Leaving a lasting mark on the organization they serve is a dream for many, but for one nurse, through her career in the Army Reserve, she’s been able to do just that.
Lt. Col. Kelly Bell, MSN, RN, CEN, USAR, commander of the 7203rd Medical Support Unit in Hobart, Indiana, successfully advocated for accommodations of pregnant Soldiers and new parents, resulting in Army policy change at the highest level.
“Be the change. Advocate for your soldiers.”
Announced and released on April 21, 2022, Bell was an integral contributor and author of the new Parenthood, Pregnancy, and Postpartum Army Directive. The directive features 12 distinct policy changes that pertain to pregnant and postpartum Soldiers as well as new parents. Changes touch on areas ranging from deployment deferments, an extended timeline to take the Army Combat Fitness Test after giving birth, and attending professional military education while pregnant, to convalescent leave after pregnancy loss or miscarriage or stillbirth, and more.
“I just wanted to take care of my pregnant Soldiers the way I wanted to be taken care of,” she said of her collaboration on policy change.
“It’s a change I never thought I’d see in my career, and it’s been needed for many, many years,” said Capt. Jennifer DeMaio, a mobilization officer with Army Reserve Medical Command, who gave birth to her fourth child on April 20, 2022, the day before the directive was published.
DeMaio, who has had all four of her children while serving in the Army, said the attitude towards pregnancy is different now than it was 18 years ago when she had her first child. For example, she only received a four-month deployment deferment after having her first child.
DeMaio also praised the new one-year timeline to prepare and train for the Army Combat Fitness Test after childbirth, mentioning the level of athleticism and healing that is necessary.
“The events are completely different,” DeMaio said of the new test. “And they are harder. This one-year prep time for the ACFT is completely needed.”
DeMaio experienced a complicated pregnancy this time around and delivered a baby girl, Jessah, via C-section at 26 weeks after several weeks of bed rest. DeMaio said she is grateful for her command’s reaction to and support of her pregnancy—a hint that culture change towards the normalization of parenthood has already begun.
“This unit is the most accepting of any unit I’ve been in,” DeMaio said of her pregnancy. “I was scared to tell my leadership because I didn’t have the best reactions (to her pregnancies) in the past. But I can’t imagine it going any better—nothing but positivity.”
Maj. Quentin F. Stewart, a plans officer at Army Reserve Medical Command and father of a newborn, said he believes the policy changes align with the Chief of Staff of the Army’s “People First” initiative and will have an impact on retention.
“This is a really great change for the health and welfare of our Soldiers and Families,” Stewart, currently on paternity leave, said. “The foundation of everything we do in the Army begins with people and I believe the parent and postpartum changes bring the Army on par with the other services when it comes to supporting the important early years of new family additions.”
“I think culture shift takes a lot longer than just writing a directive, but we hope that the directive will give the tools to begin the normalization of parenthood that’s necessary.”
For Bell, advocating for new parents and helping foster change to Army policy isn’t new; she’s been fostering accommodations around this topic for a while.
Bell commissioned into the Army Reserve in 1999 through Marquette University’s Reserve Officer Training Corps program after earning a bachelor’s degree in nursing. Since then, she has worked as a nurse both in the Army, which included a deployment to Afghanistan and a stateside mobilization during the COVID-19 pandemic, and in her civilian career. In her civilian capacity, she now works at a Des Moines, Iowa Veterans Affairs primary care clinic.
With the bulk of her experience in emergency room nursing, Bell has loved taking care of others as a career. She explained that becoming pregnant with her first child while serving as a commander of a medical unit was eye-opening to the challenges faced by military mothers and new parents.
Winning the battle to support lactating mothers in a modern army
Bell encountered vague guidance on the postpartum period for new Army mothers, including in the area of accommodating a time and place for pumping breastmilk for their new infants.
“It’s a huge mental stress on a lactating Soldier if they aren’t provided the services to pump and store breastmilk for their children,” she explained.
And her first foray into advocacy touched on this issue. In 2018, Bell wrote an email to the sergeant major of uniforms branch, asking for provisions be made for lactating Soldiers to wear an alternate nursing t-shirt that would make pumping breastmilk more easily accessible: her request was approved.
This led to a revision to AR 670-1 in 2021 which includes the undershirt authorization and notes that Soldiers are permitted to breastfeed their nursing child anywhere the Soldier and child are authorized to be. Additionally, the updated uniform regulation does not require breastfeeding Soldiers to cover themselves with additional items while doing so.
“This is a really great change for the health and welfare of our Soldiers and Families.”
