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VOLUME 9 | NUMBER 1 | DECEMBER 2015Quarterly publication direct mailed to approximately 243,000 Registered Nurses & Licensed Practical Nurses in Ohio.

The Ohio Nursing License Plate is moving full steam ahead. The Ohio Nurses Association (thanks to your help!) has collected the petition signatures needed. ONA has also obtained a sponsor and legislation has been introduced. The next step is to pass the bill through Ohio’s General Assembly. Once that bill is signed into law, the license plate will be available within 90 days at your local BMV. Check the Ohio Nurses Association’s Facebook for updates!

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The Highs and Lows of Thyroid Diseases . . . .3

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Mark Your Calendar2016 Dates

ATTENTION APRNsPrescribing Schedule II Medications in Ohio: A Three

Hour Online Course for APRNs on Legal, Ethical and Fiscal Implications (Rule 4723-0-02.A 2b)

This online course is designed to increase knowledge regarding the legal, ethical and fiscal implications of prescribing medications in the Ohio advance practice registered nurse (APRN) role. After this course, the APRN will be able to apply learned knowledge from this course when prescribing medications, including Schedule II. This course meets the three contact hours requirement mandated by the Ohio Board of Nursing in order to be eligible for Certificate to Prescribe (CTP). This independent study can be found online at www.CE4Nurses.org.

Please visit the www.CE4Nurses.org website for an array of independent studies on various topics.

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Page 2 Ohio Nurse December 2015

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__ The Highs and Lows of Thyroid Diseases

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The Highs and Lows of Thyroid DiseasesThis independent study was developed by:

Barbara Walton, MS, RN.

This independent study has been developed for nurses to better understand thyroid diseases and related nursing implications.1.48 contact hours will be awarded for successful completion of this independent study.

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OBJECTIVES1. Identify signs and symptoms of hyperthyroidism and

hypothyroidism.2. Identify nursing implications in caring for a patient

with hyperthyroidism or hypothyroidism.

The Thyroid Gland and Hormones.As you will recall, the thyroid gland lies just below

the thyroid cartilage (Adam’s apple) and is made up of two lobes connected by a strip of tissue referred to as an isthmus. The gland may be palpated by having the patient swallow; the gland moves upward. The gland is very vascular and is composed of follicular cells. The follicular cells produce and store two hormones: Thyroxine (T4) and Triiodothyronine (T3). Collectively T3 and T4 are known as thyroid hormone. Hormone levels are controlled via a feedback loop. When T3 and T4 levels drop, the hypothalamus releases thyrotropin releasing hormone (TRH). TRH causes the anterior pituitary gland to release thyroid stimulating hormone (TSH). TSH binds to receptor sites on the thyroid gland and causes it to immediately release stored T3 and T4 into circulation. TSH also stimulates the thyroid gland to produce more T3 and T4 and increases the uptake and use of iodine. Once thyroid hormone levels return to normal, this feedback loop is completed. Feedback loops are important in maintaining the correct hormonal levels. A disruption in the feedback loop can result in either a deficit or an excess of T3 or T4.

Ninety percent of the hormone produced by the thyroid gland is in the form of T4, while the remaining 10% is produced in the form of T3. Most T4 is bound to proteins; with a small amount being free T4 T4 is converted to T3 through the uptake of iodine. T3 has the greatest physiologic effects. While many of us think of the metabolic effects of thyroid hormones, there are actually many body systems affected by these hormones. The actions of thyroid hormones are listed in the following table.

Body System Effects of T3 and T4

Metabolic and Digestive

• Increasessecretionofdigestivejuicesandincreasesmotility.• Enhancesabilitytoabsorbglucose.• Increasesmetabolicrateviaglucoseuptake,thusincreasingoxygenconsumptionandbody

heat.• Increasesproteinsynthesisandfatmetabolism.• Lowersbloodcholesterolbyincreasingcholesterolexcretion.

Nervous • Promotenormaldevelopmentoffetalnervoustissues

Respiratory • Increasesrateofoxygenuseandproductionofcarbondioxide.

Cardiovascular • Increasestheforceofcardiaccontractility(positiveinotropiceffect)andcardiacoutput.• Increasesheartrate(positivechronotropiceffect)

Musculoskeletal • Enhancesbonegrowthuntiladulthood.• Stimulatesproteinsynthesisnecessaryformusclecontractionandrelaxation.

Integumentary • Controlssweatandoilglands,tokeepskinmoistandsupple.

HyperthyroidismHyperthyroidism results when a patient produces too

much T3 and T4. Keeping in mind the feedback loop, the cause can be identified. Perhaps a particular patient has a tumor of the hypothalamus that hyper-secretes TRH; a tumor of the pituitary gland that hyper-secretes TSH, or a problem with the thyroid gland itself. Diffuse toxic goiter, or Graves’ Disease is caused by antibodies in the blood that stimulate the thyroid to grow and secrete too much hormone. This type of hyperthyroidism tends to run in families and is not well understood, yet it is the most common cause of hyperthyroidism.

Toxic nodular or multinodular goiter (Plummer’s Disease) usually seen in an elderly patient, is another type of hyperthyroidism. In this situation, one or more nodules of the thyroid gland become hyperactive for unknown reasons. An important factor in the nursing assessment of a patient with a large goiter is to assess for esophageal or tracheal compression. Some goiters can become large enough over a period of time and may compress or narrow the airway causing breathing difficulties. Patients may develop hyperthyroidism due to an infection and acquire a resulting thyroiditis, yet no specific bacteria or virus has been identified. Hyperthyroidism may also result from a tumor of the thyroid gland, or when a patient who has hypothyroidism takes too much thyroid hormone replacement.

When a patient reveals abnormal laboratory values and signs and symptoms, indicating hyperthyroidism, it is called thyrotoxicosis. Thyroid storm occurs when a patient with thyrotoxicosis further decompensates, in other words it is the extreme version of hyperthyroidism. Thyroid storm is rare, but can be life threatening, with 20 to 50% of the patients dying. Thyroid storm may be precipitated when a patient with hyperthyroidism becomes ill or sustains an injury, or may occur with sudden discontinuation of medication. Therefore, as with any medication, the patient should be taught to never discontinue medication without consulting a healthcare professional.

Thyrotoxic Myopathy is a neuromuscular disease that is linked to Graves’ disease and hyperthyroidism. This condition is also referred to as Graves’ myopathy,

hyperthyroid myopathy, Basedow’s myopathy or Basedow paraplegia. It is possible for a patient to have thyrotoxic myopathy alone, without hyperthyroidism or Graves’ disease. But we need to be particularly watchful for this complication in our patients who have been diagnosed with hyperthyroid conditions. In thyrotoxic myopathy the patient experiences excessive levels of the thyroid hormone thyroxine, just as they do with hyperthyroidism. It is believed the excessive levels of thyroxine over extended periods of time accelerate lipid oxidation, mitochondrial oxygen consumption and protein degradation, all of which can result in muscle fiber damage. Left untreated, the muscle loss may result in rhabdomyolysis. One of the complications of rhabdomyolysis is kidney failure as large protein molecules from the degradation of the muscles occlude and damage nephrons and capillary beds in the kidney.

Primarily muscles of the pelvic girdle, shoulders, torso, eyes and eyelids are affected. Loss of torso muscles (back and abdomen) accompanied by loss of pelvic girdle muscles puts a patient at risk of falling, resulting in further injury. Some patients may experience severe attacks of thyrotoxic myopathy that can result in a periodic paralysis. The paralysis results when there is a massive influx of potassium into the intracellular space, yielding a low extracellular potassium level. In extreme situations, this can lead to respiratory and or cardiac arrest. Thyroid myopathy is treated with the same modalities we use to treat any other hyperthyroid condition. We will be discussing treatment a little later in this paper. In thinking about the signs and symptoms of hyperthyroidism, simply remember what all the thyroid hormone actions are and amplify these. For example, you already know that thyroid hormone exerts a positive inotropic (increased heart rate) and positive chronotropic (increased force of contraction) effect on the heart.

Therefore, if one has too much thyroid hormone, these effects will be exaggerated and the patient may experience tachycardias, bounding pulses and a pounding sensation in the chest. This may be very detrimental to a

Thyroid Diseases continued on page 4

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Thyroid Diseases continued from page 3

patient who has pre-existing heart disease, and may even bring on angina or heart failure. Other signs and symptoms of hyperthyroidism may include: nervousness, irritability and agitation up to and including overt psychosis; hyperreflexia, tremors, fatigue; and difficulty sleeping including insomnia; abdominal pain and cramping, diarrhea; heat intolerance, hyperthermia, warm, moist, flushed oily skin; weight loss in spite of a healthy appetite; rales, pulmonary edema, goiter (enlarged thyroid gland), and retracted eyelids (exophthalmos seen with Graves’ disease).

