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CONTENTS age •
Editorial - Prof Jenny Carryer
New Direction for Te Puawai
• College Annual General Meeting announcement
• Training Prison Inmates as Hospice Volunteers - Siobhan Thompson
Moving (a long way) forward
NZ Nurse Leaders Study - Donna Donovan
Maori Men and Hypertension - Katherine Archer
• Professor Donna Diers- Guest speaker, Rotorua, 11th October 2011
Professional Portfolio Schedule 2011
Conferences and Events
List of Regional Co-ordinators
Inside Back Cover
Editorial contractural situation at Ministry, DHB and PHO level the situation remains pretty much unchanged. Only general practitioners( GPs) are seemingly being accepted to enroll people and to receive and control the disbursement of capitation funding. Whatever the actual nuances of the contractural situation it appears from communications with Ministry staff that it is widely considered that a Nurse Practitioner (NP) has a limited scope of practice when compared with a GP and is therefore considered unable to offer the ALL of first level contact. This view is extremely problematic and needs to be unpacked in two different ways. Can anyone articulate exactly how and where the NP scope is limited when compared to that of a GP? We know there are a number of frustratingly persistent legislative barriers to NP practice and yes NPs currently remain as designated prescribers rather than authorised prescribers. But both of these limitations are only real because of prolonged bureaucratic procrastination and possible medical resistance. It seems, thankfully, that the current Minister of Health is indeed focused on clearing them as quickly as possible but it is a travesty that they have remained through many previous years of struggle and through the prolonged previous administration.
Professor Jenny Carryer RN, PhD, FCNA(NZ), MNZM Executive Director
Time to turn the paradigm on its head!! This editorial is largely based on recent page I wrote for Nursing Review. Please forgive the areas of repetition but I do think this topic is so important and can do with many "airings�
But putting these easily changed barriers aside, how exactly is the NP scope less than that of a GP? Does anyone know for sure? And why not turn the question around and ask how exactly is a GP's scope less than that of an NP. More interestingly why not consider why the question is never framed that way.
First, in order to set the scene, lets recall that In 2007 when updating the Investing in Health (2003) document, many nurses identified patient enrollment practices as a significant impediment to freeing up ready access to primary health care for all patients. At the same time it is also a barrier to fully utilizing the capacities of nursing and nurse practitioners to meet unmet patient need.
My suggestion is that despite it being 10 years since we launched a primary health care strategy, our health system and many of its stakeholders still think and see the world through a strongly biomedical lens.
In 2011 despite much debate about the
TE PUAWAI This means that the system privileges diagnosis and treatment over the myriad of other considerations, which allow for truly holistic person centered care. It also means that we can remain blind to the gross inequities, which persist and indeed are currently increasing. Even the NZMA has recently come out against the disgraceful inequalities, which underpin access to good health in NZ.
we have spent ten years trying to implement a primary health strategy we have had a vision of one paradigm of health service underpinned by the operations of another paradigm entirely. For ten years at least now, various sources have espoused the need to anticipate the tidal wave of demand engulfing the health system. Health professionals have been constantly challenged to work differently and to consider new ways of doing things. For a long time now we have been aware of the current and soon to be more serious shortage of GPs in New Zealand. People and especially those with little or no access to a GP are being denied high quality care if they cannot enroll with the increasing number of NPs becoming slowly but steadily available. Similarly there are vast areas of care which, are neglected when nurses do not have sufficient control, autonomy or access to funding to determine the exact nature of their contribution to the team.
True primary health care needs to engage in the struggles of people to live well with what ails them, to assist people to manage their disabilities (physical and mental) as best they can, to be alert to the struggles of the frail elderly as they negotiate increasing loss of function and to strongly accommodate cultural and other differences. It is about so much more than first contact encounters for presenting problems. In focus groups conducted in my recent research, GPs consistently made it clear that their interest and passion was diagnosis and treatment and that they were more than happy for nurses to address "all that other stuff". One or two actually (rather bravely perhaps) referred to it as "that boring stuff". Boring it may be for someone trained in biomedicine but boring it is not when one cares for people with the optimal level of well being as the principal goal for the encounter.
The need to actually operationalise the vision and intent of the primary health care strategy has never been greater. The need to eradicate these minor but persistent legislative and custom and practice barriers is now urgent. Patients and especially the most vulnerable patient groups deserve nothing less. References
But, and this is the critical point, we still do not consider that as a good enough reason for seeing the GP scope as limited and we assume that if a person is receiving care from a GP then all is taken care of. Of course a well functioning team is the gold standard but this does not answer the burning question as to why a NP scope of practice (which includes diagnostic, prescriptive and treatment capacity) is seen as so limited that they cannot enroll patients nor receive capitation funding, but a GP can as a matter of course.
Starfield, B The hidden inequity in health care. International Journal for Equity in Health 2011, 10:15 Matheson, D & Loring, B Health inequities are rising unseen in New Zealand. NZMJ 13 May 124 No 1334 Ministry of Health. (2008). Standard PHO-DHB primary care service a gree me n t ve rsi o n 1 8 . Pri mary care agreements. Retrieved from http://www. moh.govt.nz/moh.nsf/indexmh/phcs-phoagreements
If we are still at the stage of believing a NP scope to be somehow less than that of a GP then we have achieved nothing. Although
Editorial cont.
New Direction for Te Puawai but the small number, who are not, may wish to take this opportunity to let the office know their email address for Te Puawai distribution or contact the office for other options.
After 19 years this may be the last editorial for a paper print version of Te Puawai. In keeping up with current trends in publications and communication, the Board has determined that a hard copy of Te Puawai is not necessarily the best way of keeping members up to date or providing stimulating articles in a timely manner. This is especially true due to the rapid increase in electronic updates and news briefs provided to members in the last year or two. These have been widely praised by members and we hope this step for Te Pauwai is just as popular.
Te Puawai's ebook version is very user friendly, it can be read online or printed by choice. We encourage you to give a little time to looking at the e-book version that will be sent to you this week by email. Future Te Pauwai's as well as many past issues are available for members anytime via the College website "Publications tab". We sincerely hope that this will be acceptable to members and consider it is well worth a trial. Please do give feedback on any aspects of this change. Perhaps we are wrong and people really do prefer a hard copy to arrive in the mail? Do let us know.
We plan to trial an ebook or online publication of Te Pauwai, which can be published more often and sent when material is available "hot off the press". The vast majority of members are now connected electronically and already receive College news by email and website links
Professor Jenny Carryer Executive Director
NOTICE OF ANNUAL GENERAL MEETING for
College of Nurses Aotearoa (NZ) Inc to be held on
Tuesday 11th October 2011 at 5.30pm Waiariki Institute of Technology
Drinks and finger food served after AGM followed by
Guest Speaker Professor Donna Diers at 7.30pm See page 18 for more information on our guest speaker or check the College website
Individuals or regional groups may submit remits for consideration at the Annual General Meeting. Remits must be in writing and received at the College office no later than 12th September 2011.
Training Prison Inmates as Hospice Volunteers During the time Florence Wald was building nursing education as Dean of the Yale University School of Nursing (1959 to 1966), she was also conceptualizing the first hospice in the United States, the Connecticut Hospice, Inc. Eventually opting to focus on educating people on hospice, she left her position as Dean and Florence's life's work became dedicated to death.