“I think the most significant thing this time around is the time I’ll have to get back to the standards,” said Spc. Kellie N. Steele from Midland, Michigan, a dental specialist in the 7203rd Medical Support Unit. Steele, who is now pregnant with her fourth child (her second while serving in the Army Reserve), said she is grateful that the new Army directive will give her a year after having her child to take a record Army Combat Fitness Test.
Steele explained that after having her last child in December 2020, she experienced hip and pelvic pain, and it wasn’t safe for her to lift weights until she had fully recovered from childbirth.
“Every woman’s body is different,” Steele said. “The fact that they are extending and accommodating things means a lot.”
Steele said she is also grateful for the lactation accommodations in the new directive, as breastfeeding her children is important to her. The directive clarified and expanded Army Regulation 600-20, Army Command Policy, and now dictates where, how long, and under what conditions commanders will provide lactating Soldiers the opportunity to express breastmilk and discusses its storage.
Bell was instrumental in facilitating the passing of a waiver to Tri-Service Bulletin Medical 530, which discusses food codes. The waiver allows for storage and management of breastmilk in field food establishment refrigerators, making it an option to store breastmilk for nursing Soldiers.
Steele explained that she was able to use this waiver firsthand while on annual training at Fort McCoy, Wisconsin and away from her then eight-month-old daughter for two weeks: she successfully stored her breastmilk and was able to transport it home after her temporary duty, rather than throwing it away.
Bell did not stop her advocacy there, and became active in moderating two popular Facebook groups aimed at giving Army mothers an outlet for discussing pregnancy and childbirth topics.
Normalizing treatment of soldier parents
Bell found in the Facebook groups that Soldiers of all ranks and components pointed out further gaps in policy, education, and empathy on behalf of command teams. Concerns that continued to come up from new mothers included maternity and paternity leave, postpartum body composition testing, being excluded from attending professional military education while pregnant, and leadership education, among others.
Bell, along with 10 other authors, wrote a white paper published in 2021 that addressed these topics and stood as recommended revisions to the Army’s pregnancy and postpartum policies. Bell’s particular area of concentration for the paper was looking at the Army’s current operational and deployment deferment for new parents. Through research, the author group concluded that a one-year deployment deferment is necessary for both the development of the child and the child’s bond to its parent.
“We wanted to keep at least one parent at home with the infant during the child’s first 12 months,” Bell explained.
The white paper had the desired effect: senior leaders listened. Just a year after the white paper was published, the policy has been issued—a speed of action which suggests how seriously the recommendations were taken by Army leadership.
“The Sergeant Major of the Army was an integral part of reading this … and working with us to get the words right from a very early stage,” said Amy Kramer, lead action officer for the policy during a Pentagon press briefing.
Kramer noted that becoming a parent is a healthy, natural part of life, and the Army is committed to de-stigmatizing it.
“I think culture shift takes a lot longer than just writing a directive, but we hope that the directive will give the tools to begin the normalization of parenthood that’s necessary,” Kramer said.
For Bell, she’s leaving behind a legacy of perhaps enabling pregnant Soldiers and new parents to be both phenomenal troops and caregivers at the same time—to be able to better balance both worlds without having to choose to compromise one.
“None of these policies are now going to help me personally, but they will give me the tools needed to be a better leader,” Bell explained, and said she won’t be having any more children herself, but wanted to help usher change to help future generations of Soldiers.
“Be the change,” she said. “Advocate for your Soldiers.”
And Bell has done just that.
To access the full directive, visit: https://armypubs.army.mil/ProductMaps/PubForm/Details.aspx?PUB_ID=1024798
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The appearance of U.S. Department of Defense (DoD) visual information does not imply or constitute DoD endorsement.
Missouri faces a shortage of primary care physicians, particularly in rural and underserved communities, making it challenging for residents in some parts of the state to access health care services.
Advanced Practice Registered Nurses (APRNs) can provide an alternative because they are trained to assess, diagnose, treat and prescribe for medical conditions in much the same way optometrists are trained to assess, diagnose, treat and prescribe for eye-related conditions.
But rules in Missouri restrict APRNs to practicing within 75 miles of their collaborating physician and require an initial one-month direct observation of practice between an APRN and an MD or DO and regular medical record reviews of the APRN from the MD or DO. What’s more, MDs and DOs cannot have collaborative practice with more than six full-time APRNs or physician’s assistants, and APRNs cannot conduct video visits or write for home health orders.