Some patients with Graves’ disease experience what is called “Graves’ orbitopathy.” In Graves’ orbitopathy patients can suffer from disfiguring exophthalmos, orbital pain, corneal ulcerations, diplopia, and optic neuropathy with compression of the optic nerve to the point of vision loss. The first line of treatment is to restore a state of euthyroidism. It is felt these patients should also be referred to an ophthalmologist and/or a neuro-ophthalmologist for follow up. Generally, for neuropathy and or corneal ulcerations, treatment may include IV glucocorticosteroids. However if steroidal treatment is not helpful within one to two weeks, surgical decompression of the optic nerve may be necessary to prevent vision loss. Because visual acuity is so important to our quality of life, we need to take a more aggressive stance in addressing this issue of Graves’ orbitopathy on behalf of our patients.

Other eye conditions may include photophobia, excess tearing, diplopia, eye pain, periorbital edema, a feeling of grittiness in the eyelids and a decrease in visual acuity. Because of the role thyroid hormone plays in the development of the skeletal system, in states of hyperthyroidism, a patient can suffer bone loss. This bone loss occurs as the body is not able to keep up with the demands for bone salts to produce more bone. Thus bone salts are harvested from existing bone in an effort to produce new bone. The overall effect is bone loss. Should this occur in a postmenopausal woman, who may also have osteoporosis, the risk for hip and or vertebral fractures greatly increase.

Hyperthyroidism in the elderly may present very atypically. In the elderly, a blunted affect and or slowed response to questions may actually be hyperthyroidism versus dementia. In an elderly patient, hyperthyroidism may present as via agitated behaviors or as an increased level of confusion in someone who is already in a confused state. While tachycardia is a common symptom of hyperthyroidism, only half of the elderly patients with hyperthyroidism have an elevated heart rate.

Once you suspect hyperthyroidism in a patient, the diagnosis is confirmed with simple blood tests. If the patient’s problem arises from a hypothalamic or pituitary tumor, the TSH levels will be high, due to a tumor hyper-secreting too much TRH or TSH. Too much TRH or TSH will in turn make the T3, T4 and Free T4 levels become elevated. If the patient’s problem arises within the thyroid gland the T3, T4 and Free T4 levels will be high while the TSH will be normal or low. It is important to include the TSH, T3, T4 and Free T4 in diagnosing thyroid disease. Evaluating just the TSH may lead one to believe a patient does not have thyroid disease, as it may appear normal. A complete laboratory profile, as well as patient history, will help one identify the cause of their disease. Once laboratory results are known, the physician may want to order other diagnostic tests such as a thyroid scan or cerebral CT or MRI scans.

Below is a table illustrating the possible laboratory profiles.

Test Normal Ranges

Hypothalamus or Pituitary Problem resulting in Hyperthyroidism

Thyroid Problem resulting in Hyperthyroidism

TSH 0.3 to 5 mIU/L High Low

Free T4 0.7 to 2 ng/dL High High

T4 5 to 12.5 mcg/dL High High

T3 80 to 200 ng/dL High High

There are a number of different ways to treat hyperthyroidism, and there are nursing implications for each of these methods.

Drugs: There are antithyroid agents such as methimazole (Tapazole ®) and propylthiouracil (PTU) that block the conversion of T4 to T3, thus having an overall effect of lowering circulating hormone levels. These medications are generally taken orally once daily. Of the two medications, methimazole has a longer duration of action and may give more consistent hormone levels. Methimazole and propylthiouracil have adverse reactions of which patients should be aware. These adverse reactions include rash, jaundice,

fever, joint pain and sore throat. Should these adverse reactions occur, patients should immediately stop taking their medications and contact their physician for follow up blood studies?

Iodine solutions such as Saturated Solution of Potassium Iodide (SSKI) or Lugol’s Solution may also be given orally in combination with an antithyroid medication. These iodine solutions prevent the release of hormone from the thyroid gland and prevent Free T4 from binding with cell receptor sites. Usually a few drops of these solutions are diluted in water, milk or juices and given after meals to avoid stomach irritation. It is also important to have the patient drink these solutions through a straw to avoid tooth discoloration. Another solution, sodium iodide may be given IV over a 24-hour period of time. To counteract the cardiac effects of hyperthyroidism, beta adrenergic blocking agents may be given.

Medications such as propranolol (Inderal®), atenolol (Tenormin®), metoprolol (Lopressor®), or nadolol (Corgard®) may be used to help decrease the accelerated heart rate and contractility experienced by some patients. These medications are particularly helpful if the patient has pre-existing heart disease. Another medication consideration is that the treatment of hyperthermia that may result in hyperthyroidism. It is preferable to treat hyperthermia with acetaminophen (Tylenol®) versus aspirin. Aspirin has the tendency to release T4 from proteins, thus making it available to attach to cell receptor sites and will worsened hyperthermia and hyperthyroidism. Patients should be advised to use acetaminophen to treat any kind of fever and to avoid aspirin. Of course the best advice to any patient is that they should always ask their healthcare professional before taking any other medications, especially over the counter medications. Another important piece of patient education is that the patient should be instructed to always take their prescribed medications and if possible take these medications at the same time each day. This will give them the most consistent hormone levels.

Routine follow up for hyperthyroidism includes monitoring blood levels of T4 and TSH at four to twelve week intervals until normal results are achieved. This is also called “euthyroidism.” Once euthyroidism is achieved, the physician may choose to lower the dosage of medications while continuing to monitor blood levels at three to four month intervals. Other aspects of routine follow up care would include assessing the patient for changes in their weight, blood pressure, heart rate, and exacerbation of any other pre-existing health problems, such as heart disease. Should the patient experience weight changes, dosing of medications may be necessary. Routine follow up care for a patient experiencing some of the eye problems previously mentioned would include sunglasses for photophobia and artificial tears for a feeling of grittiness. Sleeping with the head elevated or diuretics may be used to treat periorbital edema. The patient may also need to be seen by an ophthalmologist.

Healthcare providers should also be made aware of and ask regarding any over the counter, vitamin, or herbal supplements or non-traditional treatment the patient may be undertaking for thyroid disease or other health concerns. These items may affect thyroid disease and treatment.

There are some special considerations should the hyperthyroid patient also be pregnant. In poorly controlled pregnant women, there is an increased likelihood of fetal loss. Propylthiouracil is the drug of choice during a pregnancy because it has a shorter half-life thus allowing for easier control of dosing. The demands of pregnancy may actually reduce the demand for the amount of medication; thus dosing may be frequently changed throughout the pregnancy. Some patients find during the third trimester, medication may actually be discontinued. During the postpartum period the patient needs to be closely monitored for a return of hyperthyroidism with medications being re-instituted. Be sure to watch the postpartum hyperthyroid patient for thyroid storm and assess the newborn for signs of hyperthyroidism.

Radioactive Iodine: The thyroid gland readily takes up iodine to make thyroid hormone. In the 1930’s it was discovered that radioactive iodine could be given to a patient and the radioactive iodine would be taken up by the thyroid gland. The radioactive iodine over the next 6 to 8 weeks will destroy thyroid tissues, thus limiting the production of thyroid hormone. Careful calculations are done to determine the dosage of radioactive iodine, but occasionally patients may require a second dosing. More commonly, hypothyroidism (underactive thyroid) results over a period of several months to years, following radioactive iodine treatment. This resulting hypothyroidism is easily treated with a daily supplement of thyroid hormone. Radioactive iodine is administered either as a capsule or a liquid solution. It is not given to pregnant patients as the radioactive iodine will damage the thyroid gland of the developing fetus. Because the patient will remain radioactive for up to 3 days after treatment, patients should avoid close contact with others, especially small children during this time. They generally should not sleep in the same room with another person for the next 7 days.

Other radiation precautions should be discussed and given to the patient at the time of treatment. It is also important to instruct the patient they are to discontinue antithyroid

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medication one week prior to radioactive iodine treatment. However they should continue taking any beta adrenergic blocking agents before, during and after radioactive iodine treatment. Bear in mind it may take a few weeks before the patient will benefit from the radiation treatment and they will still have high levels of thyroid hormone present. They will therefore need these beta adrenergic blocking agents to help control cardiac problems. It is also possible after radioactive iodine; patients will experience “thyroid storm,” or an exaggeration of hyperthyroidism. This occurs when the damaged thyroid cells release their stored thyroid hormone into circulation.

Surgery: In some instances, physicians will recommend removal of part of or all of the thyroid gland. If a single nodule or lump is identified as being overactive, a partial removal of the gland is completed. The remaining gland will usually return to a normal level of functioning. If the entire gland is deemed to be overactive, and the patient is not a candidate for radioactive iodine therapy, the entire gland may be removed. In this instance the patient will then develop hypothyroidism and will require lifelong treatment. Postoperatively it is important to monitor the patient’s airway patency. With swelling at the surgical site there may be some occlusion of the patient’s airway.

