AACN News—October 2001—Practice

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Vol. 18, No. 10, OCTOBER 2001


Wyeth-Ayerst Nursing Fellows Program Marks 10th Year
New Class Begins Projects Focusing on Cardiopulmonary Topics


A partnership that has guided more than 300 AACN members through a unique professional development opportunity marks its 10th year with the 2001-02 class of the Wyeth-Ayerst Nursing Fellows Program.

Sponsored by Wyeth-Ayerst Pharmaceuticals in collaboration with AACN and the American Journal of Nursing, the program pairs mentors and fellows to prepare personal, clinically focused fellowship plans. These plans include completing an individualized project, attending AACN’s National Teaching Institute™ and Critical Care Exposition and developing a manuscript that is published in an annual supplement to AJN.

Special recognition of the 10-year milestone is planned throughout the year. All alumni of the program will be invited to the annual Wyeth-Ayerst convocation ceremony and reception in conjunction with NTI 2002 in May in Atlanta, Ga.

In addition, mentors and fellows from the 2000-01 class have been invited to provide “testimonials” about what the program has meant to them. Their contributions will appear in AACN News throughout the year in a special column titled “Sharing the Experience.”

“The appreciation shown by the fellows and their mentors toward Wyeth-Ayerst is extremely rewarding,” commented Marc Greenberg, manager of Account Marketing, Field Marketing & Support for Wyeth-Ayerst Pharmaceuticals.
“Our partnership with AACN on this project over the past 10 years has provided many opportunities for dedicated nurses to improve patient care through their professional development.
“We look forward to continued support of the Wyeth-Ayerst AACN Nursing Fellows Program.”

Ten new pairs of AACN members have now begun the fellowship. This year’s manuscripts, which will focus on a current cardiopulmonary topic, will be published in the supplement to the May 2002 issue of AJN and showcased at the NTI in in Atlanta, Ga.

“Helping nurses write about what they do is at the heart of AJN’s 100-year history,” said Maureen “Shawn” Kennedy, RN, MA, the journal’s news director. “This class will join the other critical care nurses who have published as part of this program and whose work has been distributed to thousands of nurses in print or on the Internet, communicating valuable information that will result in better patient care.

“The American Journal of Nursing congratulates Wyeth-Ayerst Laboratories for their continued support and AACN for its commitment to their members.

In addition to the recognition that comes with publishing an article in a national nursing journal, the fellows receive registration, travel and lodging for the NTI. Mentors who attend the NTI receive complimentary registration and a $500 educational grant.


2001-02 Class of Wyeth-Ayerst Fellows and Mentors

Mentors Fellows
Karen Giuliano, RN, MS, CCRN, ACNP
Atkinson, N.H.
Boston College School of Nursing
Nancy Richards, RN,MSN,CCRN,CS
Baldwin City, Kan.
St Luke's Hospital
Mid America Heart Institute
Topic: Transfusion practices
Margaret L. Campbell, RN, MSN, CS, FAAN
Detroit, Mich.
Detriot Receiving Hospital
Christine Westphal, RN, MSN, CCRN, CNS
Allen Park, Mich.
Oakwood Healthcare System
Topic: Nebulized morphine for relief of dyspnea in CHF & COPD
Mary Ellen Mc Morrow, RN, CCRN, CNS, EdD
Bayonne, N.J.
College of Staten Island
Angela M. Nelson, RN, MSN, CCRN, ACNP-C
Manalapa, N.J.
New York University Medical Center
Topic: Neurogenic pulmonary edema
Ana Gawlinski, RN, DNSc, ACNP
Los Angeles, Calif.
UCLA Medical Center
Peggy McAtee, RN, MN, CCRN
Anaheim, Calif.
Long Beach Memorial Heart Insitute
Topic: Biventricular pacing for CHF
Mary Mason Wyckoff, RN, MSN, ARNP, C-FNP, NNP, ARNP
North Miami Beach, Fla.
Jackson Health Institute
University of Miami
Valerie Diaz, RN, BSN, CCRN, TNCC
Pembroke Pines, Fla.
Jackson Health System
University of Miami
Topic: Cardiorespiratory & hepatotoxicity due to Ecstacy
Nelda Martin, RN, CS, MS, CNS, ANP
Pevely, Mo.
Barnes Jewish Hospital
Cathy Powers, RN, MSN, CS
St. Louis, Mo.
Barnes Jewish Hospital
Topic: Inhospital use on AEDs
Karen Kilian, RN, ARNP, CCRN
Seattle, Wash.
Children's Hospital and Regional Medical Center
Eileen K. Fry-Bowers, RN, MS, CCRN, CPNP
Riverside, Calif.
Loma Linda Univ. Children's Hospital
Topic: Troubleshooting complications in Pediatric cardiac surgical patients
Betsy M. McDowell, RN, PhD, CCRN
Ninety Six, S.C.
Lander University
Pamela D. Bartley, RN, CEN, CCRN
Prosperity, S.C.
Mid-Carolina Area Health Education Center
Topic: Historical reflections of ACLS
Darlene Lovasik, RN, MN, CCRN, CNRN
Pittsburgh, Pa.
University of Pittsburgh Health System
Denise Caldwell, RN, BSN
Greensburg, Pa.
University of Pittsburgh Health System
Topic: Endocarditis in immunosuppressed patients
Lynn Rodgers, RNC, MSN, CCRN, CNRN, ACNP-C
Evansville, Ind.
Deaconess Hospital
Lynn Smith Schnautz, RN, MSN, CCRN
Evansville, Ind.
Deaconess Hospital
Topic: Septic emboli