Siobhan and Florence at an event (one of many) she and I attended as a tribute to Hospice workers in the state of Connecticut in 2005.
The Plan As she began her prison outreach Florence sought me out to write a grant for a feasibility study that could evaluate both the need for and interest in prison hospice. At the time I was working as a Project Director in AIDS research in a state prison, which was unusual deployment for someone working on the Yale campus. Part of my job was to develop and oversee the intake assessments and conduct lifetime history interviews of high-risk inmates in Connecticut's sole correctional facility for women. She recognized that I was already connected to the nursing, medical, and
In 1995, 24 years after pioneering the hospice movement in America, and at the age of 78, Florence Wald had the vision and social conscience to address the medical, social, and spiritual needs of dying patients behind bars in Connecticut. So Florence reached out to help and to inspire prison inmates. In a 1996 letter to Dr. Brett Rayford of the Connecticut Department of Corrections she wrote "prisons are settings where space, number of caregivers are limited, and funds hard to come by are unlike hospice settings. Security precautions are a first priority, how does that mesh with care?"
Training Prison Inmates as Hospice Volunteers... cont. social service staff in the prison infirmary, and that I was comfortable in a prison environment. She was most interested in my knowledge about inmates. Florence asked me to design a study that would help her better understand inmates, their families as they defined them, their community, and the correctional environment responsible for their constitutional right to medical care. Her goal was straightforward but complicated: a proposal that would bring about "realistic, durable change in Connecticut's care for terminally ill prisoners". (F. Wald, personal communication, August 2007).
lack of confidence among CT correctional employees in believing that a prison facility could institute such a program; together with extensive institutional barriers, presented a unique challenge to those volunteering to implement change. Inmates with a diagnosis of cancer, HIV disease, AIDS, or mental illness were no more likely to have heard of hospice than inmates living without chronic illness. In addition, correctional care providers had limited experience in administering palliative and hospice care and a there was a lack of infirmary beds designated to do so (Thompson, 1998). Furthermore, institutional barriers inherent in prison systems such as the prioritization of security and safety posed problems in inmate transport logistics.
The Feasibility Study Funding for the Connecticut prison hospice feasibility study from the Project on Death in America at the George Soros Foundation began on December 1, 1996, Florence Wald was the Principal Investigator. Eight months into the feasibility study, trips with Florence to prisons, transitional housing programs, and community service organizations became routine. She looked to me to interview more than 200 inmates on the touchy subject of end-of-life care in multiple correctional facilities. She aspired to build from "a many faceted network that needs to be accounted for and explored for the possibility of collaboration" (F. Wald, personal communication, July 10, 1997).
Our team of three, Florence, Nealy Zimmerman, and I, had to design a training program that was to include an interdisciplinary team of correctional staff, community and inmate volunteers without having any dedicated monies for prison hospice. Connecticut's Response Prison hospice began with research and community-based educational efforts on the need for hospice in six Connecticut prisons. While correctional initiatives that focused on support for dying prisoners had been undertaken in the past, they were met with limited success until the findings of our 1998 feasibility study identified the need for improved end-of-life care and solutions to implement change (Zimmerman, Wald, & Thompson, 2002).
Florence's focus was not only on the human condition, but the conditions surrounding humans. Prisons challenged this focus. While implementing the prison program we were constantly reminded of why the word hospice in its Latin origin, "hospes" has three meanings, - guest, host, and stranger.
After two years of planning, interdisciplinary professionals in Connecticut responded and made the commitment to make a hospice program flourish in Connecticut's correctional facilities. From our research efforts, teams consisting of nurses, physicians, social workers, clergy, wardens, correctional officers and community volunteers came together to negotiate service needs and align resources to overcome multiple barriers in day-to-day program management.
The Connecticut Challenge Florence Wald in a letter to Professor John Simon, Yale Law School, May 19, 1997:
"I am heartened by what seems to be a growing realization that prisons in their present forms are not solutions to crime and there are many ways proposed for change." Initially, barriers such as the lack of knowledge of hospice care among inmates; the
TE PUAWAI To address the lack of confidence in program implementation we designed a comprehensive seven-session training program to ensure that inmate volunteers would be comfortable in the role of a hospice volunteer. It took years of constant vigilance and guidance for correctional staff to become comfortable with inmate volunteer companionship.
In 2001, the Connecticut Department of Correction (CT DOC) launched the first prison palliative and end-of-life care program in New England. Inmate health inequities and lack of knowledge coupled with scarce resources to deliver end-of-life care eventually drove the program's indoctrination in three state prison facilities. Prison Hospice Volunteer Training To strengthen the voice for access by inmate patients and support inmate hospice volunteers, our team designed an inmate teaching curriculum and institutional training program. I designed questionnaires and analyzed data to properly scale the work, refine the process, make improvements, and communicate standards. The training program was designed to unite interdisciplinary teams, develop criteria for selecting inmate volunteers, assemble a training manual, and ultimately facilitate development of policies and procedures.
Confidence in the hospice program results from interdisciplinary team development and leveraging support for inmate caregiving from custody and administration. We refined the curriculum to engage more and more correctional staff in the training. Correctional social workers, nurses, physicians, and religious ministry help finalize the inmate applicant pool. Some staff members participate in the formal interview process and score applications, and many of them now train inmate volunteers in their area of expertise. Careful consideration was given to the correctional officers' responsibilities and our program addressed them with some clever strategies. Importantly, custody officers were informed that inmate hospice volunteers are not paid, receive no special privileges, and are not permitted to use their hospice volunteer work for special consideration in parole hearings. Hospice shirts must be worn by all volunteers only while on duty. Custody officers are an important part of the interdisciplinary team and often their presence in the classroom results in peer-based education about the program to other officers. At graduation custody secure family visitation, they voluntarily attend the ceremony, and some, like wardens, are invited to give testimonials about the program.
We set standards high. Following the training, our expectations were that attendees would: 1. U nderstand the philosophy of hospice and the history of prison hospice 2. Have a basic understanding of common hospice diagnoses, pain assessment and signs and symptoms of dying 3. Be familiar with various emotional reactions of terminally ill patients 4. Be able to demonstrate empathic listening skills 5. Recognize and explain differences between religiosity and spirituality 6. Formulate personal thoughts and feelings in regard to dying and loss 7. Understand the bereavement process 8. Identify ways to relieve caregiver stress 9. Learn techniques of bedside care 10. Understand advanced directives within the context of curative vs. palliative care 11. U n d e r s t a n d t h e r o l e o f a h o s p i c e volunteer both in prison and the free society 12. Understand Infection Control
Innovative Approaches to the Provision of Compassionate Care Innovative aspects of the Connecticut prison hospice include: 1. A diverse inmate training program Reiki massage, spiritual development, meditation, grief and bereavement
Training Prison Inmates as Hospice Volunteers... cont.
