DiversityNursing Blog

Apple has compiled a list of its top 11 apps available in the App Store that are designed specifically for nurses. And knowing all of the submissions and apps that run through the store every day, if Apple says these are awesome, we are apt to believe it. Or at least, to check them out!

According to Mobi Health News, “most of these nurse apps have remained on Apple’s list since it first published its iTunes section for healthcare providers.” And it makes sense that the company has worked hard to ensure there are good, popular apps available to nurses, as healthcare professionals are known to be some of the first adopters of using smartphones at and for work.

In fact, a study last year by Wolters Kluwer Health’s Lippincott Williams Wilkins (LLW) of 3,900 nurses revealed that in early 2012, 71 percent of nurses were already using smartphones professionally. They’re also being used more and more in nursing school.

Here’s the list:

Voalte One by Voalte

“Voalte One is designed to be a unified communications solution enabling phone calls across the hospital VoIP system, text messaging via the user directory, and user-friendly alarm management.”

Nursing Central by Unbound Medicine

“Nursing Central helps nurses and students find detailed information on diseases, tests, drugs, and procedures. The moment a question arises you can consult the automatically updating database of 5,000 drugs, find a definition in the dictionary with more than 65,000 entries, interpret hundreds of laboratory and diagnostic tests, and consult the latest disease information. You can also subscribe to your favorite nursing journals and search the entire MEDLINE/PubMed database directly from your mobile device.”

NurseTabs: Fundamentals by AusQuinn, LLC

“This app allows novice nurses and nursing students to access over 120 skills and procedures separated by topic areas learned through fundamental nursing courses. Once the user selects the skill, they will be presented with equipment they will need to perform the procedure and a step-by-step approach to performing the procedure safely. In addition, users will have access to basic information related to common subject matter learned in fundamentals courses to utilize in the clinical setting.”

PatientTouch by PatientSafe Solutions

“PatientTouch is a Mobile Care Orchestration solution that enables you to orchestrate people, processes, and data in real time. By connecting frontline clinicians to their patients, care team, and existing EHR infrastructure, PatientTouch improves safety, quality, efficiency, and nursing satisfaction, while reducing costs. Ultimately, PatientTouch allows you to spend more time on direct patient care. PatientTouch delivers Positive Patient Identification (PPID) workflows, clinically contextual communications, and configurable care interventions.”

Medigram by Medigram, Inc.

“Stop using that pager from the ’80s! Medigram for iPhone is a secure group messaging application designed to improve communication and care coordination in the hospital environment.”

NurseTabs: Medsurge by AusQuinn, LLC

“This application allows novice nurses and nursing students to search for over 340 common diseases and disorders, separated by body system. Once the disease/disorder is selected, the user will be able to have useful information right at their fingertips, including a nursing process approach to managing client care. There are simple explanations of what each of the diseases/disorders are and common assessment findings associated with them. In addition, useful information is included that incorporates priority assessments needed for clients with the selected disease/disorder.”

Lab Values Reference by Imago LLC

“This app is perfect for both academic and clinical settings, providing clear, concise coverage of 375 of the most commonly performed laboratory tests. Organized by body system and lab panels, and presented in a consistent format with normal findings, indications, test explanation, test results and clinical significance, as well as an overview of order of draw.”

NCSBN Learning Extension Medication Flashcards by National Council of the State Boards of Nursing

"Preparing for NCLEX? Discover a simpler way to master drug information as part of your NCLEX review. Study thousands of drugs grouped into manageable categories, all with common actions and effects. Quickly access interesting facts about medications that will stick with you as you prepare for NCLEX.”

The Merck Manuals for Mobile + Web by Unbound Medicine, Inc.

“The Merck Manuals deliver trusted disease management information to any iOS device and the web. Choose The Merck Manual for Mobile and Web standalone app or bundle it with the Merck Manual of Patient Symptoms and Davis’s Drug Guide to create a versatile point-of-need solution.”

Shots by STFM by Group on Immunization Education of the Society of Teachers of Family Medicine

“SHOTS by STFM is an up-to-date digital immunization reference. Perfect for clinicians, teachers, and health care providers or for anyone who need quick answers to tough vaccination questions. SHOTS by STFM is the most comprehensive immunization app available. In addition to the complete set of CDC vaccine schedules and footnotes, it also includes graphics, images, and commentary. Important up-to-date information is available for each vaccine, including: basics, high risk indications, adverse reactions, contraindications, catch-up, administration, epidemiology, brand names, and additives.”