Sharing the Experience
Editor’s Note: In celebration of the 10th anniversary of the AACN Wyeth-Ayerst Nursing Fellows Program, AACN invited mentors and fellows alumni to share their thoughts about and experiences with the program. These accounts will be published in AACN News throughout this anniversary year.

By Diane Ford, RN, MS, CCRN
Wyeth-Ayerst Fellow

As a nursing faculty member at Andrews University, Berrien Springs, Mich., I believed I needed to publish. I considered the AACN Wyeth-Ayerst Nursing Fellows Program to be an excellent opportunity to accomplish this goal—and get a chance to attend the NTI for the first time.

However, I was initially discouraged because I did not know of a nurse who had both an interest in cardiovascular topics and publishing experience. My department chair called the Department of Nursing at the University of Illinois, Chicago, Ill., her alma mater, to ask whether a faculty member there might be willing to help, As a result, I was able to connect with Julie Zerwic, RN, PhD, who agreed to apply to be my mentor.

Although we had never met in person, we were able to complete our project without any problems. We communicated primarily via mail and e-mail.
I had an interest in Kawasaki disease, and participating in the AACN Wyeth-Ayerst Nursing Fellows Program motivated me to dig deeper to learn more. A literature review provided valuable information, some of which I decided to present in the form of a case study.

The AACN Wyeth-Ayerst Nursing Fellows Program is a wonderful opportunity to write an article for publication. At the NTI, mentors and fellows receive royal treatment—and the fellows’ conference expenses are paid! This program is definitely a win-win situation!


Family Care Giving: The Synergy Model as a Foundation for Ethical Practice

By Cheryl McGaffic, RN, PhD, CCRN
2000-01 Ethics Work Group

As the number of elderly patients in ICUs continues to increase, nurses must consider care of the family as a critical aspect of optimizing patient outcomes. As moral agents for patients and their families, nurses need to recognize the unique characteristics of the family system and their own limitations, and act as advocates to solve ethical problems in the clinical environment.

The disruption that critical illness and hospitalization can create in the family system can be devastating to the physical, social, psychological and spiritual well being of patients and their families. Each patient has
a unique pattern of family relationships that includes a history, roles for each member in the family system, power structure within the family and patterns of behavior that characterize each family member when one member is ill. The complexity of family relationships and the type and nature of care given prior to hospitalization must be considered.

The Synergy Model
The Synergy Model offers a foundation for ethical practice and for nursing care of patients with critical illness and their families. The Synergy Model recognizes the unique characteristics of patients, their capacities for health and the vulnerabilities that accompany illness. Without understanding these unique characteristics—stability, complexity, predictability, resiliency, vulnerability, participation in decision making and care, and resource availability—and the fact that they extend beyond the patient to the family as a whole, ethical decisions cannot be made. When these patient and family characteristics are congruent with nurses’ competencies, patient and family outcomes are optimized. The following example of an elderly patient admitted to an ICU with do-not-resuscitate orders illustrates the Synergy Model as the foundation for nurses’ ethical practice.