5. 6.
counseling, and "care for caregiver" classes are taught in addition to standard bedside care; A formal graduation ceremony featuring external keynote speakers, inmate graduate speeches, in-house gospel singing, and catering by prison-based cooking schools; Team-building between inmate hospice volunteers and correctional staff that establish trust and generate mutual respect; Collaboration within correctional teams in pioneering strategies that facilitate the deployment and supervision of inmate hospice volunteers on prison grounds; Continuing education lessons for hospice volunteers on topics of interest identified by inmates Monitoring through interdisciplinary team meetings (IDT), inmate support groups, and timely use of program evaluations in further expanding the program under correctional leadership.
The simple fact is that inmates are wellsuited for hospice caregiving because they repeatedly demonstrate the ability to learn, the ability to give back, the ability to grow, the ability to change, and importantly, the ability to contribute. Not only does their work in prison infirmaries have an impact on the quality of life of patients, but by serving as volunteers, they are role models for other inmates, family members, staff, and other volunteers in the community. Role Model to Other Prisons Today the Connecticut prison hospice program has earned a place in the correctional community. By 2011, a total of 170 inmate hospice volunteers have graduated. Terminally ill inmate patients can now request transfer to a facility with a prison hospice program. Here are some examples of how we know hospice is succeeding: 1. Our education is working. More inmates now report that they have heard of hospice and can define it compared to 10 years ago. 2. Our training is working. For every inmate volunteer we train, we estimate that they educate an average of 8 other people about hospice care who wouldn't have known otherwise. This includes families, friends, and other inmates. 3. Our outreach is working. Our enrollment rates for those who first learn of hospice in prison have increased in the volunteer training program. 4. Our focus is expanding. Hospice training now addresses themes, attitudes, beliefs, and values that are more specific to incarcerated people. 5. Our program is working. More and more inmate patients are using hospice services when given the option. 6. Hospice training leads to nursing. A number of inmate volunteers become Certified Nurse's Aids (CNAs) through prison education programs allowing them to earn a small salary, plan further education, and leave prison with a skill set that can change their future.
Promoting Quality of Life by Providing Death with Dignity The essence of prison hospice is teamwork among correctional staff and inmate hospice caregivers. Correctional hospice team members often spend their own free time, off shift and on weekends to secure palliative care resources upon a patient's entry into the program through to death. Teams work together to secure patients' living wills, advanced directives, the compilation of "wish lists" for family visitation, letter writing, burial guidelines, managing hospice inmate volunteer team support, and assembling 24-hour bedside vigils in prison infirmaries when a patient is actively dying. The prison hospice volunteer team is racially and ethnically diverse, which gives them an incredible aptitude for culturally competent care. Some inmates are bilingual; they come from different geographic locations and socio-economic backgrounds. Patients benefit from the diversity of their inmate caregivers.
TE PUAWAI The Joy of Caregiving
Upon leaving prison she was asked to care for a dying family member. Her parole officer, noting her hospice experience in prison, enabled her to delay getting a job so she could care for her uncle in the last 6 months of his life. After his death, she proceeded to search for jobs, often thwarted by her prison record, but, eventually, a Visiting Nurse Association nurse, who cared for her uncle recommended she go in person to a VNA agency to volunteer her talents.
Prison hospice shows that caregiving is an instinct that lives within all of us, and makes us better for it.
From the Graduation ceremony, MacDougall Walker CI, September 7, 2004 "Good afternoon Ladies and gentlemen, distinguished guests, and hospice volunteers. I've been asked to give a short speech about what hospice has done for me… I'll just give you what I consider to be the most important change for me in my life that this program has brought about for me. It has shown me that even though I am in this environment, I can care and tend to the needs of another person and not feel as though I am any less of a man... For what we the volunteers do, I would consider this to be qualities of real men. The satisfaction that I often receive when I help someone to deal with the most difficult time in his life is unexplainable, and the fact that I can make his remaining days a little more comfortable gives me much joy. I've also become more sensitive to the ideas and emotions of others, and I'm able to listen and be open-minded that I may still learn. I want to extend my deepest gratitude to the interdisciplinary team for choosing me and allowing me to be a part of this great experience which allows me to give back." Inmate hospice volunteer
She accidentally walked into the wrong VNA agency but met with exactly the right person to help her. She reports that she eventually earned a volunteer position and that she managed to not only get and keep a job, but had been promoted to Assistant Manager in retail. She continues to do hospice volunteer work, has her children living with her again, and in the past year, has remarried. Florence Wald was expertly prepared to bring hospice to prisons. And our proposal did bring about "realistic, durable change in Connecticut's care for terminally ill prisoners." As a result, our prison hospice program has grown into a paradigm that is systemic, replicable and sustainable. A. Siobhan Thompson, MPH A. Siobhan Thompson is currently directing intervention trials in cancer management at the Yale University School of Nursing. She continues to teach and train volunteers in the prison hospice program.
One inmate describes caregiving this way:
"Experiencing the death of a client that had passed gave me the feeling of courage and gratification, unconditional acceptance and appreciation." Prison hospice has also helped inmates transition back to society in powerful ways prison often cannot. One female inmate hospice trainee who volunteered for 5 of her 6 years in prison relates her success story directly to the prison hospice program, which she says helped heal many of her issues.
Moving (a long • NZ have troops in Vietnam
• Australia and New Zealand signed a Free trade agreement NAFTA • NZ's last steam train left Wellington for Auckland • First Astronaut walked in space (Russian) • Winston Churchill died • Butter cost 2/- per pound • A slim fresh faced young woman started nursing training in NZ.
• Saturday shift, staff of 2 student nurses and one hospital aide to provide patient care for entire ward. Mr Robert Smith admitted with pressure sore.
• Student Nurse M straightens her cap (on her naturally brown hair) rolls up her long sleeves, cleans and assembles equipment. • Requests help from senior colleague (2nd year student nurse) who was enjoying a cigarette in ward office. • Formal introduction to Mr Smith, "I am Nurse *** and am here to dress your bedsore". • Together they lift and roll patient then complete his sponge bath.. Uses "shoulder lifts" – to protect from back injury - straightens cap after each lift and rolls patient for dressing. • Washes hands using memorised 2 minute technique. • Sets up dressing set (trolley metal bowls, instruments, cotton wool balls, Savlon 1:100). • Positions patient using pillows to support him on hard mattress (horsehair, wool, fibre) with rigid thick striped cover. • Handwash etc • From memorised technique manual, removes old gauze dressing. • Unsure with clinical presentation and management so seeks guidance from only experienced nurse available (2nd year student nurse) • Cleans wound with Savlon 1:100. Dresses with clean gauze, secures with sleek or plaster. • As a "special treat" Mr Smith is given a massage of reddened hip, elbows and heels using Surgical spirit "to toughen up the skin". • Washes instruments and bowls, sterilises in autoclave and repacks for next dressing. • Drapes put into linen bags • Disposes of small amount waste in paper bag! • After completion documents clearly in red pen to denote afternoon shift, "Bedsore redressed, satisfactory, nil untoward" S/N PM • Ward Sister will check charts on Monday and leave instructions for care following surgeon's round • Mr Smith unable to listen to radio as in a 6 bed ward and others are sleeping. • For entertainment he watches pigeons mating outside his window ledge of hospital tower block
• Nurse M (a non-smoker) enjoys luke-warm tea brewed in urn, from a china cup and a cheese sandwich – Free to staff… her colleagues all have another smoke!
way) forward • NZ have troops in Afghanistan • NZ can now send Apples to Australian markets! (Free trade!) • New Electric Train Centre for Auckland City • Paying customers can now go into space • Elizabeth Taylor died • Butter costs $4.25 per 500g • A wrinkled older woman is still nursing in NZ having registered as a Nurse Practitioner in 2004. • Monday morning, busy surgical ward, staff of 6 RNs. Bob Smith admitted with pressure injury. Request from university nursing student on clinical experience for advice and mentoring from NP.