Lexicomp by Wolters Kluwer Health

“Lexicomp, the most trusted and comprehensive resource for mobile drug and clinical information for pharmacists, physicians, nurses, and other healthcare professionals.”

Do you use any of these apps? Have other options nurses should be checking out? Tell us about them in the comments below!

Source: Mobi Health News

BY MARIJKE DURNING

‘Twas the night before Christmas and night in the ward

I glanced at the names that graced the white board.

The charts were all piled on the desk without care

In the hopes I’d have time to see what was there.

The patients were restless, moving about in their beds

While call bells went off, causing pain in my head.

Charge nurse in scrubs, I with my lab coat

Waited for the effects of our latest coffee jolt.

When way down the hall, there arose such a clatter!

We ran from the office to see what was the matter.

Away down the hall, I flew like a flash

Clipped my knee on a wheelchair, my teeth I did gnash.

The light in the hall, turned low for the night

Showed me a scene that gave me a fright.

Because what to my fearful eyes should appear

A lonely walking patient, coming ever so near.

The patient stumbled forward, an IV in his hand

Trailing behind, a catheter bag, a train so grand.

Now Nurse! Now Doctor! Now anyone here!

Come on anybody, I want me some beer!

Along he went to the top of the hall,

My colleague and I were afraid he would fall!

By his side I did go, to help calm him down

He greeted my presence with an obvious frown

He called for a chair and then again for a beer

We quietly told him, “Sorry, we don’t serve that here.”

And then, in a twinkling, I heard in a room

A lady calling, she needs a broom!

A crash we then heard, the patient came to the door

Come, see what’s a mess, see on the floor!

I left the beer drinker to go have a peek

The sight on the floor made me send out a shriek.

I went to the phone: “Get me housekeeping, please!

I need your help now, I’m starting to wheeze!”

The patient was moved to a room that was clean

I thought of the patients I hadn’t yet seen.

The patients got settled, the call bells stopped beeping

Midnight was coming, we felt the time creeping.

IVs we did check and vital signs we did take

Wondering if this Christmas, we’d both get a break.

Back down to the desk, we had paperwork to do

Looked at the clock, still plenty of night to get through.

We went through chart after chart, the orders we checked

When the call bells went off, down the hallway we trekked!

Midnight was coming, Christmas Eve would soon end

We wondered if admin would mind if some rules we would bend

For the holiday season is the time for some fun

As long as our patient work was all done!

We went back to the desk, just for a moment or two

When we found treats on the desk—from where and from who?

The treats, they were good and touching to get

But from where they arrived, we hadn’t found yet.

We heard sounds of someone running out of sight

And heard very clearly, “Merry Christmas to all and to all a good night!”

Source: Scrubs Mag

BY ELIZABETH SCALA

Why am I doing this again?

Now that the holiday season is upon us (and many of us nurses have to work while our loved ones get to stay home and play), we might be questioning why we went into nursing in the first place. It’s no fun working when everyone else is off, enjoying meals, gifts and holiday traditions with family and friends.

But this is the time of year when many of our patients need us most.

Some of them don’t have family and friends. Many of them are scared and alone. And I can bet that all of them would rather be anywhere but in the hospital during this time of year.

Instead of focusing on the downsides of nursing during the holidays, let’s choose something different. Together we can empower ourselves and enjoy our work and our home life, no matter where we find ourselves on these special days.

Here are three tips for shifting your nursing perspective during this busy time of year:

1. Reconnect with what you enjoy. One of the simplest ways to reconnect ourselves with our nursing selves is to remember what brought us to nursing in the first place. After that memory is brought back to life, bring it into the here-and-now. You might ask yourself the following questions: What is it about nursing that I love? What’s my favorite part of my job? In what ways am I passionate about this really awesome and humbling profession? Reconnecting with your purpose is a wonderful way to shed light on the joy of your life.

2. Discover the good in everyone. I had a client last week tell me how she was making a conscious choice to find the good in every single person she worked with, even when it was hard. From the front desk to the parking garage, from the manager to the newest graduate on your unit, from the CEO to the ancillary staff, what can you appreciate in every single person? The more you see the good in everything you do–and everyone you greet–the more your environment is filled with good things to see. Try it for yourself. Give this a shot for a week or so and see what happens.