HypothyroidismHypothyroidism results when a patient has too little thyroid hormone. Again

thinking of the feedback loop for the hormone, the primary problem may occur in the hypothalamus or pituitary gland resulting in low levels of TSH, or the problem may occur in the thyroid gland itself, resulting in low T3 and T4 levels. A patient, who was treated for hyperthyroidism, may have developed a hypothyroidism, as we just discussed in the previous section. Other causes of hypothyroidism include a chronic thyroiditis, insufficient treatment of hypothyroidism by not taking enough hormone supplements, or a history of taking lithium carbonate. Lithium carbonate blocks thyroid hormone synthesis. Patients taking lithium carbonate should be periodically evaluated for the development of a goiter, indicating hypothyroidism. If the goiter is allowed to continue growing, it may actually start to produce too much thyroid hormone, causing the patient to develop hyperthyroidism. Also as the goiter becomes larger there is an increased risk of tracheal or esophageal compression. Hashimoto’s thyroiditis is the most common cause of hypothyroidism and is believed to be an autoimmune process. The extreme of hypothyroidism is called myxedema coma. Myxedema coma is a life-threatening emergency. Myxedema coma can be triggered by a concurrent or severe illness, infection, trauma, surgery, anesthesia, exposure to cold, administration of narcotics or sedatives, or other forms of physical stress. Myxedema coma may be fatal, thus often requires intensive care and intravenous replacement of thyroid medications. Knowing the patient’s history of hypothyroidism is helpful in identifying or preventing myxedema coma.

Think again of the effects of thyroid hormone on the body. Now imagine one does not have enough thyroid hormone. Signs and symptoms of hypothyroidism include: slow mentation, memory impairment, confusion up to and including coma; hoarse voice, slow speech; dull affect, facial puffiness, periorbital edema and non-pitting edema; goiter (The thyroid gland enlarges in an effort to produce more thyroid hormone.) may be present, cool dry skin up to hypothermia (body temperatures may be 91 to 95o F); loss of eyebrow and scalp hair, bradycardia; slow shallow respirations; and an exaggerated response to narcotics or sedatives.

The elderly may present very differently than a younger patient with hypothyroidism. Many of the signs and symptoms seen in an elderly patient with hypothyroidism will mimic other diseases. Weight loss versus weight gain is one common presentation of hypothyroidism in an elderly patient, which is just the opposite of what one would expect to see. Most patients with hypothyroidism experience weight gain. Pericardial or pleural effusions may be present and are often attributed to heart failure. Synovial effusions seen with hypothyroidism may be diagnosed as osteoarthritis or rheumatoid arthritis. In the elderly, hypothyroidism and hypertension often co-exist. Usually by treating the hypothyroidism, the hypertension will normalize. Because of the general slowing of metabolism that occurs with hypothyroidism, there can also be a slowing of ambulation. In elderly patients with hypothyroidism, it has been demonstrated they have compromised mobility. Therefore they are less able to walk and/or exercise with ease, undertake physical activity and maintain cardiovascular stamina. Impaired mobility also increases their risk of falling and sustaining further injuries.

Many patients with hypothyroidism also experience abnormal lipid profiles or dyslipidemia. Because hypothyroidism results in a slowing of metabolism, it is not unusual to see patients have elevated triglyceride, cholesterol, and LDL levels, while the HDL level will be low. Of course, all of this is a contributor to cardiovascular disease. The patient may not necessarily require treatment with one of the popular statin drugs. But treating the hypothyroidism and restoring a state of euthyroidism may well remedy the dyslipidemia problem, thereby avoiding the side effects of some of the statin medications.

In diagnosing hypothyroidism, again laboratory tests are done, just as we discussed with hyperthyroidism. Depending on test results and patient history, the physician may also obtain thyroid scans, CT or MRI scans as discussed in hyperthyroidism. Below is a table showing possible test results for hypothyroidism. As one looks at this table note that when the problem originates in the hypothalamus or pituitary gland a low TSH level along with low T3, T4 and Free T4 levels exist. The low T3, T4 and Free T4 levels exist because there is a low level of TSH coming from the pituitary gland, so there is a lower level of stimulation to the thyroid to produce its hormones. When the problem originates with a hypo-functioning thyroid gland, the TSH level will be high as the pituitary gland is responding to the low T3, T4 and Free T4 levels. IN other words the pituitary gland produces more and more TSH in an effort to increase the T3, T4 and Free T4 levels.

Test Normal Ranges

Hypothalamus or Pituitary Problem resulting in Hypothyroidism

Thyroid Problem resulting in Hypothyroidism

TSH 0.3 to 5 mIU/L Low High

Free T4 0.7 to 2 ng/dL Low Low

T4 5 to 12.5 mcg/dL Low Low

T3 80 to 200 ng/dL Low Low

In reviewing the signs and symptoms of hypothyroidism, you will note many of these mimic some of the signs and symptoms of aging. As many as 1 in 10 people over the age of 65 years may have hypothyroidism and not know it. They may have no symptoms at all or may present with very vague symptoms such as fatigue or apathy. In many cases the elderly person is labeled as a dementia patient or they are told they’re “old,” while in fact, it may be hypothyroidism that is very treatable. The earliest sign of hypothyroidism in an elderly person is an elevated TSH level. Routine TSH and T4 monitoring should be considered with every elderly patient so as not to overlook this problem. Hypothyroidism can accompany many other diseases and can often disguise itself as other diseases. Therefore, patients who are over the age of sixty, those with unexplained depression, cognitive dysfunction, confusion, autoimmune diseases or hypercholesterolemia should have routine monitoring of TSH levels performed.

Treating hypothyroidism is relatively simple. Here the patient lacks thyroid hormone, so he or she will be given hormone supplements. It is still controversial as to whether or not to treat an elderly patient with elevated TSH levels, yet their T3 and T4 levels remain normal and the patient is asymptomatic. Of elderly patients with elevated TSH levels only,

20% will progress to true hypothyroidism per year. It is something to be discussed with the physician, as some patients in this situation simply “ just feel better” taking thyroid hormone supplements. Enough thyroid hormone is given to return the TSH level to normal or a state of euthyroidism. Studies have found that thyroid hormone will improve symptoms of fatigue, constipation, and poor energy. As with hyperthyroidism, patients who are being treated for hypothyroidism should routinely receive follow up care to include weight, heart rate and blood pressure screening as well as routine laboratory tests aimed at achieving euthyroidism.

If the patient experiences a weight change, medication dosages may also require changing. As the patient’s age advances, it is imperative to continue to monitor for the effects of medications, adverse reactions and adjust medication dosages as necessary.

Drugs: There are a number of thyroid hormone supplements available. Since potency of generic thyroid products may vary, it is imperative the patient know what medication they are prescribed and they should not switch preparations without first discussing it with their health care professional.

Thyroid Diseases continued on page 6

Thousands of Dollars in Scholarships and Grants Available

Applications due January 15thThe Ohio Nurses Foundation awards thousands of dollars annually in research

grants and scholarships to notable nurses and future nurses.Browse the list below of available scholarship and grant opportunities and their

corresponding applications. Scholarships and research grants are awarded at the annual Nurses Choice Awards and Scholarship Luncheon. The deadline for all applications is January 15th of each year.

Scholarships• Hague Memorial Scholarship: For a graduate nursing student who is an

aspiring nurse leader.• Minority Scholarship: For students who are pursuing their first nursing degree

that leads to RN licensure; live in the state of Ohio and are of a minority race.• Hayward Memorial Scholarship: For RNs preparing to teach nursing.• Traditional Nursing Student Scholarship: For students who do not have breaks

longer than 2 years in their formal education (from high school to college) and have not yet obtained a degree.

• RNs Majoring in Nursing: For students that are already RNs who want to advance the profession of nursing in Ohio.

• Students Returning to School for Nursing Scholarship: For students who have been out of school more than 2 years and are not an RN.

• Summit and Portage District Scholarship: For sophomore, junior, or senior student or returning R.N. working toward an advanced nursing degree at Hiram College, Kent State University, or The University of Akron.

• Mary Runyan Scholarship: For students at Kent State-Ashtabula Campus. A scholarship award of $250 is presented to two graduating seniors per year. The scholarship recipients are chosen by the nursing faculty of the school. This award is made possible by the nurses of Ashtabula County, Ohio Nurses Foundation, and the Ohio Nurses Association. “

Grants• Research Grants: For the support of sound research projects conducted by

registered nurses in Ohio. Up to 3 $2,000 grants are awarded per year. For more information and to download the applications, visit

www.ohionursesfoundation.org.

http://www.otterbein.edu/graduatenursing


Thyroid Diseases continued from page 5

Below is a table of thyroid hormone supplements.

Medication Brand Names ® Nursing Considerations

Levothyroxine Sodium Eltroxin, Levo-T, Levothroid, Levoxine, Oroxine, Synthroid

This is the preferred medication as it is synthetic T4. There is constant absorption and conversion of the medication that gives a consistent level of T3. The patient only has to take this once per day.

Iiothyronine Sodium Cytomel, Tertroxin, Triostat

This is pure T3 and is usually not used alone due to its rapid turnover rate. Remember T3 is the active form of thyroid hormone. Because of its rapid effects, this medication is given usually twice per day. Use this with extreme caution with elderly patients or patients with heart disease, it may aggravate angina.

Iiotrix Thyrolar This is a combination of both T3 and T4. Patients generally take this once per day. Because of the component of T3, again use with caution with patients who have heart disease.