• Completes documentation in patient record. (Waterlow Scale, wound chart, size, exudate, tissue type, peri-wound skin, pain, nutrition, mobility, psychosocial, ethic, cultural values, referrals). Details entered into Trendcare for handovers and reporting. • NP dictates letter for typist, clinical photographer emails pictures to typist and this is saved in Bob's electronic record. Printed copy given to Bob and copy emailed to his iPHONE.
• After dressing Bob switches on his iPHONE, with ear piece and gets the latest international news and music. • For entertainment he connects to Skype and watches pigeons mating on window ledge of girlfriend's hotel in London
• NP stops at "Coffee-on the Go" mobile cafe in foyer and has a cappuccino (with chocolate) from an environmentally friendly paper cup $4.00
• Grey haired nurse practitioner and student gather range of disposable equipment and discuss patient's case, history, risks, and objectives for care. • Cleans hands with gel • Greets patient by first name, explain who we are and gets consent. • Lowers electric bed head- end and raises bed to working level. Removes old dressing. • Cleans hands with gel • Uses hoist to move Bob to shower chair. After shower, hoists Bob back to bed. Low air loss alternating pressure mattress in place. • Cleans hands with gel • Full patient and wound assessment done in collaboration with student nurse, pressure injury staged as per Pan Pacific Guidelines (Oct 2011) digital clinical photography done for electronic record with Bob's consent. • Ulcer irrigated with warmed saline, and negative pressure wound therapy applied. • Biochemistry, blood count, radiology reviewed, vital signs, alterations in care plan made after discussion with surgical team. • Unsure about aspects of clinical presentation, seeks guidance from 2011 Pan Pacific Guidelines –student nurse downloads this resource to use in her university assignments • Referrals to OT for seating assessment, physio, Kaitakawaenga, social worker, dietician, and plastic surgeon. • Disposes of large amount of waste in environmentally friendly recycling bins and/or yellow hazardous material waste bags.
Nurse Leaders Study in NZ Yale Student dipping toes into Kiwi Culture??? I was in the first semester of my final year of graduate school when my advisor, Professor Donna Diers asked me to begin thinking about what and where I wanted to study for my final assignment. I had spent two amazing years at Yale School of Nursing in New Haven Connecticut, USA, in a unique program in nursing leadership, management and health policy. I was not sure exactly what I wanted to study but I did know I wanted to learn more about nursing leadership and I knew I wanted to take the opportunity to travel somewhere fabulous.
Donna Donovan interviews Dr Jill Wilkinson College Fellow on Nurse Leadership in New Zealand.
A few weeks later I attended a lecture at the Yale School of Nursing (YSN) given by Professor Jenny Carryer, as Visiting Professor from New Zealand and that is where my plan for my final paper began to take shape. I learned that afternoon that Yale School of Nursing and Jenny at The College Of Nurses Aoteoroa and at Massey University had a relationship that began back in 2000. I learned that YSN students had come to Palmerston North for their community health experiences, that Professor Diers had worked with Massey and with Jenny in several capacities. I was thrilled at the possibility of being the newest thread in this skein of relationships. I soon began discussions about the opportunity to conduct a study in New Zealand, interviewing nurse leaders across the coun-
try. The idea was an eerily natural fit for my final semester. The excitement of this incredible opportunity began to fade a bit once I realized that there were a lot logistics that would need to be worked out. I would need to negotiate the time off from work needed to travel (about 3 weeks) and then a plan for the care of my three children while I was away. I had never been away for more than a couple of days and certainly never as far as the southern hemisphere of the world! A couple of months and lots of planning later I was on a plane to New Zealand. I was fortunate enough to have one of my best friends Christine along with me on the trip. She is
TE PUAWAI struck by the relationship between art and ideas I saw in the offices and homes I was privileged to enter. It seemed as if everyone I talked with produced art (or music) or surrounded themselves with it. My research revealed themes that demonstrated the rich and complex nature of nursing leadership in New Zealand. The themes ranged from very New Zealand perceptions of being a small country and local metaphors of Tall Poppies and Queen Bees to reflections on leadership development (or lack thereof). Taken together, the themes from the interviews may point the way for new discussions as nursing evolves in this beautiful country. I am presently drafting an article which I hope will be published in the not too distant future.
Christine and Donna in Akaroa.
an artist and photographer, armed with her camera ready to document our adventure. It was surreal when at last I stepped off the plane in Wellington. We were greeted by our first kiwi friends, Dr. Jill Wilkinson and her family, who graciously opened their home to us and introduced us to the New Zealand way of life.
The help of The College was formidable and I came reluctantly home to analyze several inches' worth of transcripts. I am deeply grateful to Jenny Carryer, The College administrator Kelly Rotherham and the extraordinary nurses I met as research participants who morphed quickly into friends. I am madly in love with New Zealand now having dipped my toes into the kiwi culture. This will not be my last trip. Donna Donovan, RN, MSN
Throughout my 3 weeks in this breathtakingly beautiful country I found the nurse leaders warm and welcoming and stunningly passionate about nursing in New Zealand. My research took me across both the north and south islands where I was fortunate to interview and learn from 19 of New Zealand's nurse leaders. My research questions asked these leaders to assess the political development of nursing at large in New Zealand, the College membership and themselves. I also spent time learning from them about their own journeys to leadership. I was particularly
Kiwi Beach day in Tauranga.
Donna in Auckland.
Maori Men and Hypertension developed to identify workers who are 'at risk' of, or have unknown or chronic health conditions. Due to the insidious nature of many health conditions, these employees may be unaware they are 'at risk," nor understand the implications of the long-term effects on them and their whanau if they remain untreated. This case study highlights issues around barriers to access in primary care, which health professionals frequently struggle to overcome. Many barriers are well known , others are more insidious but more concerning as will be revealed in the case study I wish to share. Many minor details have been altered to ensure the clients anonymity but without altering the nature of the case. Mike* is a relatively young Maori man. Mike had enrolled for a health check with me at his workplace. He was whakama (shy) and reluctant to talk. A Nurse Led Clinic, held once a week had been established at his workplace. There was no cost to the employee and the clinic room was an office at the worksite. Taking the clinic to the client is one way of breaking down the barriers to access, particularly for Maori men who are over represented in this industry.
By Katherine Archer Impact Health New Zealand Ltd is a primary health care focused group of specialist nurses who provide health assessments and ongoing primary health management to employees in their work place. Our aim is to support employees and industries to increase productivity, morale and wellness through good health.
