Practice Nurses Research Articles

Assessing and managing lower limb oedema: a clinical review.

Lower limb oedema is a common condition in clinical practice, frequently affecting the distal lower limbs. Whereas benign causes such as prolonged sitting or standing are typical, oedema can also indicate serious systemic diseases such as cardiac failure, liver disease, or renal impairment. Identifying the cause is crucial to prevent irreversible skin and tissue changes. This clinical review aims to increase the knowledge of advanced clinical practitioners (ACPs) and generalist practitioners, including practice and community nurses, by providing an overview of how to approach patients with lower limb oedema, encompassing history-taking, examinations, investigations, and management plans. The main focus is on lymphoedema, which can be primary or secondary. Primary lymphoedema results from genetic abnormalities, while secondary lymphoedema arises from acquired defects due to factors such as obesity, infections, neoplasms, and trauma. Effective management includes addressing the underlying cause, ensuring proper skin care, recommending appropriate exercises, and the use of compression garments. Referral to a lymphoedema specialist is recommended for patient education on managing and treating the condition when required. Additionally, the article discusses the importance of regular skin inspections, minor injury management, environmental considerations, and the critical role of compression garments in lymphoedema management. This comprehensive approach aims to enhance patient outcomes and provide a thorough strategy for ACPs and generalist practitioners.

Current Practices for Delivering New Diagnosis Education at Children's Oncology Group Institutions: A Report From the Children's Oncology Group.

The Children's Oncology Group (COG) Nursing Discipline developed expert consensus recommendations and resources to guide the delivery of new diagnosis education across its member institutions. Current new diagnosis education practices across COG member institutions are unknown. To understand current new diagnosis education practices across COG member institutions. We conducted a cross-sectional survey of COG nurses between July and October 2023 to elicit current practices to deliver new diagnosis education to families across COG institutions. Data were collected and managed using REDCap electronic data capture tools. Individual responses from single institutions were averaged as a single institution-level response. Respondents included 146/227 (64.3%) COG institutions across 5 countries. Advanced practice nurses and nurse educators have primary responsibility for new diagnosis education at 28.1% and 26.7% of institutions, respectively. Less than half (42.4%) of institutions have a clearly defined process for delivering new diagnosis patient/family education. Almost all (88.2%) institutions use the COG Family Handbook; 64.7% use the COG New Diagnosis Guide, and 41.9% use the COG KidsCare app to support the delivery of new diagnosis education. More than half (61.5%) of institutions use checklists to facilitate the delivery of new diagnosis education, with 81.6% of large institutions versus 44.1% of small institutions reporting the use of checklists ( P = .004). There is variability in current new diagnosis education practices across COG institutions. These findings highlight opportunities for implementing standardized approaches aligned with expert consensus recommendations for the delivery of new diagnosis education.

Community Nursing Practice in Hypertension Management in China: Qualitative Analysis Using a Bourdieusian Framework.

This study explores the practices of Chinese community nurses in hypertension management, using Pierre Bourdieu's theory of practice to understand how their routines are shaped by sociocultural and institutional forces, along with their professional dispositions. A qualitative descriptive study was conducted in Shenzhen, China, between March and June 2024, and is reported following the COREQ guidelines. Eighteen nurses, each with at least 1 year of full-time experience in hypertension care within the local community healthcare system, were recruited from a participant pool established through prior research. Face-to-face individual semistructured interviews were conducted using a structured interview protocol, and data were analyzed through thematic analysis. Community nurses face tensions between traditional health beliefs and modern hypertension care, as well as institutional pressures that prioritize efficiency over personalized care. Power imbalances, particularly the authority of doctors, complicate their role. However, nurses adapt their care strategies through embodied practices, balancing clinical standards with patient needs. Community nurses are not mere enforcers of guidelines but adaptive professionals who navigate complex sociocultural norms, institutional demands, and power dynamics in hypertension care. This study underscores the necessity for flexible, culturally sensitive practices to improve public health outcomes.

The resonance of trauma in the military: to each his own war

Our experience of working with veterans traumatized by their encounter with death has enabled us to evolve our nursing practice so as to better welcome the singular voice of the psychically wounded in a military environment. This approach aims to highlight the resonance between an unspeakable experience of annihilation and the singularity of the subject. The interest of this notion lies in its clinical value, which is tending to disappear in modern therapies, as the personal history of our soldiers becomes the necessary framework for attempting to heal a major existential rupture. In this way, it confers an ethical value on treatment, by respecting the symptoms of these soldiers through their specific experiences. Every war has its share of suffering, but every soldier has his own war and his own unique story.