Jack, an 80-year-old retired army colonel with end-stage Parkinson’s disease, was admitted directly from home to the ICU. During the past 24 hours, he had developed worsening dysphagia and shortness of breath. His admission diagnosis was aspiration pneumonia and sepsis.
Although Jack had been unable to communicate verbally for almost a year, he remained cognitively intact and used hand signals to answer “yes” and “no” questions. He required assistance with all activities of daily living.
Jack’s family included his wife, adult daughter, son-in-law and adult grandchildren. When his condition had worsened to the point that he required 24-hour care, his daughter and her husband remodeled their home so that Jack and his wife could live with them. Although his daughter was the primary caregiver, the entire family helped with care-giving activities. Jack’s wife was most uncomfortable providing care and expressed her grief openly for the life she and Jack had had before he became ill.

When conflict between values results in ethical dilemmas, there often is more than one dilemma that needs to be addressed. In Jack’s case, the nurse faced the following ethical dilemmas:
1. Jack had not received his evening dose of amantadine for his Parkinson’s disease, because the liquid form was not available from the hospital pharmacy. Without this medication, Jack was extremely agitated and less able to move purposefully. His daughter asked if she could give him the syrup she had brought from home, but was told by the nurse that it was “against hospital policy” for family to administer any medications brought from home. The nurse also expressed concern that administering the amantadine by mouth might cause Jack to aspirate, further compromising his condition. Through the use of hand signals, Jack refused insertion of a nasogastric tube.

Although allowing Jack’s family to administer his medications from home violated hospital policy, he needed the amantadine because he was becoming increasingly agitated and rigid. Administering the amantadine by mouth could potentially harm Jack by causing him to aspirate. Nevertheless, this was the only method available to administer the medication.

2. Jack’s family members maintained a continuous vigil at the bedside, refusing to leave even when the nurse asked that they “respect the visiting hours policy.” She contended that it was not “fair” to the other patients’ families for Jack’s family to stay in his room and that she was better able to care for Jack without his family “watching everything we do.”

The family members believed their presence was needed and important to Jack’s and their well being. Permitting the family to stay violated unit policy. The nurse perceived this to be unfair to the other patients and the family believed the policy was unfair to them. The nurse believed the family was interfering with Jack’s care and with her ability to complete her work in a timely manner.

3. The nurse spent little time with Jack and, when questioned by Jack’s daughter about the care she was providing, replied that she was “extremely busy with another patient.” At this point, Jack’s daughter became angry, cried and asked to see the nursing supervisor.

The nurse prioritized another patient’s care over Jack’s, because Jack had DNR orders and she believed a viable patient’s needs should receive priority when her time is limited.

Ethical dilemmas arise when there is a conflict in values, often between values of healthcare providers and those of patients and their families. Consistent with ethical dilemmas is the fact that there are often no absolute right and wrong answers. However, the central tenet of the Synergy Model reflects beneficence and states: The goal of nursing care is to facilitate the patient and family experience so that optimal outcomes for the patient are achieved.

For Jack and his family, optimal outcomes included meeting the psychosocial and spiritual needs of the family as a whole, as well as meeting Jack’s physiologic needs. For synergy to occur, the characteristics of Jack and his family must match his nurse’s competencies. Thus, the first step in ethical decision making is to assess both patient and family characteristics.

In applying the Synergy Model to Jack’s family, characteristics of the family as a whole can be assessed as minimally stable, highly complex, highly vulnerable and minimally resilient. His family members are also highly predictable, able to fully participate in his care and in decision making.

Jack’s family system was also highly complex, reflecting differences in each family member’s relationship with him. Although all members loved and cared for Jack, his daughter and son-in-law care for him willingly, whereas his wife and granddaughters openly expressed the burden of his care.

Because of the critical nature of Jack’s illness, resiliency was at a minimal level. Under normal circumstances, this family was highly resilient and able to face the problems associated with Jack’s care. Jack and his family were highly predictable. Acknowledging that Jack was at the end stage of his illness, his family members expressed the common feelings of anger and sadness that accompany grief.

The second step in ethical decision making, according to the framework of the Synergy Model, is to assess the nurse’s competencies to care for Jack and his family. The nurse had less than two years of ICU experience and had had limited opportunities to care for patients with complex family systems and care-giving needs. The focus of her education since graduation had been on acquiring the technical skills necessary to provide safe, competent care in the ICU environment.

However, her interactions with the family and her appeal to hospital policies for visitation and care giving occurred without consideration for the unique characteristics of this patient and family. This behavior indicated minimally competent levels of practice in the areas of clinical judgment, advocacy, caring practices, collaboration, systems thinking, response to diversity, clinical inquiry and facilitator of learning. The nurse would have better served the needs of this family, thereby optimizing patient outcomes, by recognizing her limitations in family care and her biases regarding the care of ICU patients with DNR orders.

