frontal cortex. Together with memory and the autonomic nervous system theories and my research, this information formed the foundation of the mid range nursing theory: Neurocognitive Model of Mirror-Viewing. Although mirrors have a tenuous historical and mythical past, and to some individuals are considered taboo, mirrors are simply tools. For example, mirrors are useful for self-assessment (e.g., diabetic foot care, skincare), self-incision and wound care, colostomy care, prosthetic alignment, and pushing during birth. Many individuals use a mirror to brush their teeth and other activities of daily living. Only in mirrors can we see our faces and whole bodies. However, Initial mirror-viewings in the aftermath of visible disfigurement, sexual trauma, or bullying may be distressing or traumatic. Ongoing mirror discomfort and mirror avoidance may occur.

Sensitive, supportive nursing mirror interventions are needed to mitigate mirror trauma. Since my visit to the dean, I cannot count the number of individuals who have considered my work absurd, frivolous, or inconsequential. Nor can I calculate the countless numbers of cheerleaders who have had traumatic mirror experiences and wished a nurse had been there for them. My hope is that my work expands nursing science to the extent that nurses do use mirrors.

The Community as Client: A Critical Caring Exemplar

Dorothea Fox-Jakob

I first heard of Dorothea Fox Jakob when I began public health nursing practice, mid-way through my nursing career.  She was well known in public health nursing circles for her strong advocacy efforts, particularly in relation to influencing public policy changes that would help to address the adverse effects poverty had on human health, and particularly that of children.  That work had earned her a letter of thanks from none other than the nursing theorist, Virginia Henderson!  (See November 20, 2013 post “An Introduction to the Canadian Nursing Theories Perspective“)

Now retired, Dorothea is sorting through her many papers and came upon one she had been invited to give at a local NANDA group meeting in Massachusetts. The request was prompted by her speaking out passionately at a national NANDA meeting on the need for the group to consider nursing diagnoses for communities-as-clients, not only for individuals. The paper, “We Look Like Giants” (click to download), represents a case study of an aspect of the work of a team of 3 public health nurses  with young mothers in a district of Toronto in which she practiced.

The educational background of the PHN team is not specified, except that one was a mental health nurse specialist, one a generalist. I know from dialogue with Dorothea, that she was the 3rd nurse and had attended NYU where she earned a Masters of Public Health Nursing, a degree that prepared her as a public health clinical nurse specialist. NYU, known for its strong emphasis on nursing theory, would also have given her a strong nursing theoretical foundation for her work. The attached paper, however, does not identify a specific nursing theoretical framework that informed the PHN team’s practice.

W hen I read “We look like Giants”, I was struck by how it demonstrated Critical Caring in action.  Although the paper was written 15 years before I articulated the theory, I have previously referred to it as a “descriptive theory”, i.e., it was my effort to articulate the practice of expert public health nurses within a coherent nursing theoretical framework, initially as I observed it in practice (Falk-Rafael, 2005), and then through research (Falk-Rafael & Betker, 2012a; Falk-Rafael & Betker, 2012b) and most recently through further reflection (Falk-Rafael, 2020).

Critical caring is rooted in the writings and example of Nightingale, Watson’s  human caring science, and feminist critical social theories. It is conceptualized  as a way of being (in relation), knowing (embracing multiple ways of knowing), and choosing (ethics). It identifies 7 carative health promoting processes (CHPPs).

In our conversations, Dorothea emphasized that the focus of the 3-public health nurses who undertook this process was in supporting a neighbourhood  drop-in centre by helping it meet the needs of young mothers in the area. And, certainly the “client” in the example may be conceptualized in this way, Client” could also refer to the larger community the drop-in centre served, or the group of Moms who attended the group sessions that the nurses facilitated. Because the paper provides more information about the nurses’ relationship with the group of Moms, I will focus on them as the “community as client” for the purpose of this blog..

CHPP I involves the preparation of self. In addition to Dorothea’s education and nursing experience, she  identifies her own experience as a mother in preparing her for the her work with the group. In addition, she identifies engaging in “soul-searching” and values clarification at the outset.

CHPP II involves developing and maintaining a helping-trusting relationship. Evidence of a respectful, non judgemental, and an authentic way of being present is evident throughout Dorothea’s narrative. Evidence of mutuality in goal-setting and evaluation methods is also described – the mothers identified the issues they wanted to rap (or talk) about and the nurses defined the temporal boundaries (1 ½ hours/week for 10 weeks) and committed to be there. The paper has many examples of inclusiveness and acceptance – sporadic attendees were as welcome as regular attendees, the presence of small children and/or babies was not only accommodated but efforts were made to “spell off” mothers with babies. Self-disclosure and human touch were also identified and contributed to the relationship-building.

Dorothea’s story describes the reflexive approach of the nurse-facilitators in identifying, planning, responding to health goals, as well as in evaluation (CHPP III – using a systematic, reflexive approach). For example, topics were added as new issues were raised. Likewise, some evidence of transpersonal teaching-learning (CHPP IV – engaging in transpersonal teaching-learning) may be seen and/or inferred as group members shared their experiences in managing situations other group members were experiencing. It is clear in the example that the nurse facilitators created a safe environment in which the women could share their experiences comfortably (CHPP V – providing, creating and/or maintaining supportive and sustainable environments).