Thyroid Dessicated Armour Thyroid, S-P-T, Thyrar, Thyroid Strong

These medications are thyroid hormone that has been harvested from beef and pork. These preparations may contain variable amounts of hormone, and because there are other more reliable synthetic preparations, these medications are not used as much. One may still encounter a patient taking these, however most patients have been switched to a synthetic preparation.

Here are some additional nursing implications regarding these medications. Patients are usually started on a lower dose of these preparations and medication dosage is adjusted to obtain a normal TSH level. Frequent monitoring is essential during the first few months of treatment to achieve the correct dosage and normal TSH. It is important for the patient to understand these medications will be taken for the rest of his or her life. They should take the medication at the same time each day so as to maintain consistent hormone levels. For example, breakfast is a good time to take their daily medications. These medications should never be discontinued unless directed by their health care provider, as myxedema coma may result. Switching medications should not be done without first discussing it with one’s health care provider.

Elderly patients or patients with heart disease should be instructed to immediately report any angina, palpitations or stroke symptoms to their health care provider. If the patient also has diabetes mellitus, it may be necessary to adjust their insulin or oral diabetes medications. Remember thyroid hormone is going to enhance glucose metabolism and may thus effect insulin requirements as well. Patients should be instructed to closely monitor their blood sugar levels while initiating or adjusting thyroid hormone therapy.

Thyroid hormone supplements may also delay blood coagulation. Therefore patients may find it necessary to adjust dosages of anticoagulant therapy. All patients taking thyroid hormone supplements should be instructed to report any unusual bleeding or bruising problems.

Women with hypothyroidism and who are taking estrogen products have increased thyroid hormone needs. Therefore careful monitoring of their thyroid hormone levels is necessary anytime estrogen or thyroid hormone dosages are being adjusted. The pregnant hypothyroidism patient may require an increase in medication due to the demands of the pregnancy. Careful monitoring of TSH levels during and after the pregnancy is imperative. Most patients will return to their pre-pregnancy dosages of medications postpartum. It is also important for healthcare providers to be aware if the patient is taking any over the counter medications, mineral, vitamin or herbal supplements, or using any non-traditional methods of treating their thyroid disease or any other health problems, as these modes of treatment may affect thyroid function and treatment.

Surgery: Nodules or lumps on the thyroid gland are very common and if a thyroid scan shows the gland to be functioning normally and hormone levels are normal, no treatment may be necessary. However, prior to any surgery

the nature of the nodule must be determined. The patient may undergo a fine needle biopsy. If the nodule is deemed to be cancer or highly suspicious of cancer, the patient will then undergo surgical intervention. Surgery may include partial or total removal of the thyroid gland. Again be sure to monitor airway patency postoperatively.

Of Special Note: Patients who have systemic lupus erythematosus (SLE)

have a predilection to also developing thyroid disorders. Most often the SLE patient will develop a hypothyroidism versus a hyperthyroidism, and most of these patients will be female. Graves’ disease may also occur in the SLE patient, but as previously stated, usually to a lesser rate of occurrence than a hypothyroidism. Often the thyroid disorder will present subclinically, with the patient experiencing no overt symptoms of the thyroid condition. Therefore, all SLE patients should be monitored for the development of thyroid disorders, by having TSH, T3 and T3 levels monitored routinely.

Gastric bypass surgeries, often known as bilio-pancreatic diversion, have become popular for permanent weight loss in the severely obese. Some obese patients may already have been diagnosed with hypothyroidism, other patients, while subclinical for hypothyroidism, have not been diagnosed. Of course, the hypothyroidism may well be a contributing factor to their obesity problem. For patients who have undergone gastric bypass surgery, a portion of the stomach is removed and a pouch about the size of a walnut is created. The small size of this pouch greatly reduces the amount of surface area available for the absorption of nutrients. Some gastric bypass patients may develop malabsorption syndromes that can include iodine malabsorption. Initially the patient may be able to compensate, but eventually they will become iodine deficient. Iodine deficiency may result in hypothyroidism, especially if the patient had a pre-existing previously subclinical hypothyroidism. Therefore it is important that gastric bypass patients be monitored for malabsorption syndromes and possibly may be prescribed iodine supplements to prevent the development of hypothyroidism.

Patient Education: The American Thyroid Association is an excellent resource for patient education materials. The association web site is www.thyroid.org. There are a number of articles that have been developed for patients with either hyperthyroidism or hypothyroidism. These articles are free of charge and may be printed. There are also a number of professional articles available that may be printed, free of charge. The American Thyroid Association’s mailing address is PO Box 1836 Falls Church, Virginia 22041.

The Pituitary Organization is another excellent resource for professionals and patients with pituitary problems. Their web site is www.pituitary.org/PituitaryLinks/htm. Their address and phone number is: The Pituitary Organization, PO Box 1958 Thousand Oaks, California 91358, 805-496-4932.

Planning Educational Activities: From A to Z

This video was developed to give the nurse educator a better understanding of the learner’s needs and strategies to meet those needs.

This video has been developed and presented by: Stephanie Clubbs, MSN, RN-BC. The author and planning committee members have declared no conflict of interest. This information is provided for educational purposes only. For legal questions, please consult appropriate legal counsel. For medical questions or personal health questions, please consult an appropriate health care professional.

1.68 contact hours will be awarded for successful completion of this web inar. To receive continuing education credits, you must register, watch the video, answer the post-test questions, and answer the evaluation questions.


Expires 3/2017, Copyright © 2015 Ohio Nurses Association

Objectives1. Identify different methods of assessing learning

needs.2. Describe the selection of teaching strategies to meet

the learner’s identified needs.

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The Highs and Lows of Thyroid DiseasesPost-Test and Evaluation

Name: _____________________Date: ______________________ Final Score: _________

DIRECTIONS: Please complete the post-test and evaluation form. There is only one answer per questions. The evaluation questions must be completed and returned with the post-test to receive a certificate.

Please circle one answer.

1. T4 is the active form of thyroid hormone and exerts the greatest physiologic effects.a. Trueb. False

2. Thyroid hormone has a positive chronotropic and positive inotropic effect of the heart.a. Trueb. False

3. Plummer’s Disease is a form of hyperthyroidism that is caused by lead toxicity.a. Trueb. False

4. In Graves’ Disease the eyes appear sunken with eyelid drooping.a. Trueb. False

5. Hyperthyroidism in postmenopausal women may increase their risk for sustaining hip or vertebral fractures.a. Trueb. False

6. Methimazole has a longer duration of action than propylthiouracil and may yield more consistent hormone levels.a. Trueb. False

7. It is best to use aspirin to treat hyperthermia that may accompany hyperthyroidism.a. Trueb. False

8. Patients receiving radioactive iodine will remain radioactive for 3 days, but there are no special precautions to be instituted during this time.a. Trueb. False

9. Patients receiving radioactive iodine should stop taking all antithyroid medications and beta adrenergic blocking agents one week prior to therapy.a. Trueb. False

10. Patients taking lithium carbonate should be evaluated for hypothyroidism and the development of goiter.a. Trueb. False

11. Goiter can occur when the thyroid gland enlarges in an effort to produce more thyroid hormone.a. Trueb. False

12. Many of the signs and symptoms of hypothyroidism mimic aging.a. Trueb. False

13. Iiothyronine may easily be substituted for Iiotrix in treating hypothyroidism.a. Trueb. False

14. Armour thyroid is the preferred thyroid hormone supplement as it delivers consistent levels of T3. a. Trueb. False

15. The patient is receiving the correct dosage of thyroid hormone supplement when the TSH level returns to normal and is the only level that needs to be monitored.a. Trueb. False

16. When taking thyroid hormone supplements, elderly patients and or patients with heart disease should be cautioned to watch for the development of angina, palpitations or stroke.a. Trueb. False

17. Diabetic patients taking thyroid hormone supplements will not need to adjust insulin or anti-diabetic medications.a. Trueb. False

18. Thyroid hormone supplements may delay clotting times, therefore patients taking anticoagulants may have to adjust dosage of these medications.a. Trueb. False

19. Whether taking antithyroid medication or thyroid hormone supplements, it is important for the patient to take these medications at the same time each day.a. Trueb. False

20. The American Thyroid Association is a resource for both professional and patient education materials.a. Trueb. False

21. In experiencing adverse reactions to methimazole or propylthiouracil, the patient should immediately stop the medications and contact his or her healthcare provider.a. Trueb. False

22. Euthyroidism is achieved when the patient’s blood levels for TSH and T4 return to normal.a. Trueb. False

23. In hyperthyroidism, there is an increased need for anti-thyroid medications during a pregnancy.a. Trueb. False

24. Following delivery, it is important to monitor the newborn of a hyperthyroid mother for signs of thyrotoxicosis.a. Trueb. False

25. An illness or injury may precipitate thyroid storm or myxedema coma.a. Trueb. False

26. In an elderly patient, hypertension may accompany hypothyroidism.a. Trueb. False

27. Sunglasses, artificial tears, sleeping with the head elevated and diuretics may help alleviate some of the symptoms occurring in the eyes.a. Trueb. False

28. Over the counter medications will not affect the treatment of thyroid disease.a. Trueb. False

29. A pregnant woman with hypothyroidism will require less medication during the pregnancy.a. Trueb. False

30. In a patient who experiences weight changes and or advancing age, changes in medication dosing may be necessary. a. Trueb. False

Evaluation:

1. Were you able to achieve the YES NO following objectives?

a. Identify the signs and symptoms of hyperthyroidism and hypothyroidism. Yes No

b. Identify nursing implications in caring for a patient with hyperthyroidism or hypothyroidism. Yes No

2. Was this independent study an effective method of learning? Yes No

If no, please comment:

3. How long did it take you to complete the study, the post-test, and the evaluation form?

4. What other topics would you like to see addressed in an independent study?

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• BeeligibleforR.N.licensureinOhio• Experienceinteachingatthecollegiatelevel• Abilitytoteachon-linecourses• Knowledgeofsimulationteaching/learning• Committedtoexcellenceinteaching,scholarship,andservice• SupportthemissionoftheUniversity• Evidenceofacademicachievement

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The ABCs of Effective Advocacy:Attention, Bipartisanship, & Collaboration

This independent study was developed by: Jan Lanier, JD, RN.