Nursing student reflections on a research internship: A reflective discussion following the Gibbs' reflective cycle

BackgroundEvidence-based practice underscores the importance of utilising research-based skills in the delivery of care. However, entry-to-practice nursing curriculums in Australia currently do not provide students with practical research opportunities. Acknowledging this gap, an Australian university initiated a two-month summer research internship that aim to expose undergraduate nursing students to clinical research under the mentorship of a nursing academic. AimTo understand the opportunities and challenges of a research internship and its contribution to developing research knowledge and skills for future nursing practice and leadership. DesignA reflective discussion following the six stages of the Gibbs' Reflective Cycle. SettingsA two-month research internship at an Australian University was held over the summer. ParticipantsTwo successful nursing students (FO and BM) who were both students in the Master of Nursing (Graduate Entry) program. MethodsFollowing the Gibbs' Reflective Cycle, a description of the internship experience was outlined, alongside feelings encountered. The opportunities and challenges of the internship are explored, evaluated, and analysed with related literature to inform an overall conclusion. To support other nursing students pursuing similar research endeavours during their professional transition, an action plan was developed. ResultsThe optional summer research internship proved to be a valuable experience for participating nursing students. FO and BM were granted co-authorship on their respective research projects, providing opportunities at international nursing and midwifery conferences and several avenues for career advancement. ConclusionsNursing research internships contribute to students' personal and professional development. This paper highlights the need for universities to provide innovative educational opportunities to students that enrich evidence-based nursing practice and inspire further opportunities.

Investigating Inappropriate Discontinuations of Enteral Nutrition Related to Gastric Residual Volume in Critically Ill Patients: A Retrospective Observational Descriptive Study

Background: Gastric residual volume (GRV) is measured by nurses in clinical practice as a simple method to assess gastrointestinal intolerance. Nutrition therapy guidelines recommend avoiding enteral tube feeding (ETF) discontinuation if GRV is < 500 mL. Aim: This study aimed to clarify the status of inappropriate ETF discontinuation related to GRV in critically ill patients. Methods: Patients who were ventilated for more than 48 hours in the intensive care unit of a university hospital in 2021 were retrospectively surveyed, and data were collected up to 2 weeks after admission. ETF discontinuation data were collected and categorized as planned or unplanned. The reasons for unplanned discontinuation were further categorized into high GRV, symptoms, and conditions. The reasons and the amount of GRV were analyzed descriptively. Inappropriate ETF discontinuation related to GRV was defined as ETF discontinuation for a GRV of < 500 mL. Results: ETF was discontinued in 10% (270 events / 2,600 orders) of critically ill patients. Unplanned discontinuations accounted for 37% (99/270) of discontinuations, with GRV being the most common reason (43%), followed by nausea and vomiting (8%), and hemodynamic instability (8%). Conclusions: Thirty-seven percent of ETF discontinuations in critically ill patients were unplanned, and 42% of these were inappropriate ETF discontinuations related to GRV. Research results and guideline recommendations need to be disseminated clearly to make more healthcare providers aware of the GRV criteria for discontinuing ETFs.

Identification and Validation of an Instrument to Measure Physicians‘and Nurses' Knowledge, Attitudes, and Practices Regarding Antibiotic Resistance and Antimicrobial Stewardship