The challenge to get the men to register for a health assessment and walk through the door of the clinic is still apparent. A team approach was the first step to endeavour to engage these Maori men on their own health journey. 'One Heart Many Lives' promotional material on undiagnosed heart disease in Maori men, was used in a presentation onsite, informing the men of the nurse led clinic, and the overall impact of heart disease on not only the individuals but their whanau also. A local hero was invited to speak to demystify what the clinic was about, This man was able to promote the significant lifestyle changes he had made and the importance of Maori men having a heart check to keep them well so they could continue to work and be providers for
The company is owned by Katherine Archer and is based in Central Hawke's Bay. The variety of workplaces covered is extensive, from roading contractors, meat and produce manufacturing plants, supermarkets staff, and rest home caregivers to name a few. This programme is fully transferable to any location in New Zealand. Currently areas include: Auckland, Hawke's Bay and Tararua. Impact Health's "Working Well – Mahi Ora" is a mobile, nurse led, health assessment and management programme that has been
TE PUAWAI their whanau. He described a term he called 'Doctor Speak', where the medical profession use jargon and terminology that is confusing and disempowering; creating a barrier to personal knowledge on their own health status. He explained in easily understood steps the process of seeing the nurse and the staff, and invited them to register for a free health check in work time.
the next day. This created a block to access for a person with a significant health need. I was unable to discuss the clinical findings with a practice nurse - there wasn't one there that day. The receptionist reluctantly put me through to the GP. As an independent nurse advocate I represent the interests of the patient even in the face of medical and institutional opposition. I believe Mike did not have the skills or knowledge to convey the urgency of an appointment with the receptionist. The GP agreed Mike needed to be seen and fitted him in at 5 p.m. I recommended Mike cease work for the rest of the day but he relied on other people for transport home and refused to stop work as he said he felt well and it would interfere with his income. Although it was apparent Mike's blood pressure was of significant risk, it was decided, when speaking with the GP that it may have been at this level for some time, so waiting till the end of the day was acceptable. Decker et al., (2006) comment on studies that report poor outcomes from sudden lowering of high blood pressure and long term outcomes are more favourable when antihypertensive treatment is aimed at gradually lowering blood pressure in a controlled and closely monitored way. Mike agreed to a lesser physical job for the remainder of the day which was a three way negotiation with his Supervisor.
Mike participated in the confidential comprehensive health assessment where it was discovered he had severe hypertension, with a blood pressure of 240/130 using a sphygmomanometer and stethoscope for accuracy. This was repeated and remained constant over two readings. He had been hospitalised in an ICU 18 months prior, with a severe injury following a violent incident. His hospital notes, viewed at a later date, indicated he had hypertensive symptoms during his hospital admission, but this was not treated in hospital nor followed up by his general practitioner on discharge contrary to the New Zealand Guidelines Group (2003). A range of other more immediate health needs, and the assumption that the hypertension could be related to anxiety, pain and other variables may account for this. This is a missed opportunity to avert a catastrophic health event. Failure to follow up suggests a breakdown in communication, an inadequate discharge plan, or the GP being unaware of the discharge summary findings (Decker, 2006; Kessler, C., & Joudeh, Y. 2010).
Mike attended the nurse led clinic the following week for review and discussion of the treatment plan undertaken with his doctor. He had been given a prescription for antihypertensive medication. He did not understand what these medications were to do, when they were to be taken and what the possible side effects were. He had yet to fill the prescription as he had not been paid, and was working long hours, so getting to the pharmacy was difficult. Mike did not appear to understand the significance of severe hypertension or its effects on his health status nor the importance of starting treatment immediately. He had been given a form for a range of blood tests which he was yet to do. Working rurally where he car pooled with others and the long hours, he had no way of getting to a laboratory resulting in another barrier to access. I faxed the prescription to the pharmacy for him to collect and took his blood at the clinic, taking
Mike said he did not know he had high blood pressure and had visited the doctor on a number of occasions in the past year for gout and flu; he doesn't remember having his blood pressure taken or discussed with him. Mike did not return to see his GP routinely. He felt well but he had used all his sick leave when in ICU, and this created a socioeconomic barrier to accessing primary health care. At the initial assessment my first response to these clinical findings was to contact Mike's general practice to arrange an appointment that day to see the GP. A referral letter was written. However, the receptionist was insistent that the doctor was fully booked and Mike could not be seen until working hours
Maori Men and Hypertension cont. efficiency of care, depending on the degree to which inter- professional relationships are collaborative. There was no effort by the GP to work in a collaborative manner to maximise the health benefit potential for Mike. He was not engaged in any further educational opportunities on hypertension or self-care management. Vulnerability and loss of independence to the institutional care system, where the doctor-patient relationship does not give the patient a sense of control, is more likely to result in a sense of 'learned helplessness' (Hewitt, 2001).
them to the laboratory for urgent analysis. A copy of the results was to be sent to his GP, a Renal Nurse Practitioner and myself. Mike's blood pressure recordings had not changed in a week. A discussion was held with Mike on what he understood about blood pressure and what his GP's future management was to be. He said he felt his GP didn't like him and judged him because of his past experiences with drugs. Mike said the doctor spent most of his time focussing his attention on his computer screen and his patient notes. GP's describe a significant barrier to involving their patients in their own care planning due to lack of time (Singh, 2005). Racism may be a determinant of health when self- reported experiences of discrimination in health have been experienced (Harris et al., 2006), whereas respectful collaborative interaction will provide opportunities for health professionals to impact in a positive way to improve the health of the client (Cram, Smith & Johnstone; 2003).
The Nurse Led Clinic appointment times are variable and individualised to meet the needs of the client, and at the follow up visit Mike stated he did not want to return to his general practice. Mike was supported in his decision to change practices to a Maori provider and I spoke directly to a Maori provider GP, explaining the situation - he was accepted into the practice. I informed the GP I had already rung the Renal Nurse Practitioner at the hospital to inform her of the clinical indicators suggesting probable renal disease and we discussed further tests being done, with a copy of results being sent to her and his new GP. The Maori provider GP then contacted the Renal Nurse Practitioner and an appointment was made for Mike to be seen urgently at the renal team clinic - his results indicated poor renal function. If this was not controlled he would eventually require dialysis.
Mike denies being told the urgency of his medical condition. He was not put off work or referred for specialist care. He was asked to go back in a week for his blood results and a repeat blood pressure. Mike described feeling patronised rushed and disconnected from his primary health care provider and was reluctant to return. Mike discussed feelings of not being heard. The doctor-patient relationship is influenced by the doctors cultural and belief systems and his interaction with the patient. Health literacy deficit is described by Nutbeam (2008) as not only measuring reading and writing achievements but enabling communicative literacy to extract information, derive meaning and actively enable the individual to take greater control over life and events. (Nutbeam,2008).