This independent study has been designed to enhance

nurse’s ability to increase their knowledge about why and how to become politically active. 1.5 contact hours will be awarded for successful completion of this independent study.

The authors and planning committee members have declared no conflict of interest. This information is provided for educational purposes only. For legal questions, please consult appropriate legal counsel. For medical questions or personal health questions, please consult an appropriate health care professional.


Expires: 6/2017. Copyright © 2013, 2015 Ohio Nurses Association.

OBJECTIVES1. Discuss the Patient Protection and Affordable Care

Act (ACA).2. Describe the legislative process.3. Describe the policy process and how it relates to the

ACA.4. Identify the various ways in which nurses can be

politically involved.

Every year legislators at both the state and federal levels enact laws that directly affect nurses and nursing practice. One such law, the Patient Protection & Affordable Care Act (ACA) was enacted in March 2010. Known as health care reform or “Obamacare,” this law makes significant changes in the way health care is delivered and how it is reimbursed. The law incentivizes community-based care with a focus on care management and prevention rather than on the sheer volume of services rendered. The ACA, despite ongoing challenges during its implementation stage, promises to change the face of health care, emphasizing activities that are the foundation of nursing practice. Under the evolving new paradigm, experts predict that admission to the hospital will be viewed as a system failure rather than a normal every day expectation.

Although nurses, as the largest segment of the health care workforce, will inevitably experience changes in their practice as a result of the ACA, they have been largely silent during the health care reform debates. Many legislators remark, “Nurses do not show up” when asked to describe their influence over health care reform and other initiatives. By not showing up, nurses are on the outside looking in when they should be front and center at the policy-making table.

Advocacy, seeing a need and finding a way to address it, is the cornerstone of nursing. An advocate builds support for a cause or issue and influences others to take action.

The American Nurses Association’s Code of Ethics for Nurses, Nursing: Scope & Standards of Practice, and Nursing’s Social Policy Statement, foundational documents of the profession, all recognize that advocacy goes beyond the bedside and must extend to the profession as a whole. “Nurses are educated to practice within a holistic framework that places a major emphasis on advocacy. So nurses not only have the ability to be an incredible force by their sheer numbers, but policy makers also rely upon nurses’ expertise.” (Haebler, 2013 p. 15).

While others recognize the important role nurses can and should play in the policy-making arena, nurses themselves find this aspect of their professional role distasteful, uncomfortable, and non-essential. “I did not become a nurse to engage in these sorts of political activities. I simply want to take care of my patients. I do not have time to take on yet another responsibility.”

While this attitude may appear sound to many, in reality nursing is a regulated profession in a regulated industry. Showing up/advocacy, therefore, is not an option. Rather, it is an obligation.

Contrary to what many believe, engaging in professional advocacy need not be time consuming or a mysterious process taken on only by those who are convinced of its essential nature. All nurses, if encouraged, mentored, and coached appropriately, can make a difference for both their profession and for their patients. Effective advocacy starts with attention—attention to process, people, politics, and perceptions. This study will first address the processes that shape law and rule making. The policy process and factors or forces influencing it will be presented, as will the role of politics in determining the “winners and losers” at the table. People and relational factors will be considered along with how perceptions affect the ultimate outcomes. Finally, the importance of bipartisanship and collaboration to nurses’ advocacy efforts will be highlighted, particularly with respect to the role these factors play in determining the staying power of the advocacy endeavor.

Attention to Process—How a bill becomes a law(The information presented here is generalized, recognizing that

each state, as well as the federal government, has its own unique nuances that shape the overall process).

Many people study the law making process in junior high and high school government classes thinking that the information is something they will never need to use. They forget the details as soon as the school bell rings. But knowing the rules of lawmaking is important to those who need or want to have an influence over the end results. Like other processes or systems, there are certain norms or rules that govern how the game is played. Just as one cannot play football without knowing what the game is all about, one cannot play in the lawmaking arena without having an idea about the rules of the road.

Legislative Process—A bill is introduced into the chamber to which the bill’s

sponsor belongs. Once a bill is introduced, it is assigned a number, sequentially, that it maintains throughout the entire process. That is a House bill would be HR 1 even when it goes to the Senate for action by that body and vice versa.

A proposal must be passed by both the senate and the house within the two-year legislative cycle, (January following a general election where voters select all members of the U.S. House of Representatives and a percentage of U.S. Senate until December after the next legislative general election). Bills can be sidetracked anytime during the process without a formal vote ever being taken.

IntroductionThe opportunity for nurses to have input into proposed

laws occurs throughout the legislative process, beginning even prior to the bill’s introduction. It is not unusual for several versions of a potential bill to be drafted prior to the actual introduction. Nurses can contribute their expertise at this point so that the emerging bill is as accurate as possible.

Determining who will be a bill’s sponsor is a very strategic decision. Proponents (nurses) influence the legislator’s perceptions about the issue that is being debated and can help bring other legislators on board, perhaps as co-sponsors. Having a sponsor who believes in the issue(s) addressed in the bill helps to ensure that legislative leadership and committee chairmen and others take it seriously. The sponsor must be a watchdog who shepherds and guides the bill through the entire process, which begins with referral to a committee. Referring a bill expeditiously to a standing committee helps get it on the radar screen of committee chairs and other decision-makers. Thousands of bills are introduced during each legislative session. Having someone who believes in the issue that is the subject matter of the bill will help to ensure the proposal gets committee attention in a timely manner. A sponsor should also ideally be a member of the majority party to help guarantee that the bill receives attention, otherwise the bill will likely

languish in committee without the legislators having taken any action whatsoever on the proposal.

Committee actionWhile the committee hearing process may appear

spontaneous, in actuality it is well orchestrated. Proponents make sure their positions are represented by witnesses carefully prepared to tell the story that strategists (AKA lobbyists) believe will be the most persuasive. Opponents typically put on the same type of campaign. Nurses are excellent witnesses who have real-life experiences to share that can help lawmakers understand the need for the proposed law. In addition, their technical expertise can be helpful in preparing the bill’s sponsor for his/her testimony that kicks-off the committee hearing process. Lawmakers may ask questions of the witnesses and may make recommendations for changes (amendments) to the bill based on the testimony. Again, nurses’ expertise can be invaluable as details are worked out.

Committee action may appear to be chaotic to an onlooker with few lawmakers paying attention to what the witnesses are saying. In reality, while the committee process is important, most crucial decisions about contentious issues are made during interested party meetings that occur in legislative offices outside of the public eye. One gets to these key meetings, however, by demonstrating interest during committee meetings.

Bills may also be referred by the full committee to a subcommittee, where more complicated matters can be debated and compromises attempted. Again, while participation in the subcommittee action is critical, nurses must realize that much of the most meaningful work occurs in less formal settings. Once its work is completed, a subcommittee sends the bill back to the full committee for the ultimate decision as to whether the bill will move forward.

Full chamber actionWhen a committee recommends a bill favorably, house

or senate leaders determine when (or IF) it will be placed on the agenda of the full house or senate for a formal vote. Lobbyists and bill sponsors are keys to leadership decisions in this regard. If no one is urging a full floor vote, the bill will most likely languish and ultimately die from inattention.

Votes by the full chamber or by committees or subcommittees do not occur randomly. Lobbyists (proponents and opponents) meet with legislators to determine their likely vote. If a bill is not likely to pass, it will be pulled from the agenda rather than risking a negative vote that effectively kills the proposal for the remainder of the current legislative session. A bill that has not been voted upon remains viable until the session is adjourned sine die (never to resume).