Background: In Italy, the presence of a suitable instrument to measure the knowledge, attitudes, and practices of intensive care physicians and nurses with respect to antibiotic resistance and antimicrobial stewardship could not be identified Objectives: To validate the Italian version of the Ashiru-Oredope tool used by the European Centre for Disease Prevention and Control (ECDC) in 2019 to investigate intensive care nurses' and physicians' knowledge, attitudes, and practices (KAP) regarding antibiotic resistance. Methods: Content validity was assessed using the Item-Content Validity Index (I-CVI), Scale Level-Content Validity Index/Universal Agreement (S-CVI/UA) score, Scale Level-Content Validity Index/Average (S-CVI/Ave) score, and Average Content Validity Ratio (CVR). Multiple correspondence analysis (MCA) was then carried out together with cluster analysis (CA) to check the correspondence of the items with the eight subdivision domains of the scale. Results: The final version consisted of 55/60 deemed relevant items, with Item-Content Validity Index (I-CVI) scores ranging from 0,625 to 1. The Scale Level-Content Validity Index/Universal Agreement (S-CVI/UA) score was 0.43; the Scale Level-Content Validity Index/Average (S-CVI/Ave) 0.90. The mean CVR of the scale was 0.43. The inter-rater reliability (Cohen's K) was between good and excellent. The combination of MCA and CA confirmed the correspondence of the items with the domains. Conclusion: The Italian version is a reliable and valid instrument for investigating antibiotic resistance and antimicrobial stewardship among Italian intensive care nurses and physicians.

Variation in organisational factors across high- and low-performing hospitals with regard to spontaneous vaginal birth for Black women in four states: a cross-sectional descriptive study

ObjectiveTo describe variation in hospital organisational factors across high- and low-performing hospitals with regard to spontaneous vaginal birth (SVB) for Black women.DesignCross-sectional descriptive.SettingWe conducted a cross-sectional study using three datasets...

Dental Coverage for Medicare Beneficiaries.

Poor oral health has been associated with various systemic diseases (e.g., endocarditis, pneumonia, cardiovascular disease, and diabetes) and decreased quality of life. When enacted in 1965, Medicare excluded coverage for comprehensive dental services. As of 2023, Medicare has allowed coverage of limited dental services inextricably linked to specific medical conditions. Many Medicare Advantage plans (Medicare Part C) offer dental coverage. Yet in 2019, approximately 24 million Medicare beneficiaries (47% of all Medicare enrollees), lacked dental coverage. Seventy-one percent of traditional Medicare enrollees (those not enrolled in a Medicare Advantage Plan) reported that high cost was the primary reason that they did not obtain dental care. The importance of oral health for the older adults has been the main reason that a national interprofessional consortium, which includes several national nursing organizations, has been advocating for legislation to expand Medicare to include dental coverage. The consortium's efforts have been thwarted by fierce opposition from the American Dental Association and many Republican legislators. Given the vital role that nurses and advanced practice nurses play in caring for the nation's older adults and disabled, nursing's voice needs to be strengthened as leaders in advocating for inclusion of dental benefits in traditional Medicare.

The growing international stage for advanced practice nursing.

The growing international stage for advanced practice nursing.

A wealth of IPA positions at the CHGR and interprofessional collaboration

Ten advanced practice nurses are already working at the Guillaume-Régnier hospital in Rennes. As part of an internship at this facility, students in the second year of the IPA master's degree in psychiatry and mental health at the University of Rennes were interested in the dynamics surrounding this still recent profession, the diversity of the missions performed, and inter-professional collaboration. An online survey was distributed to IPAs, and four interviews were conducted with healthcare professionals working with them.

Patient Safety Culture Among Nurses: Comparison Between Public and Private Hospital in Indonesia

Aims: This study aimed to describe the patient safety culture among nurses working in both public and private hospitals in Karawang, Indonesia. By examining the perceptions and practices of nurses regarding patient safety, the research sought to identify strengths and areas for improvement within the healthcare system. The findings are intended to inform strategies for enhancing patient safety practices, thereby contributing to better healthcare outcomes for patients in the region. Methods This study employed a cross-sectional methodology to investigate the patient safety culture in the intensive care units of two private and two public hospitals in Karawang, Indonesia. The researchers utilized the Hospital Survey on Patient Safety Culture (HSPSC) to gather data on nurses' perceptions and practices regarding patient safety. To analyze the data and identify any significant differences in patient safety cultural practices between the various hospital groups, both chi-square tests and independent t-tests were conducted. This approach allowed for a comprehensive assessment of the patient safety culture within the selected hospitals, facilitating comparisons between public and private healthcare settings. Results The study included a total of 118 nurses, with 52 working in a public hospital and 66 in a private hospital. The average age of nurses in the public hospital was 36.11 years (SD: 4.78), while those in the private hospital had a lower average age of 32.45 years (SD: 3.67). The results indicated a significant difference in the scores related to patient safety culture between the two groups of nurses. Specifically, nurses in the private hospital reported a higher patient safety culture compared to their counterparts in the public hospital, highlighting the disparities in perceptions and practices regarding patient safety in these different healthcare settings. Conclusion Nurses employed in private hospitals reported a higher level of patient safety culture compared to those working in public hospitals. This finding underscores the importance of creating a comfortable work environment in healthcare settings, as it is essential for minimizing the risk of patient safety incidents. By fostering a supportive and safe atmosphere, healthcare facilities can enhance the overall quality of care provided to patients and promote better outcomes in both private and public hospitals.