An appointment was made with the renal team during Mike's work-time. My relationship within Mike's employing company enabled me to work with Mike and his supervisor to ensure that he had time off work to attend the appointment. Mike had used all his sick leave from his time in ICU and he was worried he would be given a hard time by his boss- discussion with Mike and his boss intercepted this. I offered to go with him to the renal clinic which he accepted. It provided an opportunity to work alongside the specialist team, reinforce the same messages, support their care and interpret any information Mike may not understand. The outcome of seeing the Renal Physician was immediate admission to hospital for blood pressure control, changes to his medication regime and time with the
The system of health care delivery as experienced by Mike was fundamentally flawed. He was seen by the GP for 10 minutes which did not allow for adequate medical management or for the delivery of information that the patient understood. There was no referral to a practice nurse for any on-going nursing follow up. Singh (2005) suggests ineffective team relationships can affect the quality and
TE PUAWAI Nurse Practitioner to develop a plan of care, including lifestyle changes that would support improving his poor renal function and on-going monitoring. A referral to a dietician was made, and discussion was held on drug and alcohol counselling, which at this time he refused.
C., & Jagoda, A. (2006). Clinical policy: Critical issues in the emergency and management of adult patients with asymptomatic hypertension in the emergency department. Annals of Emergency Medicine, 47(3), 237-249. Hewitt, J. (2001). A critical review of the arguments debating the role of the nurse advocate. Journal of Advanced Nursing, 37(5), 439-445. Kessler, C., & Joudeh, Y. (2010). Evaluation and treatment of severe asymptomatic hypertension. American Academy of Family Physician, 81(4), 470-476. New Zealand Guidelines Group. (2003). (NZGG).:The assessment and management of cardiovascular risk. Wellington.
Over the next few months, Mike attended the weekly clinic at his workplace, where his recordings were taken and consequently reported back to the renal team and his new GP. Mike took responsibility for his medication by bringing some to work to leave in his locker, in case he forgot to take it first thing in the morning. His blood pressure and renal functions have improved and stablilised with a BP of 120/70. Mike attends his appointments with his new GP and the practice nurse will ring the workplace clinic if a blood test is required prior to an appointment. This is taken onsite without Mike needing time off to go to the laboratory. Mike is more relaxed and open in conversation when he attends clinic. He says he can't believe how well he feels now, he didn't realise he felt unwell for so long. Mike has taken on a number of other significant life changing roles including counselling for alcohol abuse and obtaining custody of his children.
Nutbeam, D. (2008). The evolving concept of health literacy. Social Science & Medicine, 67(12), 20722078. doi: 10.1016/j.socscimed.2008.09.050 Singh, D. (2005). Transforming chronic care: Evidence about improving care for people with long-term conditions. Health Services Management Centre: University of Birmingham. Retrieved 8 December, 2007 from http://www.hsmc.bham. ac.uk/news/TransformingChronicCare
This case study for me demonstrates that every theory of the primary health strategy including continuity, integration, advocacy, nurse navigator roles and attention to vulnerable populations is important. They are important for quality of care and prevention of long term illness, disability and suffering. The tragedy is that for a great many people none of these theories have yet been reliably applied to their care. The existing model of general practice care may still prove unsatisfactory for many people when there is no real multidisciplinary team available.
Moving House or Changing Job Remember to update your details with the College office ASAP.
* Not his real name References available on request
Cram, F., Smith, L., & Johnstone, W. (2003). Mapping the themes of Maori talk about health. New Zealand Medical Journal, 116(1170),357. Retrieved March 12, 2006, from http://www.nzma. org.nz/journal/116-1170/357 Decker, W., Godwin, S., Hess, E., Lenamond,
(06) 358 6000 19
College of Nurses Aotearoa (NZ) & Waiariki Institute of Technology are delighted to present guest speaker
Professor Donna Diers PhD, RN, FAAN.
Annie W. Goodrich Professor Emerita. Lecturer American Academy of Nursing "Living Legend"
Waiariki Institute of Technology School of Forestry in O block Mokoia Drive, Rotorua (Parking access for O block also via Old Taupo Rd SH5)
11 October 2011 at 7.30pm followed by a light supper Gold Coin Donation on entry
for full details visit www.nurse.org.nz
All Welcome
RSVP - Please indicate your attendance by email to firstname.lastname@example.com for catering purposes by 5th October 2011 Donna Diers is the Annie W. Goodrich Professor Emerita and Lecturer in the Nursing Management, Policy and Leadership specialty at the Yale School of Nursing. She holds Adjunct Professor appointments at the University of Technology – Sydney and Sydney University in Australia. She also does work in New Zealand. In the United States, Professor Diers is identified with the emergence of clinical nursing research methodologies, as she wrote the first textbook on that subject. She is also recognized for her work on the policy and politics of advanced practice nursing (nursing practitioner and nurse-midwifery). Her work with DRG-based information for hospital data systems, begun in Australia, has informed clinical, operational and financial decision making in that country and the USA. Donna was Dean of the Yale School of Nursing from 1972 to 1985. Her publications have appeared in all major nursing journals in the USA and in many journals in health services and nursing in the USA, Australia and New Zealand. She was Editor of Image-Journal of Nursing Scholarship for eight years and continues to serve as manuscript reviewer for a number of professional journals in nursing and health services. A popular public speaker, Professor Diers also consults and teaches on writing for publication. Her book, Speaking of Nursing … Narratives of Practice, Research, Policy and the Profession, received the AJN Book of the Year Award in 2005. In 2010, she was named a Living Legend by the American Academy of Nursing, recognized particularly for her nursing advocacy in public prose. Donna teaches Uses of Data in Decision Making and the NMPL Capstone courses. Selected publications Diers, D. (2008) Noses and Eyes: Nurse Practitioners in New Zealand. Nursing Praxis (New Zealand), 24 (1), 4-10 Diers, D. (2009) Before Hospice: Florence Wald at the Yale School of Nursing. Illness, Crisis and Loss. 17 (4), 299-312 Roche, M.A., Diers, D., Duffield, C., & Catling-Paull, C. (2010) Violence toward nurses, the work environment and patient outcomes. Journal of Nursing Scholarship, 42 (1), 13-22 Duffield, C. M., Diers, D., O'Brien-Pallas, L. L., Aisbett, C., Roche, M. A., King, M. T., et al. (2010). Nursing staffing, nursing workload, the work environment and patient outcomes. Applied Nursing Research. doi:10.1016/j.apnr.2009.12.004 Carryer, J.B., Diers, D., McCloskey, B., and Wilson, D.L. (2010) Effects of health policy reforms on nursing resources and patient outcomes in New Zealand. Policy, Politics and Nursing Practice, 11(4), 275-285 More on website www.nurse.org.nz
Portfolio Management and Competency Assessment Workshop for Registered Nurses presented by Dr Stephen Neville. These workshops are an enjoyable and invaluable day providing you with all the skills and information required to complete and maintain your own Professional Portfolio with ease as required under the HPCA(2004). You also receive a certificate of attendance adding 6 hours towards your required professional development hours. Workshops are catered with morning tea on arrival and lunch. Registration is open to all Registered Nurses. Book Now for Location Auckland
Workshop CNA(NZ) * Discounted rate Fee Thursday 17th Novem- Massey University $190 $170 ber 2011 Albany AUCKLAND
* College of Nurses Aotearoa (NZ) Members discounted rate. ** PHO Hosted workshops do have limited spaces available for non PHO nurses to attend, register your interest ASAP if you would like to attend on these PHO Hosted days.
