Public Health Nursing
Section Newsletter
Winter 2010

Message from the Chair

Greetings! 

It is a privilege and honor to serve as the Section chair. Thank you to everyone who contributed his or her time and energy to the success of the Annual Meeting in Philadelphia. I would like to give a special acknowledgement to Sonda Oppewal, our program chair, and to Nancy Rothman and her Local Arrangement Committee for their extraordinary efforts. And finally, on behalf of the entire Public Health Nursing Section, I would like to express gratitude to Beth Lamana and her Board for their leadership over the past year and their commitment to advancing the mission of the Section.

This is a challenging but exciting time for public health nursing. Public health nurses throughout the nation have stepped up to the challenges of H1N1 virus in their communities – conducting mass immunization clinics, reaching out to populations at risk, detecting and tracking influenza. As the largest component of the public health work force, public health nurses are vital to the protection of health in America’s communities. The 2008 NACCHO National Profile of Local Health Departments reported that almost every health department in the nation, large or small, employs public health nurses. Our response to this pandemic validates the critical role of public health nurses in responding to emerging public health threats. A public health nursing work force in numbers sufficient to deliver essential public health services is critical for the health and economic well-being of communities.

Public Health Nursing Visibility
The Section is working hard to make sure that public health nursing’s voice is heard:
• Linda Olson Keller will be representing the PHN Section on the Champion Nursing Council of the Center to Champion Nursing in America
http://championnursing.org/.

• Beth Lamana continues to represent the PHN Section on the Steering Committee of the Alliance for Nurses for a Healthy Environment.

• Susan Zahner and Betty Daniels continue to serve as Quad Council PHN liaisons to the Task Force on Community Preventive Services.

• The Johnson & Johnson Campaign for Nursing’s Future, which has done a great job of recruiting for acute care nursing, is developing a campaign that promotes public health nursing. Their January 2010 Nursing Notes profiles the partnership between the PHN Section and the Alliance of Nurses for Healthy Environments. The article quotes Jeanne Matthews (a past chair and current Section Councilor) and concludes with an interview with Beth Lamana (our own past-chair) about her public health nursing career!  Check it out at http://www.jjnursingnotes.com/JAN10/.   
 
The J & J Campaign will be soon be releasing a new recruitment brochure detailing the public health nurse specialty on www.discovernursing.com.  The brochure will feature real public health nurses who are making a difference in the health of their communities.

 

 

 Did you know that?

• Public health nursing is the oldest organized specialty group within professional nursing. It was the first to require university courses to the standard nursing curricula in the pre-World War I period.
• In 1923, the Public Health Nursing (PHN) Section was established within APHA.
• You can find “peer counties” for any county in the United States (as well as useful health status indicators) on the Community Health Status Indicators (CHSI) Web site here:
http://www.communityhealth.hhs.gov/homepage.aspx.

 

Upcoming Events

138th Annual Meeting & Exposition: Nov. 6-10, Denver

The theme of the 2010 APHA Annual Meeting is Social Justice. Not only is social justice a core value of public health nursing, it is also one of the PHN Section’s strategic goals. Our new 2010 Program Co-Chairs Cecilia Venzon and Huey-Shys Chen are working hard to put together an outstanding program that highlights the character and spirit of social justice and public health nursing.

The Quad Council Learning Institute will present the “PHN Challenges of Practicing Social Justice in a Market Justice World” on Sunday, Nov. 6. The Quad Council Learning Institute is free, but you must register for the Institute when you register for the Annual Meeting.

Closing Thoughts
It had been a long and difficult meeting about public health nursing reimbursement rates for elderly waiver services. As we walked out of the meeting, a colleague from the state’s human service division commented to me “if public health nurses advocated for themselves as well as they advocated for their clients, they wouldn’t be in this mess.” I thought long and hard about his comment.  Public health nurses are very skilled in advocacy, but too often, we save that skill set for our clients and communities, not for our profession or ourselves. In order to achieve our potential, we must increase our visibility and policy advocacy.

I invite you to become involved with the PHN Section!  If you are interested, drop me an e-mail at olson173@umn.edu or give me a call at (612) 626-5144. 