3. Be mindful of gratitude. The fastest and easiest to shift your perspective is through the practice of gratitude. We get what we give. Now, during the holidays, or at any time of year. Our thoughts become our worlds. If you’re able to focus on what you’re thankful for–about your job, your place of employment and your coworkers–you’re much more likely to enjoy working the holiday shifts. Yes, they may still be hard…we all want to be with family. But what is it about being a nurse and sharing the holiday with a patient that can lift your spirits? How can you be grateful today?

Source: Scrubs Mag

By Megan Murdock Krischke

“The nurses I work with are the smartest, funniest people I know. Our work causes us to problem-solve and to think critically about everything, and that leads us to coming up with solutions in every aspect of our lives.  It just fits that we would be inventors,” remarked Stacey Tatroe, RN, BSN, inventor of RN I.D. Scrubs.

Fellow nurse entrepreneur Sarah Mott, RN, agrees. “My colleagues and I were always making little inventions to provide patient care--like things to elevate a leg or to make an IV work. But we weren’t thinking about these as inventions. That is why I wanted to encourage other nurses to pursue their inventions and to bring their products to market.”

Mott has recently started her own company, Nurse Born. Her vision is to market products created by nurses that are inspired by practical experience.

“I want to encourage nurses to think about the needs of their colleagues and patients and then to pursue their ideas,” said Mott. “As the company grow, I would like to hire nurses who, because of an injury, can no longer tolerate long hours on the floor.”

Mott’s own work-related injury is part of the story of how she became a nurse inventor and a business owner.

“It has been a very long road. It started when I was working as a staff nurse on a post-op ortho floor. My neck was bothering me and I was uncomfortable with the stethoscope hanging on my neck. It also bothered me to keep an item that carried so many germs so close to my face. I was looking for an alternative way to carry it and I couldn’t find anything, and I thought someone should invent something,” she explained.

A few months later, her injury had progressed to the point that she had to take some time off work. At home and bored, she started experimenting with household items to create a stethoscope clip. Once she assembled a workable clip, she began pursuing a patent and was accepted into a free program where a local university student helped her apply for it. An engineer acquaintance of hers was willing to create a prototype.

In due time, her Stethoscope Holster became a reality, and is now the first product to be marketed through Nurse Born.

Mott says her biggest challenge so far is just getting the word out about her product.

“My experience as a nurse has helped me in my new career as an entrepreneur. I learned to be more confident and to trust my own judgment,” she stated. “Nursing helps you develop good instincts about people because you are constantly interacting with different kinds of people and personalities.”

Along the path of bringing her product to market, Mott was mentored by members of a local small business association as well as other nurse inventors she found through online research. She would love to provide that same kind of support to other nurse inventors and encourages them to contact her.

Tatroe is one of the inventors who mentored Mott.

Tatroe works as an ER nurse at Wellstar Health Systems in Atlanta, Ga., and fell into the role of nurse entrepreneur through a different route.

After working as an LPN for six years, she had completed her RN licensure and wanted to celebrate.

“For work that day, I hand-made scrubs that said RN and wore a sash and a crown!” she said. “What was so interesting was that colleagues I had worked with for years were surprised to find out that I wasn’t already an RN. Even though our licensure is written on our IDs, clearly no one was reading that. But they saw it when it was written on my scrubs.”

“It is frustrating for patients when they don’t know who is walking into your room.  Some hospitals use a color-coding system, and that can be helpful for the staff, but the code often remains unclear to patients, family members and providers who don’t work at the facility. I.D. Scrubs communicate to the patient, ‘I am your nurse. I am the one who is here to take care of you and answer your questions.’”

Tatroe pursued a patent and contacted her favorite scrub manufacturer, Cherokee Uniforms, to pitch her idea. They are now marketing her line as RN I.D. Scrubs.

Tatroe agrees with Mott that marketing can be the most challenging part of inventing a product and getting it off the ground.

“Every time I am at a trade show or show another nurse these scrubs, they love them and they ‘get it’ immediately. The challenge is getting the word out and letting nurses know that I.D. Scrubs are available,” she remarked. “I hope we will be able to expand the line to include IDs for all scrub-wearing clinicians and staff.”