House Senate

Introduced & assigned a number

HR 1

Introduced & assigned a number

S 1

Referred to a standing committee

for hearings

Referred to a standing committee

for hearings

Referred to other chamber (or to executive for

signature)

Referred to other chamber or to executive for

signature

May be referred to a subcommittee

May be referred to a subcommittee

Floor action.Vote on passage

Full chamber floor vote on passage

Returned to full committee and

recommended to the full House for action

Returned to full committee for

recommendations regarding passage

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December 2015 Ohio Nurse Page 9Bills may be amended on the floor as

well as in committee or subcommittee. If a bill is approved it will either be referred to the other chamber to begin the process over again or, if both chambers have acted, go to the chief executive (president or governor) for signature.

When a bill passes one chamber and goes to the other, it is not unusual for changes to occur in the second venue. Even the smallest changes require the initiating chamber to concur. If agreement cannot be obtained, house and senate leadership name a conference committee. This committee considers both versions of the bill and makes recommendations regarding the final proposal. A conference committee report is prepared and voted upon by both chambers. Senators and representatives may vote only “yes” or “no” to accept the report. They may not amend it in any way.

SignatureThe governor or president as chief

executive of either the state or U.S. government respectively is charged with signing a bill into law. A bill may be vetoed or approved upon submission to the chief executive. The president may only veto a bill in its entirety. Governors in some states have what is known as line-item veto authority over certain pieces of legislation. That is, they can veto portions of a bill while allowing the remaining provisions to become law. Once signed, a bill becomes an “act” or the law of the land, effective either immediately if it has been declared an emergency proposal or within the number of days specified in the law itself, or within the time frame specified by the state’s Constitution.

The iceberg phenomenaLike an iceberg where much of the massive ice floe is

hidden far beneath the surface of the water, the law making process is not always what it seems to be on the surface. Some may believe the process described above is set in stone—that all steps of the process must occur over a period of time, usually taking many months (or even years to complete). That is not the case, however. The entire process may be short-circuited when expediency demands. In other words, what you see may not always be what you get.

A moving bill may be amended to include language that lawmakers believe should be enacted without going through the tedious committee process. After a general election when a legislative session is winding down, the newly elected lawmakers or executive may have a different political philosophy or agenda than the current office holders. Consequently, there is considerable pressure to get the legislative agenda enacted quickly before the personnel changes take place. During this so-called lame duck session, bills are amended frequently often with little regard to subject matter relevance. Sometimes called Christmas tree bills these proposals are a conglomeration of selected provisions from multiple bills, some of which have stalled in committee and others that may have been introduced only recently. Regardless of the source, these bills are typically a potpourri of concepts that may or may not fit together coherently or logically. Following these rapidly changing measures poses many challenges for even the most veteran legislative watchdogs.

While the typical nurse may not be expected to know the details of the lame duck session, and all the deal-making that characterizes it, understanding that the phenomena exists is essential to effective advocacy. Time truly is of the essence in the waning days of Congress or state legislatures, which means getting a message to a law maker in a timely manner may require immediate targeted contact. For those not aware of this strategy, the process can pose significant challenges and frequent legislative surprises. Awareness of the phenomena, however, makes it a tool that can be used to one’s advantage.

Rule making—the lifeblood of bureaucracyAs if law making were not enough, the executive branch

of government (agencies such as boards of nursing, and departments such as Health & Human Services, the Environmental Protective Agency etc.) have been granted authority by the legislative branch to engage in rule making. The laws basically direct these agencies to adopt rules on specific issues. In other words the law tells affected parties what they must do and the agency’s rules tell them how to do it. Typically, rules are more detailed than laws and must be adopted in accordance with the federal or state administrative procedures acts. Most importantly from an advocacy perspective, these procedures always include a public comment period. Generally, agencies heed what they receive from the public and make changes to the proposed rules before final filing takes place.

While some may believe it is the law that matters most, in reality, when properly enacted a rule has the force and effect of a law and is often where far-reaching policy decisions are debated and made.

Of particular significance when considering rule making is the fact that there is no time frame paralleling the two-year legislative cycle. In other words, agencies are constantly proposing rules for adoption, putting

the proposed rule out for public comment (usually electronically) and seeking public input during a specified time period without regard for whether Congress is in session or pending adjournment.

Policy ProcessPolicy-making occurs in many venues both public and

private. For purposes of this study public policy (laws and rules enacted by governmental entities) is the focus. However, the principles are largely the same whether policy is being made in the work place, by an organization, or by a legislative body.

“Policy is the deliberative course of action chosen by an individual or group to deal with a problem.” (Mason 2012 p. 3) Policy-making entails choice. It is all about choosing between two or more options for dealing with an identified problem. Laws and rules are the ultimate reflection of the policy choices that are made, but how do people determine what those laws and rules should address?

The process has four discernible stages:1. Problem identification or agenda setting2. Development of the plan to solve the identified

problem3. Implementation of the plan4. Evaluation

(Note the parallels between the policy process and the nursing process). The process is not linear nor is it an isolated exercise that takes place free from the dynamic forces that affect every facet of the overall system. Those forces include values, analysis & analysts, advocacy and activism, politics, media, interest groups, science & research, and presidential (or executive) power. (Mason. 2013).

To apply these concepts think about the enactment of the ACA and how these forces affected the ultimate legislation or policy options that were approved. While some may have preferred single payer universal health care, the force at play dictated what was and was not possible to achieve.

Legislation enacted

Comments reviewed &

changes made

Regulations published

Final rules reviewed

Agency develops draft rules

Public comment period 30-120

days

ACA & Policy Forces

Values—small government, choice, independence, state’s rights, limited taxes all shaped or limited policy options.

Media—emphasized the conflicts and protests; 24-hour news shows & multiple news sources—some reliable some not. Many had their own bias or prejudice that shaped public opinion and perceptions.

Interest groups—the medical association, nurses association, the pharmaceutical industry, hospital association, long-term care, health plans, and business interests were all at the table initially, but some distanced themselves when their members voiced loud opposition to the policy that was emerging. Reluctance to disturb the status quo was often paramount, especially for those benefitting from the current system. Keeping these interest groups neutral (or from becoming vocal opponents to the bill) led to many compromises.

Advocacy and activism—people rallied to oppose the law often without understanding the complexity of the health care system and the current reimbursement processes. Opposition was partisan, with the media focusing on the protests and angry responses across the country. Can we afford the new system? Will our value/preference for small government go by the wayside if the ACA is implemented? Proponents emphasized the lack of sustainability of the current system. “If something cannot go on forever it will stop.” Stein’s Law (Herbert Stein). What alternatives are possible?

Policy analysis—the cost of health care in the U.S. is not sustainable and the general outcomes are not reflective of the amount being spent. Many are uninsured and baby boomers are looming to create even greater demand on existing services. The current system pays for the wrong things, rewarding volume rather than quality. There is general agreement that the current system cannot continue unchanged.

Politics—opposition was loud and persistent. Passage of the bill was partisan creating dynamics that played out in the 2012 elections and various court decisions. Repeal and lack of acceptance of the law remain rampant. The U.S. House of Representatives has voted 50 times to repeal the ACA.

Presidential power—President Obama made health care reform the cornerstone of his first term identifying it as the primary objective of his administration. The makeup of Congress allowed the bill to pass with no support from the Republicans setting up a political tsunami., that continues to cause backlash, unrest, and a lack of commitment to the complexities of implementing this complicated law. States became the battleground as implementation moves forward. Whether to authorize Medicaid expansion or to administer the insurance exchanges required by the law have been hot topics with significant long-standing implications.

Science & research—indicate that U.S. outcomes are not reflective of the amount spent on health care. We are not getting our monies worth. Many dollars are going to pay for preventable chronic diseases. There is a need to emphasize prevention and better care management of chronic diseases.

Effective Advocacy continued on page 10

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Effective Advocacy continued from page 9

Nurses tend to get involved in the policy process at the implementation stage when not surprisingly the plan to be implemented may not be easily put into place nor will it work effectively to address the underlying problems. To be the most effective, the time to be at the table is at the agenda setting stage. How a problem is framed will determine the ultimate plan; therefore, framing the issue is critically important to the entire process. Nurses need to be part of those early discussions and debates.

Agenda settingAs more individuals have health insurance coverage

because of requirements in the ACA, access to care could be problematic. In fact people in policy-making roles have recognized that there are not enough primary care providers to meet the anticipated demand. This problem can be framed in one of two ways—we need more primary care physicians to meet the need OR advanced practice registered nurses must be allowed to practice to the full extent of their education and training. Obviously, the way the problem is characterized or framed will dictate the policy solutions adopted to address the access void. How can the problem be framed to help ensure a stronger nursing presence in the programs developed to fill the identified void?

A further example of agenda setting can be seen in conjunction with the tragic school shootings that occurred in December 2012 in Sandy Hook, CT. Immediately following the shooting many advocacy groups began to opine about what must be done to prevent similar tragedies in the future. Briefly, there were several options vying for the policy spotlight—better mental health care for young people; a ban on assault weapons/background checks to ensure guns are not available to those who should not have them; and finally regulating video games so as to minimize young peoples’ exposure to the violence depicted in them. Quickly, the policy forces (values, interest groups, the president, and politics) combined to turn the debate into a conflict between those who wanted a measure of gun control and those who believed even the smallest amount of regulation of gun sales would violate the 2nd Amendment of the U.S. Constitution. Mental health issues and video game violence became non-factors and were subsumed by the loud debate on the emotional gun control issue. Policy solutions followed suit.