Best regards,

Your PHN Colleague - Linda Olson Keller

PHN Section Endorses Mandatory Annual Influenza Vaccination for Health Care Workers

At its opening business meeting session in Philadelphia held Sunday Nov. 8, 2009, the PHN Section voted to endorse a late-breaker proposal that APHA support mandatory annual influenza vaccination for health care workers, including volunteers, contract workers and students.  This late-breaker was initiated, in part, due to misinformation about influenza vaccine conveyed to public media by nurses – albeit not public health nurses.  The members present considered the implications of such a mandate on different communities and nurses.

 

The resolution, initiated by PHN Section members Jo Anne Bennett, Jeanne Matthews, and Nonceba Lubanga, requires a majority vote of the APHA Governing Council to become an official policy position of the association.  Derryl Block, Diane Downing, Judy Gibson, and Carol McDonald contributed to its further development.  Framed as an issue of social justice and ethics, the resolution has a firm foundation in the science of infection control and vaccinology.

 

During the Sunday afternoon Policy Forum, members from other sections raised questions and contributed modifications.  The Joint Policy Committee (JPC) then reviewed it and forwarded it to the Governing Council (GC) without a recommendation regarding adoption; the GC subsequently “referred it back to committee” without considering its adoption as a one-year interim policy while the resolution goes through the full annual policy development process.

 

Since November, other sections have joined our Section in co-endorsement of the proposal including the Epidemiology Section and School Health and Education Services Section.  Members from the Ethics Special Interest Group, the Health Administration Section, the Maternal Child Health Section, and the Public Health Education and Health Promotion Section also signed on to the proposal. The proposed resolution is posted on the APHA policy Web site for all members to review and offer comments.  After its spring meeting, the JPC will make a recommendation to the APHA Executive Committee about whether to put it on the Governing Council’s agenda next November.  Public policy statements adopted through this process provide a record of APHA’s stance on a variety of public health issues and reflect the diverse interest of the membership.

 

Why mandate influenza vaccination?

 

Deferring consideration of the resolution to the 2010 policy review cycle has allowed for a more robust literature review and broader consideration of the issues involved.  The proposed position statement does not insist on the mandatory approach when non-mandatory programs achieve vaccination rates higher than 90 percent. In other words, mandatory influenza vaccination is not a goal in itself.  Support for vaccination mandates is made upon the premise that a sufficiently vaccinated health care work force is a critical component of maintaining and promoting the public's health.  Whereas health care workers may choose to pursue other individual health behaviors, the choice of vaccination, and the potential result of that choice, does not rest with the individual alone, but rather with others with which they come into contact.  Vaccination thus exemplifies one of the critical aspects of public health policy: providing the means to be healthy (in this case an influenza-free health care work force) which the individual cannot obtain for themselves.

 

Mandates are not inherently coercive.  Rather, they serve as structural supports.  Surveys of health care workers' opinions and reasons for not being vaccinated support this perspective.  Many unvaccinated health care workers say they would support mandates; many also say they intended to, but never got around to it.  “Round toits” are hard to find, so mandates can be a necessary tool for reducing influenza susceptibility.

 

For questions about this resolution, please contact Jo Anne Bennett at joannebenn@gmail.com.

Call for 2010 PHN Section Award Nominees

The Public Health Nursing Section of APHA is calling for nominations for awards to be presented at the 2010 Annual Meeting in Denver. The Ruth B. Freeman Award honors a person who has had a distinguished career in public health administration, education, policy, practice, or research. The Public Health Nurse Creative Achievement Award is bestowed in recognition of an individual's exceptional and creative contribution to public health nursing administration, education, practice, or research. The Lillian Wald Service Award is awarded to agencies, individuals, organizations, or media, for depicting exemplary public health nursing especially through legislative, professional, or public advocacy.

Deadline for submissions is April 16, 2010. Nominees must be members of APHA and voting members of the Public Health Nursing Section. If the nominee is a group, at least one member of the group must be a paid member of APHA and a voting member of the Public Health Nursing Section. The Awards Committee encourages nominations and is happy to answer questions regarding preparation of materials. For questions, please contact Marylyn Morris McEwen, chair of the APHA PHN Section Awards Committee, at the address or numbers listed below. For complete details about eligibility for the 2010 PHN Section Awards, click here.  For a PDF™ version of the awards application, click here.  For a Word™ version of the awards application, click here. For additional information or questions, please contact:

 

Marylyn Morris McEwen, PhD, PHCNS-BC, FAAN

University of Arizona, College of Nursing

1305 N. Martin Avenue

Tucson, AZ 85721-0203

Telephone: (520) 626-6926

FAX: (520) 626-7891

E-mail: mmcewen@nursing.arizona.edu

 

Congratulations 2009 Award Winners!