Tatroe urges other nurses to pursue their ideas.

“Go for it!” she said. “You will never know unless you try. Think of all the innovations in history--what if those inventors hadn’t given it a go? You have to put yourself out there and work for it. Nothing comes easy or free.”

Source: TravelNursing.com

A generational gap is showing in nurses’ views of the practice, with younger RNs more likely to have a positive opinion of the nurse supply and use of electronic medical records, according to a survey.

The fourth annual survey was conducted by AMN Healthcare, a healthcare workforce and staffing company. Results were based on 3,413 responses from questionnaires emailed to 101,431 RNs during April 2013. 

“In a time of unprecedented change in the healthcare industry, it becomes even more important to study how the nursing workforce is responding to the myriad new systems, requirements and quality measurements that accompany healthcare reform,” Marcia Faller, RN, PhD, chief clinical officer of AMN Healthcare, said in a news release. 

“While the vast majority of nurses remain satisfied with career choice, the younger generation is more optimistic about the profession and more receptive to the changes the industry is experiencing. These are differences that health systems must understand as they work with multiple generations of nurses.”

Despite existing shortages, RNs ages 19-39 are more confident about the supply of nurses and their ability to meet the demands of healthcare reform, according to the survey. Findings show 45% of younger RNs believe the shortage has improved during the past five years, compared with 41% of RNs ages 40-54 and 34% of RNs ages 55 and older. 

The generational differences widened when nurses were asked whether healthcare reform will ensure an adequate supply of quality nurses, with 38% of younger nurses saying they were “very confident” or “somewhat confident,” compared with 29% and 27% of nurses 40-54 and 55 and older, respectively.

Generational differences also appeared in answers about the use of electronic medical records, a requirement of the Affordable Care Act. Younger RNs were more likely to believe their use positively influenced job satisfaction, efficiency and patient care. While 67% of younger nurses agreed or strongly agreed EMRs were a positive influence on job satisfaction, that number fell to 51% for nurses 40-54 and 45% for RNs 55 and older. 

Similarly, more young RNs (60%) agreed EMRs positively influence productivity and time management compared with older RNs (38%), the survey found. 

Other key findings:

• Almost 90% of nurses, regardless of age, are satisfied with their career choice, and 73% are satisfied with their current jobs.

• With the improving economy, approximately 23% of nurses age 55 and older plan to dramatically change their work life, citing retirement, taking a non-nursing job or working part-time as very near-term possibilities.

• Less than half of RNs with an associate’s degree or a diploma plan to pursue any additional education in nursing. However, RNs ages 19-39 are more likely to pursue higher education, with nearly 25% saying they expect to pursue a BSN and 34% planning to obtain an MSN, compared with 22% of RNs ages 40-54 planning to pursue a BSN and 22% eying an MSN.

• Of younger nurses, 21% are certified in their specialty, but 59% expect to seek certification.

• RNs ages 19-39 were less likely to believe the quality of care has generally declined (37%), compared with RNs 40-54 (56%) and RNs 55 and older (66%).

“The potential departure of a significant number of older nurses from the workforce can be concerning, given the unclear supply and demand for nurses in the coming years, but is to be expected as nurses approach retirement age,” Faller said in the news release. 

“Healthcare systems must use innovative approaches to attract and retain their workforce while keeping them effective and satisfied. Innovative workforce solutions could help maintain high standards of patient care and efficiency in the era of dramatic change in the healthcare industry.”

Report (registration required): www.amnhealthcare.com/industry-research/2147484433/1033/

Source: Nurse.com

Despite “measurable progress” in the three years since the release of the Institute of Medicine’s landmark report on the future of nursing, more work remains “to fully realize the potential of qualified nurses to improve health and provide care to people who need it.”

That assessment is part of a commentary by Harvey V. Fineberg, MD, PhD, president of the IOM, and Risa Lavizzo-Mourey, MD, MBA, president and CEO of the Robert Wood Johnson Foundation, on the aftermath of the report.

“The Future of Nursing: Leading Change, Advancing Health” was released Oct. 5, 2010, by the IOM with the support of RWJF. It provided a blueprint for transforming the nursing profession to “respond effectively to rapidly changing healthcare settings and an evolving healthcare system,” according to a report brief.