Establishment of Evidence-Based Nursing Indices for Dysphagia After Anterior Cervical Spine Surgery.

To select and obtain relevant evidence for the management of dysphagia after anterior cervical spine surgery both domestically and internationally, clinical quality evaluation indicators were developed based on evidence-based nursing practices, and obstacles and promoting factors in evidence-based nursing practices were analysed. This research was aimed to provide a basis for evidence-based nursing practices to promote standardized management of dysphagia after anterior cervical surgery. Dysphagia is the most common complication following anterior cervical surgery, but there is a lack of standard protocols and guidelines to direct clinical practice. Mixed methods were employed for the translational research to support evidence-based practice. This study was based on the JBI evidence-based health care model. According to the '6S Evidence Resource Pyramid Model', we searched from top to bottom. This study is guided by the knowledge to action (KTA) evidence-based practice model. Utilizing a comprehensive evidence-based approach and following the 6S evidence resource pyramid model, relevant evidence on the management of swallowing disorders after cervical anterior surgery was selected from both domestic and international sources. Based on the best available evidence, the Delphi expert consultation method was used to establish a management plan for swallowing disorders post-cervical anterior surgery. Semi-structured interviews were then conducted to identify barriers to clinical implementation, and clinical quality evaluation indicators, as well as promoting factors, were subsequently developed. Based on the 31 best evidence points, 12 evaluation indicators were developed. The baseline results of these indicators reveal that, apart from evaluation indicator 8, which has a compliance rate of 72.2%, the compliance rates for most of the other indicators are relatively low. Based on the results of the clinical quality review, the following main obstacles were analysed: negative behaviours and attributes, lack of professional knowledge, and lack of standardized management. Effective management of swallowing disorders after cervical spine surgery is crucial for enhancing treatment outcomes, reducing complications, shortening hospital stays and improving patient quality of life. This study identified the best evidence for managing dysphagia post-anterior cervical surgery and developed corresponding solutions. The next step involves applying these measures in clinical practice to improve patient prognosis and elevate the quality of care.

Literature Review on the Effectiveness of Modern Dressing in the Wound Care Process on Diabetic Wound Healing

Background: Diabetes mellitus is a health problem due to insulin deficiency or insulin resistance that causes high blood glucose. A frequent complication is diabetic ulcer, which is a condition of partial or complete tissue deformity. If it does not get proper treatment, it is very risky to get an infection that leads to amputation.Diabetes Mellitus (DM) has become a prevalent disease, imposing a significant burden on public health due to its widespread occurrence and association with numerous disabilities and fatalities. Uncontrolled DM can lead to severe metabolic complications and long-term vascular issues, including microangiopathy and macroangiopathy. Additionally, individuals with DM are highly susceptible to foot infections, which can escalate into gangrene if not properly managed. Purpose: To determine the effectiveness of modern dressing in the wound care process on diabetic wound healing. Methods: Data collection used descriptive analysis and literature study. The databases used were PubMed, CINAHL, ProQuest and Web of Science. Journal inclusion criteria used PICO and article analysis was conducted by 6 authors. Findings: The evaluated article's findings elucidate the patient's degree of comfort and the more important healing process. It has been demonstrated that contemporary wound care applications make patients feel more at ease as their wounds heal, greatly aiding nurses in nursing care. Modern wound care is a practice that will evolve in response to advancements in nursing science; in this instance, it centers on how comfortable patients are while obtaining wound care-related medical treatments. Therefore, nurses must advance the knowledge behind the use of contemporary wound care to promote patient comfort and hasten the healing process. Conclusion: Modern wound care enhances patient comfort and accelerates healing, greatly supporting nursing practice. With evolving knowledge in nursing science, nurses need to master these methods to maximize patient comfort and recovery in wound care

Closing gaps in emergency care

Abstract: Current socio, political, and economic events may disproportionately affect those who are identified as vulnerable, as well as their presentation to Canadian emergency departments. The housing crisis, food instability, and concurrent issues with mental health and addictions are a harsh reality for many of these individuals. The emergency department may not be suited to complex health and social issues, but it provides an essential safety net for the vulnerable who cannot access care through traditional primary care routes. Alternative, patient-centered solutions to the problem are necessary, and advanced practice nurses can be the key to appropriately organizing and delivering integrated care innovative models. Raising awareness and influencing public policy to drive meaningful social change and address alarming health inequities is an important consideration for nurses working in emergency departments.