Ruth B. Freeman Award: Mary J. McLaughlin

Lilian Wald Service Award: Joan M. Marren

PHN Creative Achievement: Mary Jo Baisch

Beverly C. Flynn Legacy Leadership Award

The Public Health Nursing Section of  APHA invites graduate nursing students with a public health concentration, BSN students who plan to engage in PHN practice, and novice public health nurses to submit an application to become a mentee of the Beverly C. Flynn Public Health Nursing Legacy Leadership Program. 

This program provides mentorship to nurses for one year for the purposes of establishing meaningful connections in the public health nursing community, developing future PHN leaders, maximizing mentee experiences at the APHA Annual Meeting, and supporting involvement in the PHN Section.  Nurses from the HHS region where the APHA Annual Meeting is held are urged to apply for the legacy leadership award. The donor of this award valued diversity and recognized the importance of developing PHN leaders from all walks of life.

All mentees will be assigned a mentor from the PHN Section.  Mentees are expected to attend the annual APHA meeting. Conference registration and PHN Section luncheon fees will be provided for each mentee.  For award eligibility and application, click here.  For more information, contact Anne Belcher, abelche@iupui.edu.

 

2009 Beverly C. Flynn Mentees

Virginia Cook - Mentor: M. Buchanan

Lakisha Flagg - Mentor: Dr. K. Russell

Esther Thatcher - Mentor: Dr. J. Matthews

APHA Seeks Candidates for 2010 APHA Leadership Positions

The Nominating Committee for APHA's Governing Council is looking for the following candidates for leadership roles in the organization:

 

  • APHA President Elect (three year commitment, one year each as president-elect, president and past-president)
  • Executive board – three positions available (4-year term)
  • Speaker of the Governing Council (3-year term)
  • Treasurer (3-year term)

The APHA Governing Council will vote to select these officers at the November (2010) meeting, and they would begin serving immediately after the APHA conference (so terms would start Nov. 10, 2010).

 

As I'm sure you know, the next APHA Annual Meeting is Nov. 6-10, 2010, in Denver.

 

Applications are due March 31, 2010 and should include the relevant (attached) one-page form along with resume/CV of the nominee, and any letters of support. The nominating committee will meet May 6 to select the list of nominees for consideration by the Governing Council at the 2010 Annual Meeting.

 

We hope you will be able to think of individuals who would be excellent candidates for the above positions. 

 

Should you or a potential candidate wish further information on these positions, please refer to the job descriptions and nomination form available on the APHA Web site at: http://www.apha.org/about/gov/nominations/default.htm

 

If you are interested in running, we suggest you contact your APHA Section, SPIG, Caucus and/or Forum leadership to solicit their support and assistance with your nomination. 

 

All nominees for the Executive Board are selected from among the membership of the Association, except that the nominees for  Honorary Vice-President may include persons who are not members of the Association.

  

For more information on the Nominating Committee, contact Ida Plummer via e-mail at governance@apha.org.

Huey-Shys Chen Presented with Inaugural Junior Investigator Award

In 2009 at the APHA Annual Meeting in Philadelphia, the PHN Section’s Research Committee presented its new award, the Junior Investigator Award, to Dr. Huey-Shys Chen for her research Psychometric properties of the Chinese version of the Decisional Balance Scale with native Taiwanese adolescents.  Dr. Chen has presented at APHA since 2000 as well as at other national, regional, and international conferences.  Dr. Chen twice received the Excellence in Scholarship Award from the Sigma Theta Tau International, Omicron Pi Chapter.

 

Dr. Chen is an assistant professor at the School of Nursing, University of Medicine & Dentistry of New Jersey, and her research interests include “understanding children and adolescents' tobacco smoking behavior.”  She has published on this topic in the Journal of Community Health Nursing, Research in Nursing and Health, and Graduate Research in Nursing.  Dr. Chen is co-principle-investigator on interdisciplinary teams conducting two federally funded projects, and has a foundation grant to study “Reducing Health Disparities: Smoking Prevention for African American Children in Urban Low Income Community.”