“I think it is very important to hear from nurses on the frontline,” said Pamela Talley, an MSN-DNP student in the College of Nursing who practices at CHIPs Health and Wellness Center on North Grand Ave. in the city of St. Louis. “We see the issues daily. We became nurses to take care of people, in response to seeing people suffer. Nurses have an ethical responsibility to advocate on behalf of those underserved populations. I believe it is a social justice issue and we must advocate for access to health care for all people.”
The students and faculty spent Tuesday morning talking to legislatures such as Sen. Steven Roberts and Sen. Brian Williams about access to health care, including for Talley’s clientele at CHIPS, a nurse-founded, free medical care clinic where most providers are volunteers in what is considered a medical-provider shortage area.
“I’ve been practicing as a pediatric nurse practitioner for over 30 years, mostly in the emergency department,” Kuensting said. “Children are a vulnerable population, often without health insurance, leaving the emergency department as their only source of health care. Organizations such as CHIPs and other nurse-led clinics in medical provider shortage areas can facilitate health maintenance and avoid episodic care visits for individuals and their healthcare needs, but the barriers APRNs face in Missouri make providing care extremely difficult.”
Talley had the opportunity to describe how restrictions impact her ability to care for patients in her community.
“It was great meeting with state legislators to discuss the need to reduce practice restrictions,” Talley said. “These restrictions are a barrier to vulnerable populations in both rural and urban areas. The current collaborative agreement creates restrictions to fundamental access to health care for people to manage their health and to live a quality life.”
She added: “If nurse practitioners could have greater independence and a less restrictive practice they would be able to provide much needed care in those areas where there are the greatest needs.”
There is precedent. Missouri temporarily lifted these restrictions for nearly two years during the COVID-19 pandemic with no adverse events, though that temporary lift expired on Dec. 31.
More and more states have also taken to permanently grants APRNs full-practice authority. On April 10, New York became the 25th state to take such action, and the Veterans Administration issue full practice authority to APRNs, regardless of the state they practice in, about two years ago.
“This course, and particularly this experience, is important for our APRN students to understand why being aware of the issues affecting our practice matter,” Kuensting said, “and more importantly, how to advocate for change.”
Photo at top includes U Missouri St Louis College of Nursing faculty members and students (from left): Laura Kuensting, Pam Talley, Marina Fischer, Marie Turner, Brooke Shahriary, Louise Miller, Kate Skrade, Carla Beckerle, Taylor Nealy, Ann Mwangi-Amann, Paige Bernau, Lucy Kokoi and Tammy Vandermolen at the Missouri Capitol last Tuesday to take part in the Association of Missouri Nurse Practitioners Advocacy Day. (Photo courtesy of Laura Kuensting)
The research explores nurses’ values, perceptions, and perspectives on MAiD and demonstrates a need for more guidance on the expectations of the nurse’s role to provide competent and quality care where MAiD is legalized.
“Nurse respondents to the study held concerns about the process, policy, potential psychological harm, legal risk, and the need to learn more about MAiD,” said Bosek, an associate professor and registered nurse. The findings suggest that nurse educators should assist nursing students to understand both their personal and professional values related to the subject, added Bosek.
“Organizations in states where MAiD is a legal option need to assist nurses to understand MAiD and carefully construct policy/standards to minimize conflict, moral distress, and psychological harm amongst nurses,” said Bosek.
MAiD is currently legal in 10 states including Vermont, plus Washington D.C., and legislation is pending in Connecticut, Arizona, and Massachusetts.
Bosek was part of the team that drafted the 2019 American Nurses Association (ANA) position statement, The Nurse’s Role When a Patient Requests Medical Aid in Dying, which addresses the growing ethical questions and challenges that nurses face when responding to a patient’s request for MAiD.
Oftentimes, social or economic disadvantages prevent a person from living their healthiest life. Last year, the American Diabetes Association (ADA) announced grant funding to support projects that focus on the impact of such health disparities on those with diabetes.
Louise Reagan, MS, APRN, ANP-BC, an assistant professor at the University of Connecticut School of Nursing, received one of those grants — called the Health Disparities and Diabetes Innovative Clinical or Transitional Science Award — as her research focuses on people with diabetes who are reentering society from prison.
Reagan says her team has found that people living with diabetes in prison lack critical knowledge and skills regarding managing their diabetes. As these individuals transition to the community, they are required to self-manage diabetes independently and are not prepared to do so.
Diabetes survival and self-management skills include knowing what foods to eat, how to control blood glucose (sugar), when to take insulin, how to manage sick days, and how to access health care. These skills are critical for incarcerated individuals, as their rate of diabetes diagnosis is almost 50% higher than the general population.