CHPP VI refers to meeting needs and building capacity. The narrative identifies meeting needs for nourishment and  child-care during the meetings, in addition to attending to the needs for social interaction and improved self-image. As participants were encouraged to call each other between meetings, it is reasonable to assume that their capacity to care for each other may have improved. On another level, the nurses’ efforts also met a need and strengthened the capacity of the drop-in centre to support young mothers in the surrounding community.

CHPP VII refers to being open to various ways of making meaning in which those for whom we care engage. Whereas the narrative does not specifically address this process, group members’ identification of the instillation of hope as one of the outcomes of the group sessions may be an aspect of this carative process.

The focus of Dorothea’s paper was to give an example of public health nursing work with a community- as-client to a group of nurses involved with NANDA at a local level. Although the explicit nursing knowledge that informed the practice of the PHN team is not specified in her paper, retrospectively the congruence of their nursing care for this community  with a nursing theoretical approach is clear. The paper identifies at least one positive outcome, in that the drop-in centre was able to remain viable for at least the next several years . The story’s title, “We Look Like Giants”, an observation of one of the mothers in the group, suggests, perhaps, that  an enhanced self-image of the participating Moms was another.

Sources

Falk-Rafael, A. (2005). Advancing nursing theory through theory-guided practice: the emergence of a critical caring perspective. ANS. Advances in Nursing Science, 28(1), 38–49. DOI 10.1097/00012272-200501000-00005

Falk-Rafael, A. (2020). Adeline Falk-Rafael’s Critical Caring Theory. In M. C. Smith (Ed.), Nursing Theories and Nursing Practice (5th ed) (pp. 509–521). FA Davis.

Falk-Rafael, A., & Betker, C. (2012a). Witnessing Social Injustice Downstream and Advocating for Health Equity Upstream: “The Trombone Slide” of Nursing. ANS. Advances in Nursing Science, 35(2), 98. DOI 10.1097/ANS.0b013e31824fe70f.

Falk-Rafael, A., & Betker, C. (2012b). The primacy of relationships: a study of public health nursing practice from a critical caring perspective. Advances in Nursing Science, 35(4), 315–332. DOI 10.1097/ANS.0b013e318271d127.

Theory-guided Practice Exemplar: United States Air Force Professional Caring Practice Using Ray’s Theory of Bureaucratic Caring

The first exemplar of theory-guided practice posted on Nursology.net was the United States Air Force Professional Caring Practice Using Ray’s Theory of Bureaucratic Caring.  In the process of preparing the information for posting, Dr. Marilyn “Dee” Ray shared how this came to be!  Here is her story:

It was a great honor to have the USAF, Nurse Corps accept my theory as their framework for

Photo credit: Lifetouch Church Directories – directories@lifetouch .com.

the new Interprofessional Person Centered Caring Model. The actual development came after Colonel Marcia Potter chose the Bureaucratic Caring Theory (BCT) for her doctoral (DNP) research on nurse and staff efficacy and economic outcomes regarding patients with diabetes. She completed her DNP in 2015. Her work improved USAF clinical practice and economic outcomes to the sum of over 2 million dollars.

At the same time, Lt General Dorothy Hogg, Surgeon General and Chief of the Air Force Nurse Corps wanted to develop a theory-guided person centered caring model for implementation in the Nurse Corps. She was the Deputy Surgeon General then but is now the first nurse and woman chosen to the rank of Lieutenant General (3 star) and Surgeon General of the US Air Force . She was recognized for her creativity, intellect, caring nature, and ability to motivate professionals toward health care collaboration and dynamic policy change. Colonel Potter recommended my theory to be the one that the executive should review to see if it would be the best to choose for development in the whole Nurse Corps for theory-guided practice because she had positive clinical and economic outcomes from her research in primary care. Colonel Potter called me on the phone after she found my information in the Society of Retired USAF nurses. So that call began our relationship and my reconnection to the executive of the USAF.

We had many discussions and a number of iterations of the model until the one posted on Nursology.net was selected. Colonel Potter has implemented Bureaucratic Caring Theory-Guided practice and research in all those areas you see on the website. It astounds me in terms of all she accomplishes.  All this has taken place since 2015.

There is now a new initiative that facilitates the development of person-centered caring in the USAF, NC called the C21 or Centers for Clinical Inquiry under the leadership of Brigadier General Robert Marks and Colonel Deedra Zabokrtsky. This initiative is planned in key locations around the Air Force where there are nurse researchers and librarians to support inquiries from the field looking for the best, most relevant research in the literature as it relates to nursing practice (evidence-based/informed practice), as well as engaging nurse researchers in different USAF sites directly in response to queries about improving nursing practice.

At the installation to Surgeon General and Lt. General in Washington, DC last June, Dorothy Hogg gave me this amazing recognition highlighting my theory as the theory that was selected to respond to the new health care initiative to focus on person centered and improve care in the USAF. As you can imagine, I was so deeply humbled and honored. I served in the USAF Nurse Corps for 32 years and served our country in many roles as flight nurse, clinician, educator, administrator, command nurse, consultant, and researcher in aerospace and organizational nursing and health care, veteran, and Colonel Retired, and now in this new role as a nursing theorist. What can I say, but a sincere thank you to so many people, including colleagues like [the Nursology.Net developers] who are role models and have encouraged and guided me throughout the years.

Kindest regards and caring thoughts,
Dee

Follow-up note –
I forgot to mention that I was invited to present the BCT guided interprofessional Person-Centered Caring Model and work in the USAF to the European Society for Person Centered Healthcare in London in September, 2016 where I was awarded an Honorary Distinguished Fellowship of the ESPCH. That is another great honor.