 

Dr. Chen has served as editor of Journal of School Health Nursing (Taiwan), and the Editorial Board of the Chinese Journal of Medicine and Californian Journal of Health Promotion.  She has also been a reviewer for several journals including Nursing Research, Research in Nursing and Health, Journal of Nursing Scholarship, Journal of Trans-cultural Nursing, and Public Health Nursing.  The Public Health Nursing Section congratulates Dr. Chen for her accomplishments and contributions to public health nursing.

How Healthy Is Your County?

On Feb. 17 the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute released the County Health Rankings — the first set of reports to rank the overall health status of every county in the United States. The 50 state reports help public health and community leaders, policy-makers, consumers and others to see how healthy their county is, compare it with others within their state and find ways to improve the health of their community.  Click here to view the full report and find your county's ranking.

AHRQ Announcements

Patient Deaths in Hospitals Cost Nearly $20 Billion

 

One of every three people who died in 2007 in the United States was in the hospital for treatment at the time of death, according to a recent report from the Agency for Healthcare Research and Quality (AHRQ). The cost of their hospital stays was about $20 billion.

 

The Federal agency's analysis of 765,651 hospital patient deaths in 2007 found that the average cost of hospital stays in which patients died was $26,035, versus an average of $9,447 for patients who were discharged alive. The costs were higher for patients who died because their hospitals stays were longer than those of patients who lived (8.8 days vs. 4.5 days).

 

The study also found that:

 

  • Medicare patients accounted for 67 percent of in-hospital deaths and $12 billion in hospital costs, while privately insured patients accounted for 20 percent of deaths and $4 billion. Medicaid patients accounted for 2 percent of deaths and $2.4 billion, and uninsured patients, 3 percent and $630 million.

 

  • The average cost for each Medicaid patient who died was $38,939 — roughly $15,000 more than the average cost of a Medicare or uninsured patient who died, and about $10,000 more than a privately insured patient who died.

 

  • About 12 percent of patients who died had been admitted for an elective procedure or other non-urgent reason, and 72 percent were emergency admissions. Roughly 7 percent of patients who died were admitted for accidents or intentional injury, and about 2 percent were newborn infants.

 

  • Septicemia, a life-threatening blood infection, was the major cause of death, accounting for 15 percent of all deaths, followed by respiratory failure (8 percent); stroke (6 percent); pneumonia (5 percent); heart attack (5 percent); and congestive heart failure (4 percent). Other leading causes of death included cancer, aspiration pneumonia, and kidney failure.

 

These findings are based on data described in The Costs of End-of-Life Hospitalizations, 2007. The report uses statistics from the 2007 Nationwide Inpatient Sample, a database of hospital inpatient stays that is nationally representative of inpatient stays in all short-term, non-federal hospitals. The data are drawn from hospitals that comprise 90 percent of all discharges in the United States and include all patients, regardless of insurance type, as well as the uninsured.


Falls Send More than Two Million Seniors to Hospital Emergency Departments

 

Hospital emergency departments (EDs) treated more than 2 million seniors for broken bones, head wounds, cuts, and other injuries caused by falls in 2006 at a cost to hospitals of approximately $7 billion for emergency and subsequent inpatient care, according to another recent report from AHRQ. Falls are the leading cause of fatal and nonfatal injuries among Americans aged 65 and older. The cost for medical treatment, which is paid mainly by Medicare, is expected to increase as the number of older Americans grows.

 

The federal agency's analysis of hospital emergency department data for patients age 65 and older treated for injuries caused by falls shows that:

 

  • One in 10 ED visits by seniors were for injuries related to falls, and ED visits related to injurious falls increases with age: one in 10 men and one in seven women over the age of 85 have an emergency department visit for an injurious fall.

 

  • Of the seniors who went to the emergency department due to falls, 41 percent had fractures, primarily of an upper extremity or a hip. Other common injuries resulting from falls included open wounds (21 percent of visits), sprains and strains (10 percent), injuries to internal organs (5 percent), and joint dislocations (1.5 percent).

 

  • About 63 percent of the patients who had injuries to an internal organ and 51 percent of people with fractures were hospitalized.

 

  • About 41 percent of patients with fractures and 33 percent of those who sustained internal organ injuries were transferred to a nursing home or other type of long-term care facility.