“I wanted to figure out what we could do to reach persons with diabetes at this critical transition period when they’re just getting out of prison and into the community, and how we could help them self-manage their illness,” Reagan says. “The Connecticut Department of Correction (CDOC), a community collaborator and advocate for the needs of persons transitioning from prison to the community, and my team don’t want citizens returning to the community from prison to end up in the emergency room being treated for hypoglycemia or dangerously low blood glucose when it can be prevented.”
Reagan worked as an advanced practice registered nurse in Hartford for 16 years, treating underserved populations with multiple comorbid diseases, including diabetes. This clinical work exposed her to the challenges that people released from prison or living in supervised community housing post-prison release face in self-managing their illness when reentering the community, and inspired her research.
She says many social barriers prevent patients from adequately caring for their own health. It can be challenging to provide diabetes education to recently released patients due to their multiple housing locations, desire for anonymity, and limited access to clinical care.
Additionally, she says, the priorities of people recently released from prison are often to avoid reentering prison, to find a job, and reestablish social and family relationships rather than manage their diabetes and other aspects of their health.
“Patients have many other competing needs when integrating into their societal roles,” Reagan says. “The Diabetes LIVE JustICE research provides an opportunity to help them with their health.”
Her study — called Diabetes Learning in Virtual Environments Just in Time for Community reEntry (Diabetes LIVE JustICE) — examines the feasibility and acceptability of a mobile app that provides diabetes education, support, and other resources in a virtual environment to people recently released from prison living in supervised community housing or on parole. Reagan’s goal is to improve health outcomes and reduce health inequities for this vulnerable population.
Reagan’s app, called LIVE Outside, contains live sessions with diabetes educators and instructive games to inform users about self-care.
Over the course of 12 weeks, Reagan will be measuring users’ diabetes knowledge, stress, and self-care after using LIVE Outside and comparing it to typical diabetes care education.
The mobile app is a culmination of projects Reagan has been working on since completing her postdoctoral fellowship at New York University. There, she served as a project director for an R01 study using a personal computer-based virtual environment called Diabetes LIVE, which promoted diabetes education to community-dwelling individuals.
Reagan’s proceeding research project with the CDOC, Diabetes Survival Skills (DSS), was an in-person intervention run within CDOC-managed correctional facilities. However, this project experienced attrition as individuals reentered society and could no longer participate, she says.
With collaboration and support from the Connecticut Department of Correction, Reagan anticipated taking in-person DSS interventions beyond prisons to supervised housing facilities to reach recently released individuals. This intervention, however, was put on hold due to the COVID-19 pandemic.
This forced Reagan to get creative with her work, leading to her innovation and the ADA grant.
“I was thinking about my work, and I wondered, ‘what if we use a virtual environment and adapt it to a mobile environment?’ ” Reagan says. “We could adapt the virtual app, use my program from the Diabetes Survival Skills, and blend them into a mobile app.”
Given the need for diabetes self-management education during the critical transition from prison to the community, the CDOC was excited to work with Reagan again to develop a remote mobile option for the people with diabetes under their care. Reagan then collaborated with her colleagues from Diabetes LIVE — Constance Johnson (UTHealth Houston), Allison Vorderstrasse (University of Massachusetts Amherst), and Stephen Walsh (UConn School of Nursing) — to combine DSS and Diabetes LIVE into a mobile app.
Diabetes LIVE JustICE was created and Reagan applied for the ADA grant to propel her innovation forward.
“My team and I had been talking about making this app mobile,” Reagan says. “The grant allows us to put all our work together to collaborate on this new idea.”
Reagan says she is grateful to have received this grant and for the strong collaboration with and involvement of the CDOC.
“When I received notice that the project was going to be funded, it was just an unbelievable feeling,” she says. “For me, this grant meant I had the opportunity to help underserved populations with their health, and I am so grateful for that. I feel so thankful that we can offer something to these people that sometimes don’t have anything.”
This research is supported by an American Diabetes Association grant #11-21-ICTSHD-05 Health Disparities and Diabetes Innovative Clinical or Translational Science Award. To learn more about the grant program, visit professional.diabetes.org. To learn more about the UConn School of Nursing, visit nursing.uconn.edu and follow the School on Facebook, Instagram, Twitter, or LinkedIn.
BSN student Valeria Soria Guzman has been translating for her parents for as long as she can remember. She knows three languages so far – and is learning two more – and she aspires to use her polylingual abilities to increase access and equity for health care patients through the nursing field.
“It’s so hard when you’re sick and when you’re at your lowest point and to not have somebody who understands you,” says Guzman. “To not have somebody who can share that compassion with you in your own language is difficult.”