The more experienced nursing supervisor was able to accurately assess the situation. After discussing the needs in depth, she was able to optimize patient and family outcomes by:
• Obtaining an order from a physician for Jack to receive the oral medications that had been brought from home
• Having the family sign a consent form acknowledging the potential for Jack to aspirate and die should he be given oral medications
• Authorizing the family to have 24-hour visitation, as long as they were not disruptive and there were no emergencies in the unit

After two days of intensive care, Jack was transferred to a step-down unit. After one week, he was discharged home, where he celebrated his 81st birthday. With the assistance of a community-based palliative care program, Jack’s family continued to care for him at home. He died peacefully at home five weeks after discharge from the ICU.


Cheryl Mallernee McGaffic is a member of the clinical faculty at the University of Arizona College of Nursing. She teaches courses in ethics, death and dying, and adult critical care nursing in the undergraduate and graduate programs.

Grants

AACN awards several grants to fund studies that are relevant to critical care nursing practice. The deadlines to apply for some of these grants are approaching. Read on for more information about these grants:

Due Jan. 15, 2002
AACN Clinical Inquiry Grant
This grant awards up to $500 to support research that focuses on one or more of AACN’s research priorities. Funds may be applied to new projects or projects in progress. Interdisciplinary projects are especially invited.

To obtain grant application materials, call (800) 899-2226 and request Item #1013, or visit the “Clinical Practice” area of the AACN Web site at http://www.aacn.org.


Practice Resource Network: Frequently Asked Questions—Dealing With Critical Incident Stress and Compassion Fatigue

QSince the Sept. 11 terrorists attacks on America, I have been bothered by terrible nightmares and feelings of dread. Although I did not have direct contact with any of the victims or the incident, I saw the horrendous sights on television and now find myself snapping at my co-workers and family. I also feel depressed and hopeless about the future, and frequently find myself crying over nothing. Do you think my feelings are because of the tragedies that have occurred, or am I only reacting to the stress in my work as a burn unit nurse. I heard the term “critical incident” used in regard to the terrorist attacks on the World Trade Center and the Pentagon and the stress people were feeling afterward. What does this mean and can those of us not directly involved in the incident be feeling this same stress?

AYes, you could be experiencing a critical incident stress response. Critical incidents are emergent events that typically involve tragedies, deaths, serious injuries, hostage situations or life-threatening scenarios. Emergency responders, such as paramedics, nurses, doctors, and fire and police personnel, typically encounter these types of situations on a daily basis. Unfortunately, these types of situations and their aftermath are sometimes so overwhelming that even professionals who have adopted skills to cope on a daily basis may be overcome by the emotional impact of such an event. During and following a major disaster, critical incident stress can occur, affecting the responder’s performance, judgment and well being.

For example, the attack on America was a critical incident that has led to widespread critical incident stress. This national event has touched the life of every American. Those not directly involved in the incident and rescues have also felt the impact of the attack and have been devastated by the images of senseless death, crushing sorrow and unrelenting grief.

During these difficult times it is easy for dedicated health professionals, regardless of whether they were directly involved in the tragic events, to lose sight of their own needs. Many feel compelled to help and provide their professional expertise, though they realize that there is little they can do to change the outcome. The stress of this situation, when added to our already stress-filled professional and personal lives, can result in more severe stress, anxiety and feelings of powerlessness. We risk the possibility of becoming victims to what Charles Figley, PhD, calls “compassion fatigue.”

Compassion fatigue is a form of stress response unique to healthcare providers who deal daily with illness and death. Unlike critical incident stress, compassion fatigue is not generally related to any single event, but is instead the result of an accumulation of stressful encounters. The day-to-day pain and suffering that healthcare workers, especially critical care nurses, are exposed to is a primary cause of compassion fatigue. The Gift From Within organization has several valuable references available on this topic on its Web site (www.giftfromwithin.org), including an excellent 15-minute videotape appropriate for inclusion in a staff discussion about compassion fatigue and critical incident stress.

Ongoing compassion fatigue, when combined with the added burden of the critical incident experienced in America on Sept. 11, can lead to severe stress signs and symptoms. These signs and symptoms may appear immediately or weeks to months later. The International Critical Incident Stress Foundation, Inc., has published on its Web site (www.icisf.org) a list of many of the possible signs and symptoms that may be experienced as a result of a critical incident. (Table 1)

What can you do to help yourself or your co-workers cope with a critical incident or compassion fatigue? You can find a number of self-help strategies in the stress literature. (Table 2) And, don’t hesitate to seek professional help if you are thinking about doing harm to yourself or others, getting feedback from family or friends expressing concern about your well being and advising you to seek help, or simply in need of someone to talk to about your experiences and feelings.