The key recommendations: allow nurses to practice to the full scope of their education and training, provide opportunities for nurses to serve as healthcare leaders and increase the proportion of nurses with a BSN to 80% by 2020. Following the report, RWJF and AARP formed the Campaign for Action to implement the report’s recommendations at the state level. 

Regarding scope of practice for advanced practice registered nurses, Fineberg and Lavizzo-Mourey wrote that 43 state action coalitions have prioritized initiatives to remove scope-of-practice regulations that prevent APRNs from delivering care to the full extent of their education and training. Iowa, Kentucky, Maryland , Nevada, North Dakota, Oregon and Rhode Island have removed barriers to APRN practice and care, and 15 states introduced bills this year to remove physician supervision requirements that can hinder APRN care.

Regarding education and training, the proportion of employed nurses with a BSN or higher degree was 49% in 2010 and 50% in 2011. “Progress is likely to accelerate in the years to come,” Fineberg and Lavizzo-Mourey wrote, “because between 2011 and 2012 along there was a 22.2% increase in enrollment in RN-to-BSN programs and a 3.5% increase in enrollment in entry-level BSN programs.” The authors also noted a recent increase in the number of students enrolled in nursing doctorate programs. Of the 51 action coalitions, 48 have worked to enable seamless academic progression in nursing.

The authors noted that the influence of the campaign has paid off with a $200 million Medicare initiative to support the training of APRNs at hospital systems in Arizona, Illinois, North Carolina, Pennsylvania and Texas.

Regarding nurse leadership, Fineberg and Lavizzo-Mourey wrote, the “Campaign for Action has tapped established and emerging nurse leaders across the nation and is working to provide them with opportunities for networking, skills development and mentoring. A key strategy is to advocate for more nurses to serve on hospital boards.” 

Full commentary: http://bit.ly/176XyZs

Campaign for Action: http://www.rwjf.org/en/topics/rwjf-topic-areas/nursing/action-coalitions.html

“Future of Nursing” report: www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx

Graduate Nurse Education Demonstration: http://innovation.cms.gov/initiatives/gne/. 

Source: Nurse.com

By Debra Wood, RN

To achieve the national goal of improved health outcomes, many researchers and health advocates agree that patients must assume a greater role in managing their health

care. But how can facilities and health systems accomplish this kind of patient engagement? The answer may rest with nurses and nurse leaders, who have long overseen patient education about how to care for chronic conditions and make lifestyle changes to improve health.

“Promoting patient education has always been a part of our nursing role and obligation to the
patient,” said Debi Sampsel, DNP, MSN, BA, RN, chief officer of innovation and entrepreneurship at the University of Cincinnati’s College of Nursing in Ohio. “It has been a long-standing practice that nurses involve the patient across the life span in their own care.”

Sampsel finds nurses strive to and take great pride in promoting healthy lifestyles. And research has demonstrated that active, engaged individuals have far better health outcomes. The University of Cincinnati includes health promotion in the nursing curriculum and gives students an opportunity gain patient-engagement experience while working with the homeless and elementary and secondary school age youth.

“What’s new is old,” added Patrick R. Coonan, EdD, RN, NEA-BC, FACHE, dean and professor at the College of Nursing and Public Health at Adelphi University in Garden City, N.Y. “I went to nursing school 35, 40 years ago and what did they teach but to be the patient advocate, to teach the patient. But we got away from that in the last few decades.”

Coonan pointed out that today’s consumers and patients, particularly baby boomers, are better informed. They often turn to the Internet for facts, but he called it a nursing professional’s obligation to verify whether the online information is accurate. Boomers are not going to settle for a paternalistic “Just take this pill” without knowing why and how it will benefit them. And that often falls to the nurse.”

“We have to get away from the patient-doctor or patient–nurse relationship that is almost like a parent–child relationship, in existence for many years, to a more informed and empowered [consumer] who will take responsibility for their health,” said Rosemary Glavan, RN, MPA, CCM, senior vice president of clinical operations at AMC Health, a telehealth provider based in New York. “Baby boomers have been go-getters and always wanted to be in charge. They want to be empowered.”