Postpartum Hemorrhage Management in Canadian Emergency Nursing Practice

Background: Postpartum hemorrhage (PPH) remains a leading cause of maternal mortality globally, claiming approximately 70,000 lives annually. Despite preventive efforts, high-income countries, including Canada, have reported increasing rates of PPH. The rising incidence and associated complications indicate improved emergency nursing practices in managing PPH are needed. Methods: PPH guidelines from the Society of Obstetricians and Gynecologists of Canada, Federation of International Gynecologists and Obstetricians, and the Canadian Association of Perinatal, and Women’s Health Nurses were compared to National Emergency Nurses Association guidelines. The competencies, medications, and obstetric maneuvers for PPH that may be relevant to emergency nurses were extracted and categorized for the emergency nursing HIRAID (History & Red flags, Assessment, Interventions, & Diagnosis) framework. Findings/Results: We found 13 discrete skills across the PPH guideline recommendations that are applicable to emergency nurses. There is near perfect overlap in medical recommendations, but gaps exist between FIGO and SOGC guidelines and NENA and CAPWHN guidelines. There are SOGC and FIGO guidelines that apply to emergency nurses that are not addressed in NENA guidelines, Discussion: There was significant overlap on treatment recommendations from maternal health bodies such as uterotonic drugs, hemorrhage control, and hemostatic resuscitation. There were significant gaps in NENA recommendations. Conclusion: The comparison of PPH guidelines highlights where NENA guidelines need further detail. These skills are particularly significant for providing nursing care in rural and remote areas. Standardized protocols for PPH management, interprofessional collaboration, and regular competency assessments are included in most guidelines but are conspicuously absent for emergency nurses. To address the gap, NENA could integrate national emergency nursing PPH competencies standards or develop recommendations for the care of maternal emergencies.

State Full Practice Authority Regulations and Nurse Practitioner Practice Autonomy: Evidence From the 2018 National Sample Survey of Registered Nurses.

State full practice authority (FPA) laws are designed to permit NPs to practice autonomously from physicians. Little is known regarding how FPA laws affect NPs' practice autonomy in daily practice. This study used nationwide survey data from 20,830 NPs to estimate how NPs' practice autonomy differs between NPs in FPA and non-FPA states. NPs in states with FPA laws were more than twice as likely as NPs in non-FPA states to practice in clinic settings with no onsite physicians and were twice as likely to not have a physician collaborator. Associations between FPA laws and four other indicators of practice autonomy were positive but smaller in magnitude. States with FPA laws more than 10 years experienced larger changes in nurse practitioner (NP) autonomy compared with states with FPA laws in effect less than 10 years. FPA laws may promote the development of autonomous NP practice sites, thereby expanding access in underserved populations.

Hemodynamic monitoring- (NOT) anursing task?!

Ensuring adequate and stable hemodynamic conditions is an essential component of patient care in emergency and intensive care units. The assessment of circulatory status is complex and influenced by patient-specific characteristics, medical staff experience, and available equipment. Hemodynamic monitoring encompasses both invasive and noninvasive methods to monitor circulatory parameters. It supports patient management and ensures therapeutic success by alerting healthcare providers to deviations, including critical values. In practice, numerical data often receive more emphasis than comprehensive patient observation, potentially leading to misinterpretation. Advanced practice nurses (APNs) are highly qualified nursing professionals who work largely autonomously due to their advanced training. However, there is currently no uniform legal regulation for these professions in Germany. Clear definitions and nationwide regulations for related academic programs are necessary. Interprofessional collaboration, as well as the qualifications and numbers of nursing staff, significantly impact therapeutic outcomes. Hemodynamics involves the physical principles of blood flow and the assessment of vital parameters to ensure organ perfusion and oxygenation. The competence and knowledge of nursing staff are crucial for safe patient care. Local standard operating procedures (SOPs) should consider interprofessional collaboration and the qualifications of team members.