Guzman moved to the U.S. from Mexico with her family when she was two years old. She is a first-year nursing student at the Bill and Sue Gross School of Nursing at the University of California Irvine (UCI), and she is also the first in her entire family to attend college.
After learning English in the third grade, Guzman found that her background in Spanish made it easy for her to pick up other languages as well. Aside from English and Spanish, Guzman also knows French, is working on American Sign Language and has just begun to dip her toes into Portuguese. As a child, Guzman became her family’s translator at more than just the grocery store – she found herself translating at medical offices, filling out complicated documents with her limited children’s vocabulary of English, and trying to get both her parents and the physicians to understand each other.
“I feel like that’s why I want to go into nursing specifically so that I can walk a patient through the treatment and help them along the way, even if they don’t speak the language,” she says.
Guzman is constantly seeking opportunities at UCI to help those facing a language barrier, especially in the medical field. Currently, she works on the translating team for a research study that is looking for ways to help dementia patients through technology.
“A lot of their patients are lower income and Spanish-speaking only,” Guzman says. “So what I do is translate documents, like ones from the research, into Spanish so the researchers can have focus groups with these Spanish-speaking participants.”
Guzman sees the accessibility of documents in languages other than English as a major point in achieving accessible care. In the future, she plans to use her abilities to serve non-English speaking communities wherever she is most needed. She especially wants to serve areas lacking in non-Spanish speakers, even if it means leaving the large Spanish-speaking community that she values so much behind.
“The thing I’ve missed most since coming to UCI is speaking Spanish in a community setting, and I feel like that’s why I like to seek out a bunch of different Spanish speaking opportunities because I want to have that again,” says Guzman.
The American Association of Critical-Care Nurses (AACN) has honored nurse and bioethicist Cynda Hylton Rushton, PhD, RN, FAAN, with its 2022 Marguerite Rodgers Kinney Award for a Distinguished Career.
Rushton receives the award for her exceptional contributions that enhance the care of critically ill patients and their families and the nurses who care for them, and further AACN’s mission and vision. The presentation will occur during the 2022 National Teaching Institute & Critical Care Exposition in Houston, May 16-18.
An international leader in bioethics and nursing, Rushton is the Anne and George L. Bunting Professor of Clinical Ethics at the Johns Hopkins University Berman Institute of Bioethics and the JHU School of Nursing. She co-chairs Johns Hopkins Hospital’s Ethics Committee and Consultation Service. A founding member of the Berman Institute, she co-led the first National Nursing Ethics Summit that produced a Blueprint for 21st Century Nursing Ethics.
In 2016, she co-led a national collaborative, State of the Science Initiative: Transforming Moral Distress into Moral Resilience in Nursing and co-chaired the American Nurses Association’s professional issues panel that created “A Call to Action: Exploring Moral Resilience Toward a Culture of Ethical Practice.” She was a member of the National Academies of Medicine, Science and Engineering Committee that produced the report “Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being.”
“Dr. Rushton is an internationally recognized leader in nursing ethics, moral resilience and workforce issues and a longtime contributor to groundbreaking work on these topics,” said AACN President Beth Wathen. “Her work has influenced nursing practice, health policy and patient care.”
A member of AACN since 1979, Rushton is a frequent presenter at NTI and regularly contributes to AACN’s clinical journals.
Rushton is the chief synergy strategist for Maryland’s R3 Resilient Nurses Initiative, a statewide initiative to build resilience and ethical practice in nursing students and novice nurses.
She is a fellow of the Hastings Center bioethics research institute, chair of the Hastings Center Fellows Council and a fellow of the American Academy of Nursing.
She is the editor and author of “Moral Resilience: Transforming Moral Suffering in Healthcare,” the first book to explore the emerging concept of moral resilience from a variety of perspectives including nursing, bioethics, philosophy, psychology, neuroscience and contemplative practice.
She earned her bachelor’s degree in nursing at the University of Kentucky, followed by a master’s degree in nursing at the Medical University of South Carolina and a PhD from Catholic University of America in Washington, D.C.
About the Marguerite Rodgers Kinney Award: Established in 1997 and named for an AACN past president, the Marguerite Rodgers Kinney Award for a Distinguished Career recognizes extraordinary and distinguished professional contributions that further AACN’s mission and vision of a healthcare system driven by the needs of patients and their families where acute and critical care nurses make their optimal contribution. Recipients of this Visionary Leadership Award receive a $1,000 gift to the charity of their choice and a crystal replica of the presidential “Vision” icon. Other Visionary Leadership awards, AACN’s highest honor, include the Lifetime Membership Award and the AACN Pioneering Spirit Award.