Morning tea is available on arrival from 9.45am. Workshops are run for 6 hours (from 10am – 4pm) Numbers are limited for each workshop, if you or any of your colleagues are interested in attending one of these workshops please register your interest ASAP. To register go to the College website http://www.nurse.org.nz/professional-portfolios.html to download the registration form and see more information or email- email@example.com with the location of the workshop in the subject line. If you are interested in hosting a Portfolio Workshop in your area for your own group/employer, please contact the College office for details. For other queries please phone (06) 358 6000 Please note –This is a day for Registered Nurses who are not on a PDRP Programme and want to develop a Professional Portfolio where they can clearly demonstrate competencies to meet the RN Scope of Practice. This is not a Nurse Practitioner Portfolio Development course.
College News
Conferences & Events College of Nurses AGM
11th October 2011 Rotorua - Waiariki Institute of Technology Followed by Guest Speaker Donna Diers Drinks and finger food will be served to AGM attendees
Pressure Ulcer Forum and Venous Leg Ulcer Forum
16-18th October 2011. Canberra. Australia. www.panpacificulcerforums.com.au for all information and registration.
Nurse Educators Conference
23-25th November 2011. Hamilton www.nursed.ac.nz
Call for abstracts and early registration closes 30 April 2011. All fully paid Earlybird registrations go into the draw to win an iPad. If you know of an event that you would like to see in this section of our next issue in April 2011, please send details to firstname.lastname@example.com
Do you have your Portfolio up to date? PROFESSIONAL PORTFOLIOS College of Nurses Professional Portfolio folders are available for purchase from the College office. This includes instructions for working through and completing your own professional portfolio to comply with Nursing Council regulations. $40 for members, $50 for non-members. (Inc postage & GST) To purchase a portfolio, please forward payment and postal address details to the College office - PO Box 1258, Palmerston North 4440 or call (06) 358 6000 for
more information.
1 day Portfolio Workshops are available around the country, check page 19 for details
Disclaimer The College of Nurses Aotearoa (NZ) provides Te Puawai as a forum for its members to express professional viewpoints, offer ideas and stimulate new ways of looking at professional practice and issues. However, the viewpoints offered are those of the contributors and the College of Nurses does not take responsibility for the viewpoints and ideas offered. Readers are encouraged to be both critical and discerning with regard to what is presented.
College of Nurses Aotearoa (NZ) Inc Members Journal
Published on Aug 30, 2011
College of Nurses Aotearoa (NZ) Inc Members Journal


text:
Listings in Health
Mount Carmel Medical Group Victorian Village
in HIV Services, Doctors
MCMG Victorian Village offers our patients the highest quality medical care in a convenient, friendly atmosphere. We focus on men's & women's health, diabetes, and LGBTQ health.
100 West Third Avenue
Suite 250
Columbus, Ohio 43201
United States
Fax: 614-299-9311
Gentle Steps Counseling - Victoria Johnson LPCC LICDC
in Mental Health, Psychotherapy, Counseling
Relationships- LGBT- Codependency- Panic- Anxiety- Trauma- EMDR- Grief- Loss- Depression- Addictions- ACOA- Mental Health
3736 North High Street
Columbus, Ohio 43214
United States
Fax: 614-447-9027
Rivers Edge Family Medicine
in Doctors, Healthcare Services
Board Certified Family Medicine
4626 Sawmill Road
Columbus, Ohio 43220
United States
Fax: 614-538-9162
Murray Hill Dental - West
in Dentists
Your Friendly Dentist in West Columbus. Murray Hill Dental provides a full range of general and cosmetic dentistry for families, children and adults. We are conveniently located off West Broad Street in West Columbus.
98 N. Murray Hill Road
Columbus, Ohio 43228
United States
Christine Paisley, Ph.D., Psychologist & Associates
in Mental Health, Psychotherapy, Counseling
Proudly Serving the Lesbian/Gay Community Since 1987
1155 W. Third Avenue
Columbus, Ohio 43212
United States
Fax: 614-424-6065
Joseph W. Shannon, Ph.D., Psychologist
Solution-Oriented Counseling and Psychotherapy
1155 W. 3rd Avenue
Columbus, Ohio 43212
United States
Fax: 614-297-1050
Columbus Springs East
Columbus Springs Dublin & Columbus Springs East specialize in the treatment of adults suffering from the devastating effects of mental illness and/or addiction.
2085 Citygate Drive
Columbus, Ohio 43219
United States
Crown Point Family Eye Care
in Optometrists, Eyewear
Let us give your eyes the ROYAL treatment! Gerald R. Page, Optometrist
1906 Bethel Road
Columbus, Ohio 43220
United States
Fax: 614 457-2429
Thomas A. Kiefer, M.D. - Allergic Disorders & Asthma
in Doctors, Wellness, Physicians, Healthcare Services
Dr. Kiefer is an experienced allergy physician serving Columbus and central Ohio communities. He is also a dedicated teacher, instructing resident physicians from the Nationwide Children's Hospital and Grant Family Practice residency programs.
500 East Main St
Suite 110
Columbus, Ohio 43215
United States
(614) 233-9200
Fax: (614) 233-9201
Club Columbus
in Adult Interests, Fitness, Baths & Sauna
A Private Men's Spa. Good. Clean. Fun. Open 24 Hrs.
795 W. Fifth Avenue
Columbus, Ohio 43212
United States
Fax: 614-299-9323

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Building Your Brand Toolkit
When I first got started creating my own graphics, I felt apprehensive about my ability. After trial and error, I have found a very simple formula. Because I never wanted to be completely dependent on a graphic designer, I learned the art of building a brand toolkit. I also found that I didn't want to stand over a designer's shoulder telling them to move the logo slightly to the left… no to the right… up… down. I'm sure you know this song and dance.
A brand toolkit is a folder on your computer that includes the following:
Your Color Codes
Your Mood Board
Your Fonts
Your Logo
Building your brand toolkit will give you the creative freedom to be sure that your brand is exactly as you imagine it on a budget. It's completely possible for you to create your own graphics provided you have the right tools. I personally always hire a killer graphic designer for one task only, to create my logo. The trick is preparation and knowing when to hire the designer. I do a lot of research in advance and I pretty much know the arc of my brand prior to hire.
I will, for example, have chosen my color scheme. I don't think it's absolutely necessary to have landed on your font because this may be a component that the designer adds to the logo. You will want to have some examples for the designer. I usually create a mood board or a Pinterest board with logo examples as well as colors and fonts.
Then the designer begins. By the time you have decided on your logo, you may have decided on your font. When the logo is complete, you will want to ask for several versions for your toolkit.
You will ask for Vector files as well as PNG & JPG versions in all of your brand colors including black and white. This is why it is essential to know your color codes. It's better to ask for more versions than less. I even ask for PSD.
See an example of my branded logo below:
Once you have the logos, you can use most apps and programs to create your graphics. You can upload them into Canva, for example, and layer them over photos on your Facebook & Twitter banners, your Instagram posts, your branded guides and more. Add your completed mood board, your codes and your fonts to your toolkit and you are on fire! Your toolkit can be used for multipurpose branding on all platforms. It is exhilarating and liberating to have the means to create banners and guides. Knowing that you are in the creative seat is so freeing!