 

These findings are based on data described in HCUP Statistical Brief #80: Emergency Department Visits for Injurious Falls Among the Elderly, 2006. The report uses statistics from the 2006 Nationwide Emergency Department Sample, a new AHRQ database that is nationally representative of emergency department visits in all non-federal hospitals. The Nationwide Emergency Department Sample contains 26 million records from emergency department visits from approximately 1,000 community hospitals nationwide. This represents 20 percent of all U.S. hospital emergency departments.


Treating Aging Baby Boomers Cost Hospitals $56 Billion

 

U.S. hospitals spent roughly $56 billion in 2007 (or 16 percent of their overall patient care costs) treating baby boomers ages 55 to 64, according to a recent AHRQ report. With an expected increase of 18 percent by 2020, the baby boom population is expected to increase at a faster rate than any other group under age 65.

 

AHRQ's analysis found that in 2007:

 

  • Hospitals' costs to treat baby boomers were nearly equal to the older generation of 65 to 74 year-olds ($56 billion and $59 billion, respectively). In contrast, baby boomers cost hospitals $10 billion more than the younger generation of patients 45 to 54 years old.

 

  • The average hospital cost for a baby boomer patient was $11,900, compared with $10,400 for 45 to 54 year olds.

 

  • Baby boomers were 2 to 3 times more likely than 45 to 54 year olds to be hospitalized for osteoarthritis, stroke, respiratory failure, irregular heartbeat, chronic obstructive pulmonary disorder, blood infections, and congestive heart failure, as well as undergo knee and hip replacements and have heart bypass surgery.

 

  • About 37 percent of baby boomer patients were covered by public insurance (mainly Medicaid), 52 percent had private insurance, and 6 percent were uninsured.

 

These findings are based on data described in Hospital Utilization among Near-Elderly Adults, Ages 55 to 64 Years, 2007. The report uses statistics from the 2007 Nationwide Inpatient Sample.


 

Emergency Departments Treat 3.5 Million Crash Victims a Year

 

According to a recent AHRQ report, about 3.5 million motor vehicle crash victims were treated in emergency departments in 2006 for injuries ranging from scrapes and bruises to life-threatening trauma.

 

Roughly, 85 percent (3 million) of the crash victims were treated and released, while another 321,000 were admitted or transferred to another acute care hospital for inpatient care. About 8,000 victims died in the emergency department.

 

AHRQ's analysis also found that:

 

  • Thirty-seven percent of crash victims were treated in hospital trauma centers that were equipped to provide comprehensive emergency medical care to individuals suffering life-threatening injuries. The remaining patients were treated in hospitals not designated as trauma centers.

 

  • About 25 percent of the victims were uninsured; 55 percent had private health insurance; 10 percent were covered under Medicaid; 4 percent under Medicare; and the remaining 7 percent had other types of coverage.

 

  • Sprains accounted for 44 percent of the injuries treated; superficial injuries such as scrapes accounted for 35 percent; open wounds accounted for 10 percent; and head injuries accounted for 5 percent of the motor vehicle injuries seen in the emergency department. Other types of injuries included fractures (about 15 percent) and internal injuries of the thorax, abdomen, and pelvis (3 percent).

 

These findings are based on data described in Emergency Department Visits Associated with Motor Vehicle Accidents, 2006. The report uses statistics from the 2006 Nationwide Emergency Department Sample.

 

 

Medicare Pays Almost Half of Rural Hospital Stays

 

A recent AHRQ report found that Medicare patients accounted for nearly half (45 percent) of all stays at rural hospitals in 2007, while the percentage of Medicare beneficiaries who were admitted to urban hospitals was considerably lower (35 percent).

 

The federal agency's analysis also found that in 2007:

 

  • About 25 percent of rural hospital patients were covered by private health insurance, versus 36 percent of urban hospital patients. One-fifth of patients in both rural and urban hospitals were covered by Medicaid, and about 5 percent were uninsured.

 

  • Half of the nation's 2,000 rural hospitals had fewer than 50 beds, compared with only one-fifth of urban hospitals.

 

  • Although rural residents are generally hospitalized in rural hospitals, one-third of their hospital stays were in urban hospitals.

 

  • The top five illnesses among rural residents who were hospitalized in rural facilities were pneumonia (267,000 stays); congestive heart failure (166,000 stays); chronic obstructive lung disease (146,000 stays); chest pain (110,000); and fluid and electrolyte disorders, primarily dehydration and fluid overload (106,000 stays).