There are also strategies that family and friends can use to help healthcare workers who are suffering from critical incident stress or compassion. For example:
• Encourage those who have been traumatized to talk about their experiences and feelings. Listen without judging or advising.
• Spend time with them and provide a comforting and accepting environment.
• Offer to listen and support them, even if they do not ask for help.
• Assist with everyday tasks and routines. For example, offer to help with a patient care assignment or a personal task like grocery shopping.
• Give them private time to be alone with their thoughts.
• Try not to take their anger or erratic emotions personally.
• Tell them how sorry you are they had such a difficult experience and that you want to be supportive of them in whatever way possible.
• Avoid telling them, “You are lucky, it could have been worse.” They don’t feel lucky and this only diminishes the trauma and negates its impact on them.
• If you see signs and symptoms that concern you, express your concern and offer support and help.

You can find additional resources that can help you deal with critical incident stress and compassion fatigue on the Web sites of the International Critical Incident Foundation and the Gift From Within.

Table 1. Signs & Symptoms of Critical Incident Stress (may occur during and/or after the incident)

Physical Intellectual Emotional Behavioral Spiritual

Thirst Nightmares Guilt Antisocial acts Anger at
God/Supreme Being

Fatigue Uncertainty Grief Inability to rest Questioning of
previously held beliefs

Nausea Hyper-vigilance Panic Intensified pacing Withdrawal from
church activities

Fainting Suspiciousness Denial Erratic movements Loss of meaning or purpose of faith

Twitches Intrusive images Anxiety Change in social Change in religious of incident activity involvement

Vomiting Blaming someone Agitation Change in speech Anger with clergy
patterns

Dizziness Poor problem solving Irritability Loss of or increase Sense of isolation
in appetite from God/Supreme
Being

Weakness Poor abstract thinking Depression Hyper-environmental Religious rituals seem
alertness empty & meaningless

Chest pain Poor attention/ decisions Intense anger Increased alcohol Inability to pray or
consumption communicate with
God/Supreme Being
Headaches Poor concentration Apprehension Change in usual Inability to find
/memory communications solace in religious
beliefs

Elevated BP Disorientation of time, Emotional shock
place or person

Rapid heart rate Difficulty identifying Emotional outbursts
objects/people

Muscle tremors Increased/decreased Feeling overwhelmed
alertness

Grinding Increased/decreased Loss of emotional control
of teeth awareness of
surroundings

Shock symptoms Inappropriate emotional response

Visual difficulties Feelings of powerlessness

Profuse sweating Desire to escape

Difficulty breathing Feelings of dread or impending doom
No reason to go on

Table 2. Self-Help Strategies

Strategies Suggestions

Do a critical incident debriefing. With a trained intervention therapist.
During or immediately after
the incident
With other team members.

Structure your time and keep busy. Re-establish old routines.
Resume a normal schedule
as soon as possible.

Give yourself permission to Take time to pamper yourself.
feel rotten.

Share your feelings with others. Participate in group debriefings
and one-to-one encounters

Accept how you are feeling Realize this as a normal response
to a dreadful experience.
Don’t feel you are going crazy.
Share your feelings with others.

Be careful about trying to numb You don’t want to complicate
the pain by overuse of drugs matters by developing a substance
or alcohol. abuse problem.

Reach out to others. People care. Give them a chance
to help.

Spend time with family Cherish the bonds that hold you
and friends. together
Celebrate your relationships.

Help your co-workers. Share feelings.
Ask how they are doing.
Encourage them to join in
group debriefing sessions

Keep a journal. Fill it with the feelings and pain
that you can’t express to others.
Writing can be especially helpful
during times of added stress and
anxiety.

Get regular, appropriate exercise. Alternate exercise with relaxation to
alleviate physical symptoms
common to the stress response.

Eat regular meals Do so, even if you are not hungry. Avoid high fat, sugar and salty foods.

Take care of your body Drink eight glasses of water per day.
Try to get at least six to eight hours
of uninterrupted sleep per night.

Reassert a sense of control Donate blood.
in your life. Give money to charity.
Volunteer your services.

Make daily decisions. Even small ones will help you feel
in control of your life again.

Accept that recurring thoughts, Talking about them might help.
images and dreams are normal Try to replace negative thoughts
and will decrease with time. with happy, joyous ones
Go through photos of happier times.

Avoid any major life changes. This is not a good time to
change jobs, move or go back to
school.