Advocating with a personal connection

“As patient advocates, nurses and nurse leaders play a key role in promoting patient engagement,” said Cynthia M. Friis, MEd, BSN, RN-BC, associate association executive for SmithBucklin’s healthcare and scientific industry practice in Chicago. “Nurses are privileged with having the opportunity to spend more time with the patients to assess, plan, implement and then help clarify the plan of care with the patient and his/her family or caregivers. Nurse leaders are key in helping to ensure this role is realized. Nurses can do their jobs better with the full support of our nurse leaders.”

Nurses ask questions, she added, and draw patients into thoughtful discussions about their care, helping them move forward when they feel overwhelmed and understand how to best care for themselves.

Establishing principles of engagement

Patewood Memorial Hospital in Greenville, S.C., participated in a national study by the Agency for Healthcare Research and Quality (AHRQ) and in the development of theGuide to Patient and Family Engagement in Hospital Quality and Safety.

Recommendations in the AHRQ guide include:

• Working with patients as advisors;
• Communicating effectively; 
• Giving bedside shift reports, where nurses do not talk with each other but involve the patient and family members he or she wants to participate; and 
• Engaging patients in transitions to home.

The hospital has experienced improvements to its HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey since implementing the program.

“The patients and families are much happier,” said Kerrie Roberson, MBA, MSN, RN-BC, CMS, nurse educator at Patewood. “Patient engagement is a partnership with the patient and families, and they trust you more when they see you are open about their care.”

Nurses at Patewood are leading discussions about patient engagement across the Greenville Health System and have begun sharing their experiences with others.

Other nurses gathered to develop Guiding Principles for Patient Engagement, released last year by the Nursing Alliance for Quality Care (NAQC), which was supported by the Robert Wood Johnson Foundation.

Principles in the NAQC guide include:

• Having a dynamic partnership with patients and their families; 
• Respecting boundaries; 
• Maintaining confidentiality; 
• Adhering to responsibilities and accountabilities; 
• Recognizing patients able to engage; 
• Appreciating patient rights; 
• Sharing information and decision making; and 
• Advocating for the patient.

“Patient-centered care and engaging patients is very important to improving quality outcomes, which includes reducing cost and better health of populations in the community, but also reductions in disparities of care,” said Maureen Dailey, PhD, RN, CWOCN, senior policy fellow for nursing practice and policy at the American Nurses Association (ANA), a member organization of the NAQC. “The patient is at the center of the team and must assume accountability for self-care and part of the outcome. But that evolution has yet to take place.”

Nurses must instill confidence and competence in patients’ self-care, Dailey explained. And patients need nurses to provide knowledge, support and symptom management.

“Nurses hold a central role in patient engagement,” Dailey concluded.

Combing nursing skills with technology

Along with the personal touch, many nurses are finding technology can assist with their patient-engagement efforts.

“As the responsibility of nursing advances to one of building and sustaining patient activation and the role of nursing moves to be more consultative across care settings, technology will play a vital role for both the nurse and the patient,” said Karen Drenkard, PhD, RN, NEA-BC, FAAN.

Drenkard, who has served as executive director of the American Nurses Credentialing Center (ANCC) and past director of the ANCC Magnet Recognition Program, will join GetWellNetwork in January as chief clinical/nursing officer, where she will lead the development of a nursing model of patient engagement. Her responsibilities will include studying and designing new ways to assess and improve patient activation through clinical practice and technology solutions across all care settings.

“Nursing can use interactive patient care technology to proactively engage the patient and shift the responsibility for completing certain care interventions,” said Drenkard, explaining patients can document daily signs and symptoms. Care providers use the network to send reminders about taking medications or the need for follow-up visits to their physician when data and input from the patient indicates the need to do so.

The Health Insurance Marketplace open enrollment launch on October 1, 2013 spurred discussion about the influx of newly insured patients and the shortage of primary care professionals. Nursing@Simmons, an online Master of Science in Nursing program for aspiring Family Nurse Practitioners, created an infographic to illustrate the state of primary and preventive health care in the U.S. and the role nursing professionals hold. This infographic provides a snapshot of what has happened in the years since the Affordable Care Act was conceptualized and enacted, in addition to showing how nurse practitioners are contributing to primary care.

Share the infographic below to raise awareness about the role that Family Nurse Practitioners play in health care reform under the Affordable Care Act.

Source: Simmons Nursing