For more tips like this, get your FREE brand voice strategy session. I'd love to help you unlock your business strategy and create the dream life and business you desire.
Happy creating!


text:
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Alone at Dawn: Medal of Honor Recipient John Chapman and the Untold Story of the World's Deadliest Special Operations Force (Hardcover)
Availability: Coming Soon - Available for Pre-Order Now
Published: Grand Central Publishing - June 25th, 2019
This work tells the story of John Chapman, an Air Force CCT who lost his life in Afghanistan and posthumously received the Congressional Medal of Honor. John Chapman's actions saved the lives of a SEAL team, and then a Ranger unit before he was killed. There are Rangers, SEALS, Delta forces and other units. There are Chechen and Uzbek Al Qaeda. Their weapons and equipment are formidable. Although the story is a sad one, it is also one that tells of the truly heroic deeds of an individual who put his brothers first.
Before reading this book, I had never heard of a CCT (Combat Control Team). It is a military occupational speciality that describes what may be the most elite soldier of all.
Training to become a CCT is reportedly more arduous than that for any other speciality, and the descriptions of that training do not lead one to assume otherwise. A reason for this is because the CCT must carry a heavier load (batteries and other equipment) than any other soldier. Once there is actionable intelligence, the military will place the CCT on the ground. His main function is to call in air strikes based on his observations. A CCT must have three-dimensional situational awareness.
Alone at Dawn traces the passage of events since Viet Nam: Grenada, Desert One, Bosnia, Somalia and then, 9/11 with Afghanistan; the Northern Alliance and Mullah Omar, vis à vis the technical evolution of the CCT.
Combat controllers did not have a high priority in World War Two. Although the Army felt that it should have jurisdiction over them, the Air Force did obtain jurisdiction, believing that technical developments would eventually eliminate the need for Combat Control Teams.
There is a great deal of military jargon. The reader will be immersed in it and must pay attention to the acronyms to follow the story. ATC (Air Traffic Control), FTX (Field Training Exercise), NVG (Night Vision Goggles), SOF (Special Operations Force), and JSOC (Joint Special Operations Command) are a few examples.
This work is a creation of John's sister, Lori Chapman Longfritz and Dan Schilling, a former CCT; Lori's recollection of her brother and Dan's expertise are well-reflected. It is a story of depth, love and brotherhood.
Steve Brehm
32nd Avenue Books, Gifts & Toys Bookstore


text:
Open access peer-reviewed chapter
By Dean Schmidlin
Submitted: June 21st 2010Reviewed: September 15th 2010Published: April 11th 2011
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Mixed Greens: German renewables cheaper than coal, gas by 2030?
Study sees German renewables cheaper than fossil fuels by 2030; big solar plans unveiled ahead of new Japan FiT; and Spain's subsidy-free 250MW solar plant.
The new head of the Clean Energy Council will focus on energy efficiency, distributed generation and community engagement. And he talks about Australia's place in the renewable world, bipartisan...
Clean Energy Council names UK sustainability leader as new CEO; private funds favoured for CEFC billions; ACT's green power price cut; China's solar shift.
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The printables I was adding to my store at that time were very inexpensive - I charged $3 at most. Throughout the month, I'd make a sale here and there. My phone had the Etsy Seller app downloaded onto it and the app would notify me of a sale by making an AMAZING "cha-ching!!" sound. I loved it even though I only made enough to pay for my fancy lattes here and there.
Cover Verse: There are in the end three things that last: faith, hope, and love, and the greatest of these is love. 1 Corinthians 13:13 Inside Verse: Though your heart must hold deep sadness right now, may it also hold the blessings of the love that will always be a part of you... Praying that God will comfort your heart, uplift your spirit, and carry you through this time of sadness.
I'm about to start a Etsy store. I'll be selling art prints. I can't decide whether to sell downloads or physical prints. If I do physical prints I'll be using the Printful integration. I've done some research on Etsy and I see others selling downloads and from the looks of it they are making a killing. 80k in sales of 6 dollar downloads over just a few years. So there is definitely a market for it. I realize however some people might not want the hassle of printing themselves. Which is why I am questioning the digital download idea. However, as I said the digital download shops seem to be doing really well. More then just a few I've found are doing well. I realize that there is always the possibility of someone stealing my work after downloading. I'm fine that since really if someone buys a physical print they could technically make a high quality scan of it and then do the same as they might with a download. For those that offer downloads what is your experience?
When you sit down with a blank greeting card in front of you, don't be surprised if you can't seem to put the pen to paper. Many of us get a case of writers block when we sit down to write a birthday card greeting, especially to the people we love the most. Sure, the birthday honoree knows just how much you love and appreciate him or her but, it doesn't hurt to remind them on their day.
There's so much to love about our funny, cute, and photo upload cards, but we also have hundreds of designs from our favourite brands. From Batman and Spiderman to Wonder Women and The Incredible Hulk, we have all the best action heroes. There's also tons of Star Wars and Game of Thrones birthday cards and a wide range of birthday cards for kids with Frozen, Trolls, Paddington, and The Little Mermaid.
I don't know if it's just the Avery software of what but these do not print the way that you see them on screen. It's incredibly frustrating when something is centered and there should be no problem with it printing centered on both the front and back but the cards end up overlapping and you can't print doubled sided because they just don't print right. I never have this type of problem when I print regular index cards or word/pdf documents so I'm going with its an Avery software glitch but as long as you print one-sided they're OK.
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November came along (5 months after I had launched the Life Binder) and I was packing my bags for Europe. The "cha-ching" sound from the Etsy app on my phone was a part of my daily life now...and life was good. As a single lady with not a lot of expenses, making even $1000 a month in passive income was a game changer. I was able to make better decisions in my business because I was not longer stressed out by money. In fact, I was working less and less, but making more and more.
However, because I did not have any clear goals for my store and definitely didn't treat it like a business, it did not make a lot of money. I was okay with that at the time because I had a lot of other things going on. I had just closed down a coffee shop business and was launching a cleaning and babysitting business. That kept me busy during the day and then at night, I'd work on my graphic design business serving clients and tinkering with this blog.
As someone who buys all art off Etsy, please offer both. My printer is not good. I have made the mistake of buying the download and been super pissed. I don't understand buying the download if I still have to go to staples or something and get the right paper and have it printed a certain way. Sorry for the rant but I'm a big fan of buying the physical print and so many people don't sell them anymore!!
Still, if you prefer to use your own photos and images and want to create quarter- or half-fold cards, Greeting Box may be a good fit. Since Greeting Box doesn't have photo editing tools, you need to use another application, such as Apple's Photos, to correct red-eye and crop images before you upload them. Once the images are in the software, you can only drag, layer, rotate and reverse them. There's also a transparency option, but compared to Hallmark Card Studio's design suite, which includes more effects and filters, Greeting Box's tools are very basic. This program's biggest benefit is its price – it only costs $9.99. Other greeting cards programs cost between $40.00 and $50.00. Our best pick, Canva, is a subscription service with a fee that, over time, can make it cost even more. While Canva has a limited free version, it can be frustrating to only have access to some of the features and graphics, and Greeting Box gives you full access with your initial download. Also, you can order more clip art directly from Greeting Box for a few extra dollars.