Find a reason to laugh. Watch comedies or play with
your children or pets.

Smile and mean it. Think about the good things and
the blessings in your life.
Show your smile to others.

Get in touch with your Talk with clergy. Attend
spiritual beliefs services/church. Meditate/pray daily.


Resources Related to Critical Incident Stress and Compassion Fatigue

International Critical Incident Stress Foundation, Inc.
10176 Baltimore National Pike, Unit 201
Ellicott City, MD 21042
Phone: (410) 750-9600
Fax: (410) 750-9601
http://www.icisf.org

Critical Incident 24-Hour Emergency Hotline
(410) 313-2473

Courses & Critical Incident Stress
Debriefing Training

Critical Incident Stress Management
in the Healthcare Setting
http://www.icisf.org/classes/getclass.asp?id=36

Table of Classes Offered
http;//www.icisf.org/classofferings.htm

6th World Congress
http;//www.icisf.org/congress6WC/

Domestic Terrorism and Weapons of Mass Destruction: A CISM Perspective
http;//www.icisf.org/classes/getclass.asp?id=32

Gift From Within
Post Traumatic Stress Disorder
Resources for Survivors & Caregivers
16 Cobb Hill Rd.
Camden, Maine 04843
Phone: (207) 236-8858
Fax: (207) 236-2818
http;//www.giftfromwithin.org

Videos
1. “When Helping Hurts: Sustaining Trauma Workers” 1998
2. “Recovering From Traumatic Events: The Healing Process” 2001

Books
1. Assessing Psychological Trauma and PTSD. Edited by: John P. Wilson and Terence M. Keane. 1997 The Guilford Press
2. Compassion Fatigue: Coping with Secondary Traumatic Stress. Charles Figley. 1995
3. Disasters: Mental Health Interventions (Crisis Management Series). John D. Weaver. 1995
4. Handbook of Posttraumatic Therapy. Edited by Mary Beth Williams and John F. Sommer Jr. Greenwood Publishing Group, 1994
5. How to Survive Trauma: A Program for War Veterans & Survivors of Rape, Assault, Abuse or Environmental Disasters. Benjamin Colodzin, Olympia Institute, PO Box 750, Bolinas, CA 94924.
6. I Can't Get Over it: A Handbook for Trauma Survivors. Aphrodite Matsakis. New Harbinger Publications, Inc., 1992
7. Post-Traumatic Stress Disorder-A complete guide to PTSD. Aphrodite Matsakis. New Harbinger Publications, Inc., 1994
8. “Post Traumatic Therapy” in the International Handbook of Traumatic Stress Syndromes, F.M. Ochberg, Author, Wilson & Raphael, Editors, Plenum 1993
9. Post Traumatic Therapy and Victims of Violence. Frank M. Ochberg, M. D. Brunner Mazel Publishers, 1988
10. Trauma and Its Wake: The Study and Treatment of Post-Traumatic Stress Disorder. (Brunner Mazel Psychosocial Stress, Vol 4) by Charles R. Figley (Editor). 1986
11. Trauma and Its Wake : Traumatic Stress Theory, Research and Intervention. (Psychosocial Stress Series, No 8). Charles Figley. 1986
12. Trauma & Recovery: The Aftermath of Violence from Domestic Abuse to Political Terror. Author, Judith Herman. Basic Books, 1992

Articles
1. Psychotherapy-Special Issue: "Psychotherapy with Victims," Guest Editors: Frank M. Ochberg and Diane J. Willis, Volume 28/No.1 Spring l99l, Available from Case Western Reserve University, Department of Psychology, 216-368-2841
2. “Bosnia’s Death Highway: My Personal Story of Trauma Work, Compassion Fatigue and Hope,” Danica Borkovich Anderson. 2001
3. “Cultivating Resiliency,” Speech given at the ISTSS Annual Conference, November 2000 Dr. Carl Bell
4. “Bound By A Trauma Called Columbine,” Frank M. Ochberg. 2000

Music
The Official CD of the Lullaby For Columbine Project featuring Rachael Lampa, Adrian Belew, Danny Oertli. 1999

Poetry
Survivor Psalm. Frank Ochberg. 1988

How Do You Handle Stress?

People deal with stress and other issues differently. Some approaches are effective for some people, but not for others. What works for you? Share your tips with your colleagues. Send ideas for dealing with stress to AACN News, 101 Columbia, Aliso Viejo, CA 92656; fax, (949) 362-2049; e-mail, aacnnews@aacn.org.
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