 

  • The top five illnesses among rural residents who were admitted to urban hospitals were hardening of the arteries (108,000 stays); osteoarthritis (79,000 stays); back disorders (75,000 stays); medical device, implant or graft complications (63,000 stays); and heart attack (61,000 stays).

 

These findings are based on data described in Inpatient Stays in Rural Hospitals, 2007. The report uses statistics from the 2007 Nationwide Inpatient Sample.

What Can Nurses Do to Aid Relief in Haiti?

Are you looking for a way to contribute to the relief efforts in Haiti?  If so, Linda Hassan, RN, MS, has provided this link to a resource that provides opportunities for nurses to volunteer as well as other ways to contribute.  If you are interested,  click here to go to the “A Call to Action in Haiti” Web site.   For more information contact:

 

Linda Lindquist Hassan, MS, RN

Nurses for Global Health

Vice Chair for Marketing and Public Relations

University of Maryland, School of Nursing

E-mail: llind001@umaryland.edu

 

Join Nurses for Global Health on Facebook!

ASTDN News

SAVE THE DATE for the ASTDN 2010 Annual Meeting

 

There will be a joint meeting of ASTDN & ACHNE this year. The title is “Embracing Diversity: Innovations in Education, Policy & Practice.”  The meeting will be held on June 10-12, 2010 at the Sheraton Crystal City Hotel in Arlington, Va. This is a wonderful opportunity for us to join together to share, explore and discuss PHN education, practice and research. The Planning Committee co-chaired by Connie Roush, PhD, RN, and Marilyn Haynes–Brokopp, MS, RN, APHN-BC, is working hard to put together an excellent conference this year. We hope to see you all there.  Please check the ASTDN Web site at www.astdn.org and the ACHNE Web site at www.achne.org for more information.

 

ASTDN Expands Membership Categories

 

The membership of ASTDN approved by-Laws revisions that included expanding the membership categories effective July 1, 2009. Previously, ASTDN had three membership categories: State/Territory representative, Alumni representative and Associate representative. There are three new membership categories: Contributing member, Local/State/Federal Governmental PHN Leadership member and a Student member.  These membership category enhancements expand the levels of ASTDN membership and will help to create more active participation. The by-law changes also enable more membership categories to hold an ASTDN office.

 

The ASTDN Membership categories are:

   Official State/Territory Representative/Designee

   Contributing (New)

   Local, State, or Federal Governmental PHN Leadership (New)

   Alumni

   Associate

   Student (New)

 

The ASTDN Membership Committee goals this year are to ensure that each state and territory has a designated ASTDN Official representative/designee and to recruit additional ASTDN members in each category.

 

Some of the many benefits to joining ASTDN include:

·        Opportunity to shape public health nursing policy and practice.

·        Forum for discussion of public health issues.

·        Meeting and networking with Public Health Nursing leaders.

·        Representation of Public Health Nurses to external groups and associations.

·        Information exchange through an electronic environment.

 

We encourage you to become a member of ASTDN, which will be celebrating its 75th anniversary this year!  For more information please contact Glynnis LaRosa at Glynnis.LaRosa@state.ma.us and visit the ASTDN Web site at www.astdn.org.

Save the Date

Environmental Considerations in Nursing Practice Conference

 

Save the date for the Environmental Consideration in Nursing Practice Conference to be held on May 7, 2010 at the William and Ida Friday Center for Continuing Education in Chapel Hill, N.C.  This conference is sponsored by the University of North Carolina at Chapel Hill School of Nursing and the Children’s Environmental Health Initiative, Nicholas School of the Environment, Duke University.  To register go to UNC School of Nursing Center for Lifelong Learning at http://nursing.unc.edu/lifelong/schedule.php .

Gifts for Students or Nurses Week Available

The 2009 Philadelphia Local Arrangements Committee has 2009 Annual Meeting bags available with the new Philadelphia Nursing Mural, The Evolving Face of Nursing. If interested e-mail Nancy Rothman at rothman@temple.edu with the number you wish and the address to which you want them sent. They are $10 each or $7.50 each if buying two or more. Nancy will e-mail back if they are available and the address to send a check.

Join the PHN Section Today

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Public Health Nursing Section?CLICK HERE TO JOIN NOW!