PlanningOnce the policy issue is on the agenda, policy-makers

may have multiple possible solutions to propose. As the debate moves forward, it becomes apparent how various policy forces will limit the viability of certain programs or options. Enforcement considerations can also pose challenges. Will the policy be enforced by imposing a penalty for non-compliance (the stick approach) or will compliance be encouraged via rewards (the carrot approach)? If there is to be a penalty, what should it be, and who will enforce it? If a reward approach is adopted, how will that be administered? What source of funds will be tapped to provide the incentive? Policy-makers may decide to forego both the carrot and stick approaches believing that compliance will occur once the public is sufficiently educated regarding its benefits.

All enforcement tools have inherent limitations, and political considerations often dictate the approach taken. Frequently, opponents can be convinced to remain neutral when proponents agree not to include penalty language in the bill. Getting a measure through the legislature, even an imperfect something, can be viewed as a victory that may pave the way toward more extensive action at a later date.

Public policy around obesityHow to address the increasing prevalence of

childhood obesity challenges policy-makers. Is it enough to educate mothers (caregivers) about the inherent health implications of childhood obesity, or is a different approach needed? Should access to unhealthy foods (sugar-sweetened soft drinks) be limited? Should healthy food choices be rewarded? What barriers deter these choices? How can those barriers be overcome? Merely identifying a problem is not enough. Policy-makers also need to be made aware of possible solutions.

ImplementationMerely enacting a law or initiating a policy change

is only the beginning. Moving from concept to reality carries its own set of challenges. When a measure is passed without widespread support, opponents may use the implementation phase to erect roadblocks that can effectively stall any and all progress. (The ACA is an excellent example of this strategy in action). One of the most effective tactics is to generally limit or refuse to appropriate the funds needed to get the program up and running. If necessary funds are not available, the intended policy change may move forward slowly, if at all. Proponents who argued the merits of the change in the legislature, consequently, are unable to point to the predicted successes, which can hamper their efforts in the future to expand or enhance the programs at issue.

Even when a policy has broad support, implementation may be slowed simply because critical logistics have not been well thought-out. If the people charged with making programs work are not able to grasp the intent of the policy-makers, the implementation efforts may stray far from the original intent, which creates its own set of problems. For these reasons, it is important for nurses to be engaged throughout the policy-making process rather than solely when it is time for implementation to begin. An implementation reality check should occur when agenda setting and planning processes are on the drawing board. If a policy, as envisioned, cannot be implemented, that fact should be made known during the formulation stages. Again, nurses’ contributions would be invaluable.

ACA implementationStates are the implementers of many of the

provisions of the ACA. If state officials want to send a message to Washington signaling continuing opposition to the law, they can enact policies or adopt tactics that impede smooth implementation. For example, the ACA relied on state-based insurance exchanges to provide qualified individuals a marketplace for purchasing affordable health care insurance coverage when the individual mandate became effective in 2014. When states opt out of administering the programs, they force the federal government to shoulder the entire administrative burden of the exchanges, which in large part contributed to the problems experienced with the roll out of the Healthcare.gov website intended to facilitate the marketplace sign-up process.

EvaluationTo determine whether a policy change is working

effectively, there should be some evaluation of the outcomes. Occasionally, the legislation that creates the change includes expectations regarding the evaluation. Pilot programs may be authorized with built-in criteria to be addressed and reported on before the program is replicated on a broader scale.

Even without a formal evaluation, policy analysts and those who are the intended beneficiaries of a program are good resources for determining the effectiveness of a particular policy. Is it reaching the intended target? Is the program affordable from a cost benefit analysis perspective? Is the change envisioned by the program being realized? These are the questions to which policy-makers may seek answers before being convinced that further change is warranted.

Nurses are frequently charged with the evaluation responsibility. Developing appropriate evaluation tools that measure outcomes fairly can be challenging, especially when those invested in the program have a lot at stake in the evaluator’s findings. The most effective evaluators are those who have a firm grasp of both the policy being analyzed and the process undertaken to achieve policy enactment.

Attention to People—it truly is who you knowCertainly knowledge of the legislative/regulatory

process is important, but success in the policy-making arena is equally all about relationships—who trusts whom; who can influence; who can manipulate; who knows whom. Studying the personnel is key to the preparation athletic teams go through before a game. They watch endless game film to identify their opponents’ patterns. What are their weaknesses, their strengths? Entering a game without that preliminary preparation virtually guarantees a losing effort. That same level of preparation ought to be part of any legislative endeavor.

Who you should knowFirst and foremost, nurses should know the identity

of their federal and state representatives and senators. While some may know their congressman or U.S. senator few can name their state representatives. Although federal lawmakers are important, state lawmakers have a greater impact on everyday nursing interests; therefore, knowing who they are is an essential first step These individuals are often more accessible, than their federal counterparts regularly conducting meetings with their constituents in local libraries and restaurants. State government websites are good sources for the needed information. Not only do these sites identify the individuals, they also include biographical information and photographs that enable their constituents to readily identify them.

When a nurse or an organization has an issue that needs legislative attention studying the personnel is step one. In making this preliminary and ongoing assessment one should of course consider the leaders. That means looking not only at the recognized leaders (the individuals elected by their peers to be Speaker of the House, President Pro Tem of the Senate and party whips) but also at those who exercise influence over their colleagues by virtue of their expertise or experience with certain issues.

A lawmaker with health care experience (a nurse, physician, or pharmacist for example) will often be considered the go-to expert by his/her peers in the legislature. It is therefore important to at least touch base with these individuals so they are not taken by surprise when an issues surfaces. In addition, some lawmakers make health care their priority and tend to be looked to as resources for health care related measures. They too need to be kept in the loop as issues evolve. Finally, it is important to ascertain how much lawmakers in general know about the particular issue that is the subject of the pending bill. For example, if a proposal were being introduced that recognized nurse practitioners as primary care providers for purposes of leading patient-centered medical homes, proponents would need to know whether lawmakers understand the education and preparation of advanced practice registered nurses as well as what they know about the overall medical home concept. If they do not have background information, educational efforts must begin with the basics.

Getting a lawmaker’s attentionBusy lawmakers seldom have time to read in-depth

multiple page documents no matter how sound the information or how impressive the research findings. Brevity is key. Summarizing the key points of an issue—the so-called one-pager or leave behind—increases the likelihood a legislator will actually read the information provided. Professional jargon should also be kept to a minimum.

It is not enough to only know the elected representatives. Other individuals also play important roles in the success or failure of any legislative initiative, and their contributions should not be ignored or minimized. Most lawmakers have aides who assist them in many significant ways. These aides are often the trusted eyes and ears of their bosses. They frequently meet with constituents and are able to devote more time to a particular issue than the legislator who has multiple competing interests vying for his/her attention. Savvy lobbyists and advocates know the value of keeping the legislators’ staff members well informed and in the loop regarding both the substance of an issue as well as other factors that may affect its progress. Nurses who find themselves meeting with a legislative aide should take full advantage of the opportunity and cultivate that connection for the future. Always provide materials about an issue to both the legislator and his/her aide. Purposefully, include aides in the discussions, respectfully recognizing the key role they play.

Executive branch agencies (the rule makers) employ many individuals who have specific expertise around certain issues. These bureaucrats often have a long history that predates legislators and their staff members. They know why an issue failed, who opposed it, the strategies used, and many other salient details. Making connections with these individuals can be extremely helpful, not only because their knowledge cannot be dismissed, but also because they can be encouraged to take advantage of the nurse’s expertise when drafting rule language and other policy documents. Input at this crucial initial stage is often more valuable than trying to change the language once it is proposed.

Attention to Politics—the elephant in the roomProcess and people do not exist in a vacuum. For better

or worse, neither can be separated from the political

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December 2015 Ohio Nurse Page 11considerations that characterize both the public and private policy-making worlds. “Intrigue,” “expediency,” “control,” “sinister,” “contrived,” “opportunistic,” “dirty” are a few negative connotations associated with politics. In actuality, politics is neither negative nor positive. It is merely the process through which people make decisions that form the basis for the authoritative allocation of values. Through politics, decision-makers determine with authority who gets what. Workplace politics often determine who gets what office, the plum work assignments, and even coveted promotions. The underlying dynamics of the political game are the same regardless of the setting in which it is being played.

Despite its inevitability, politics is the proverbial elephant in the room, often being cited as the reason people (nurses) do not want to participate in the law and rule-making activities. Before so readily opting out of the policy-making arena, however, nurses should look more closely at what that means for their professional practice and consider how they can play the political game without compromising the public trust or their own core values.

Admittedly, playing the political game in the legislative arena is not for the faint of heart. Politics is rooted in power, and that can be a deterrent for many nurses who are reluctant to embrace some of the most obvious power elements associated with lawmaking. The role of money and the amount of it that changes hands is one of the most troublesome aspects of lawmaking, often cited as the reason why nurses and others refuse to engage in political advocacy.