ASSESSMENT OF NURSES' KNOWLEDGE REGARDING PERSONAL PROTECTIVE EQUIPMENT AT TERTIARY CARE HOSPITAL LAHORE

Personal Protective Equipment (PPE) is crucial for protecting healthcare workers from occupational hazards and infections, particularly in high-risk environments such as hospitals. Adequate knowledge and proper use of PPE are essential to ensure the safety of both healthcare workers and patients. This study aimed to assess the knowledge, attitudes, and practices of nurses regarding PPE at a tertiary care hospital in Lahore, Pakistan. Methods: A descriptive cross-sectional study design was utilized. A structured questionnaire was used to collect data from 152 nurses working in various departments of the hospital. Purposive sampling was employed, and the sample size was determined using RaoSoft with a 95% confidence interval and a 0.5% margin of error. The questionnaire comprised sections on demographic information, knowledge assessment, and attitudes and practices evaluation. Data were analyzed using SPSS version 25.0, with descriptive statistics and chi-square tests to identify associations between demographic characteristics and knowledge levels. Results: Of the 152 participants, 77% were female, with a mean age of 36.5 years (SD ± 9.05 years). Most participants held a diploma in nursing (46%), and the majority (93.4%) had less than 12 years of professional experience. The findings revealed that 67% of nurses demonstrated good knowledge of PPE, 20% had average knowledge, and 13% exhibited poor knowledge. While 92% of participants reported being knowledgeable about PPE usage, inconsistencies were noted in the adherence to specific practices, such as glove and mask usage. Additionally, only 34% of participants believed that consistent use of PPE would reduce their risk of infection, indicating a potential gap between perceived and actual knowledge. Conclusion: The study highlights both strengths and gaps in nurses' knowledge and practices regarding PPE at a tertiary care hospital in Lahore. While most nurses demonstrated a satisfactory understanding of PPE, inconsistencies in practical application underscore the need for targeted training and reinforcement of guidelines. Regular training sessions, active monitoring, and continuous professional development are essential to enhance adherence to PPE protocols and safeguard healthcare workers in resource-limited settings like Pakistan.

ISCO-08 Classification and scope of practice of nurses: Survey among WHO-Europe member states

Abstract Background The expansion of nurse’s roles in the delivery of care needs transparent defining of roles, extra education/training opportunities, and complementary legislative regulations. Methods This cross-sectional study was planned to explore status of nursing and midwifery workforce in WHO Europe member states. Data were collected from December 2020 until September 2023. Results ISCO-08 2221 is used to classify for only bachelor prepared-nurses in 2 of countries (Bulgaria and Spain). Besides, it is used only for vocational prepared-nurses in 2 of countries (Kyrgyzstan and Tajikistan). Those countries only have vocational or bachelor education. ISCO-08 2221 is used in 1 of countries which have two entry levels with vocational and bachelor prepared-nurses (Georgia). ISCO-08 3221 is referred to vocational training in 5 (20%) countries (Armenia, Finland, the UK, Croatia, Hungary). ISCO-08 2221 is main classification for all levels prepared nurses in 18 countries including Switzerland, Cyprus, Czechia, Germany, Denmark, Ireland, Israel, Iceland, Kazakhstan, Lithuania Latvia, Malta, Poland, Portugal, Romania, Sweden, Slovakia, Türkiye. Scope of practice of vocational and bachelor prepared nurses is defined by law/legislation in 25 of member states. Scope of practice vocational versus bachelor depends on conduct scientific tasks (Switzerland), being broader (Kazakhstan), competency level (Hungary, Croatia, Portugal) exceptionally there is no difference in Malta. Scope of Registered Nurse, Specialist Nurse and Advanced Nurse Practitioner differ in 22 of countries of those which on activities/practice/roles, expanded authority, working with determined care group. As a result, while scope of practice of professional nurses varies in line with their education level, ISCO-08 2221 is used for nurses’ classification from all education levels in member states. Key messages • There is no classification for postgraduate trained nurses (as is the case for physicians), even though scope of practice is different across education levels. • When revising the ISCO-08 classification, it should be recommended that a common terminology is needed to define postgraduate nurses in region.