While money is important, it is not the only source of political power. Numbers can be equally influential, and nurses as the largest segment of the health care workforce have numbers others can only envy. These numbers give nurses an enviable source of potential power that cannot be readily duplicated Making those numbers work is a major challenge facing those who advocate on behalf of nursing’s professional interests.

As a profession, nurses readily divide themselves according to their specialty areas of practice. “I’m a school nurse.” “I work in oncology.” “I work in the OR.” “I’m a staff nurse.” “I’m a nurse practitioner.” If the issue does not affect one’s practice directly, nurses generally will not become involved in it. As a result, when three million nurses could be communicating with their elected officials, only the thousands directly impacted by an issue send messages. The real extent of nursing’s power base goes unrecognized and untapped and success in the legislature is diminished.

Characterized as a “sleeping giant,” nursing’s power would be enhanced ten-fold if its practitioners could come together cohesively to advocate as a unit without regard for practice specialty, educational preparation, or union affiliation. Nursing’s lack of unity is fostered by those groups with interests that are best served by keeping nurses off balance. Subtly emphasizing divisive differences within nursing allows rival groups to enhance their own power positions at nursing’s expense. Until nurses refuse to fall into that trap they will continue to face unnecessary obstacles in achieving their legislative goals.

Attention to perceptionsThe cliché, “a picture is worth a thousand words” holds

true in the policy-making arena. While advocates may produce mounds of evidence supporting a particular position, lawmakers’ personal connections remain a powerful force that words cannot always overcome, especially if the message being conveyed is inconsistent with personal perceptions.

Most legislators know a nurse and many have nurses as family members. Despite these connections a legislator’s knowledge of nurses and nursing practice may be based on out-dated or incorrect information. Further, if the media were the primary sources of lawmakers’ understanding of the role nurses play in health care delivery, it would not be a surprise if they believe nurses make few if any decisions regarding a patient’s health status or outcome. Further, if a lawmaker has a positive or negative personal experience with a nurse, that experience is likely to be generalized and color his/her perceptions of nurses and/or their practice.

Perceptions at workA legislator watched the care her mother received

in a long-term care facility and noted that nurses were not administering medications to the residents. They merely left a cup of pills in the room and exited as quickly as possible. Later, when a proposal surfaced in the legislature to authorize unlicensed individuals to administer medications in these settings, the legislator could not be convinced that resident safety was jeopardized by the change. Nurses argued that the pre-administration assessments they performed were essential to the residents’ safe care; however, that contention was not supported by the actual practice experienced by the legislator. In her experience nurses were not performing those assessments so the change was merely codifying existing practice. No amount of advocacy could alter her perceptions, and her voice carried significant weight with her colleagues.

Because these personal experiences can be difficult to overcome, to make inroads requires acknowledgement of the validity of the experience while bringing other evidence to the table in an attempt to temper or counteract

it. One strategy would be to invite a lawmaker to shadow a nurse constituent at work. Having them see first-hand what nurses do can make a lasting powerful impression.

More about perceptions—a different perspectiveNursing remains primarily a female-dominated

profession even though the number of males has been increasing. Consequently, some of the lessons learned through childhood games are played out in the policy-making world where men’s rules dominate. Boys through their team sports learn to understand competition, winning, hierarchy and how to lose and move on. Girls, on the other hand typically form strong small alliances that emphasize non-verbal communication, collaboration, and friendships. Women focus first on process—making sure everyone has his/her say before making decisions about more controversial substantive issues. Men are more directly goal driven with many of the most critical issues decided before the actual meeting ever occurs. Women are less comfortable playing with people they do not like and tend to carry the meeting dynamics with them afterwards. They are less willing to accept that when the game is over it is over with all that went on during the game/meeting forgotten. These dynamics if not recognized tend to hamper some nurses’ advocacy efforts. Although it may not be possible to change one’s basic approach to these interactions, recognizing the gender differences can help women increase their effectiveness in the policy-making game.

Legislators frequently remark that nurses do not show up. That reputation makes it easier for policy-makers to give short shrift to nurses’ legislative agenda, especially when other competing interest group are in opposition or are making noisy demands regarding their own initiatives.

A graduate nursing student attended an interested parties meeting in a legislator’s office where various interest groups were invited to come together informally to discuss their concerns about a scope of practice bill that would have expanded one discipline’s authority with respect to prescribing medications. After listening to all participants the student observed that group A was “too nice.” They were too willing to make accommodations. Group B was more demanding and its position seemed unwavering. While its demeanor was more aggressive, Group B also came across as more self-assured and confident in the correctness of its arguments. Such perceptions often make the difference between success and failure. Nurses often find themselves in the group A category when the group B approach would serve their interests better.

Nurses need not compromise their integrity to be effective in the legislative arena. By speaking with a consistent voice with patience, passion, and perseverance, legislators will get the message that nurses are not going away nor are they willing to sit by and watch their initiatives go unheeded. Changing perceptions can be time-consuming but worthwhile in the long run. The first step is recognizing the importance of perceptions and the need to make changes.

BipartisanshipThe political game, and it is truly a game, is a marathon

not a sprint; therefore, taking a long-term view is essential for prolonged success. That means developing relationships and connections that span political parties, election results, and other partisan considerations. Those who recognize the long-term nature of the game will develop sustainable relationships that span legislative sessions and election turnarounds.

Politics does indeed make strange bedfellows. Today’s opponent may be tomorrow’s sponsor of your key bill. One cannot afford to make enemies on one side of the political aisle or the other. While one political party may hold a seemingly insurmountable majority today, election results could completely change control of the house, senate, and executive branch in the future thus making previous alliances essentially meaningless.

Members of the nursing profession are not homogenous in their political beliefs or philosophies. Rather than being identified or aligned with one party or the other, nursing’s larger interests are best served by maintaining positive relationships with both political parties. That means respecting members on both sides of the aisle and keeping the lines of communication open even when engaging in more overt political activities such as candidate endorsements and political contributions.

CollaborationAs noted previously, unity among nurses would enhance

the overall effectiveness of the profession’s advocacy efforts. Because numbers can be powerful influencers over public policy decisions, building coalitions between nursing groups and others can be yet another strategy for ensuring that advocacy efforts are even more powerful than they otherwise might be. These collaborations while positive in many respects are not without challenges, however.

In order to increase the likelihood of success, a collaborative effort must overcome several obstacles—both tangible and intangible. Typically, people (interest groups) find they have a shared interest in a particular issue and agree that working together would be mutually beneficial. At that point, efforts begin to put together a coalition, often without sufficient attention to key details.

To be a truly effective collaborative several issues must be addressed. They include:

• Having the right people at the table—people whocan speak for the organizations they represent and who are committed to the level of participation required by the circumstances.

• Agreeing on how the group will function. Willprocesses for decision-making be formal or informal? How will consensus be reached? What constitutes agreement? Who will speak for the group? Too much process can stymie progress and make the quick action often required in a policy-making endeavor impossible to achieve.

• Recognizing that there may be a level of mistrustamong participants based on previous interactions. These dynamics, if not acknowledged, will make it difficult to reach any meaningful level of consensus within the coalition.

• Turf battles are another reality that can hampereffectiveness. For some groups, getting credit for outcomes is critically important so control over the processes becomes an issue that can ultimately doom the effort.

• Too much planning, too many meetings and toofew resources deter and discourage even the most ardent supporters. Few coalitions can survive without resources, but nurses often pride themselves on their ability to make something out of nothing. While that may be admirable, in reality it is a guaranteed road to frustration and failure.

• Communicating within the coalition and outsideof it must be carefully considered. Who will speak for the group and what will the message be? How will members of the coalition be kept informed of developments?

Because of the value a collaborative effort can have, overcoming the challenges is often well worth the effort. With planning and attention to possible pitfalls from the outset an effective coalition can be built and sustained.

ConclusionNurses who want to make a difference for their profession

and ultimately for their patients need not be intimidated by the idea of advocacy in the policy-making arena. Several relatively simple steps provide a roadmap to success.

• Accepttheobligationtobeinvolved,atleasttosomeextent. Involvement need not be a full-time job, but it is also not an option.

• Connect with a nursing organization to buildnetworks and stay informed. Policy-making is often time sensitive and always dynamic. While employers may be good resources for information, always look elsewhere for additional perspectives to make sure you have the fullest picture possible of the issues.

• Share informationwithcolleagues.Yourenthusiasmcould be contagious and influence others to also get involved.

• Recognize you are the boss—elected officials workfor you. Many have very little in-depth knowledge about nursing and health care delivery so you are the expert. They need you!

• Vote for those who will be representing you incongress, at the statehouse, and on school boards and city councils. AND vote knowledgeably.

• Reachout to your own legislators at the local, stateand federal levels. Know who they are and offer your considerable expertise to help them understand some of the complex issues they must deal with around health care.

• Use the skills that are the foundation of nursingpractice—communication in difficult circumstances and a knack for education—in the advocacy arena.

Remember, “Those who refuse to participate in politics shall be governed by their inferiors”–Plato

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